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Nursing Leadership And Management Homework


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Effective Leadership and Management in Nursing

Eleanor J. Sullivan, PhD, RN, FAAN

Eighth Edition

Boston Columbus Indianapolis New York San Francisco Upper Saddle River Amsterdam Cape Town Dubai London Madrid Milan Munich Paris Montréal Toronto

Delhi Mexico City São Paulo Sydney Hong Kong Seoul Singapore Taipei Tokyo


Eleanor J. Sullivan, PhD, RN, FAAN, is the former dean of the University of Kansas School of Nurs- ing, past president of Sigma Theta Tau International, and previous editor of the Journal of Professional Nursing. She has served on the board of directors of the American Association of Colleges of Nursing, testified before the U.S. Senate, served on a National Institutes of Health council, presented papers to international audiences, been quoted in the Chicago Tribune, St. Louis Post-Dispatch, and Rolling Stone Magazine, and named to the “Who’s Who in Health Care” by the Kansas City Business Journal.

She earned nursing degrees from St. Louis Community College, St. Louis University, and Southern Illinois University and holds a PhD from St. Louis University.

Dr. Sullivan is known for her publications in nursing, including this award-winning textbook, Effective Leadership & Management in Nursing, and Becoming Influential: A Guide for Nurses, 2nd edition, from Prentice Hall. Other publica- tions include Creating Nursing’s Future: Issues, Opportunities and Challenges and Nursing Care for Clients with Sub- stance Abuse.

Today, Dr. Sullivan is a mystery writer. Her first three (Twice Dead, Deadly Diversion, and Assumed Dead) feature nurse sleuth Monika Everhardt.

Her latest book, Cover Her Body, A Singular Village Mystery, is the first in a new series of historical mysteries featur- ing a 19th-century midwife and set in the Northern Ohio village of Dr. Sullivan’s ancestors. Dr. Sullivan’s blog posts, found at www.EleanorSullivan.com, reveal the history behind her historical fiction.

Connect with Dr. Sullivan at www.EleanorSullivan.com.

This book is dedicated to my family for their continuing love and support.

Eleanor J. Sullivan



Our heartfelt thanks go out to our colleagues from schools of nursing across the country who have given their time generously to help us create this exciting new edition of our book. We have reaped the benefit of your collective experi- ence as nurses and teachers and have made many improvements due to your efforts. Among those who gave us their encouragement and comments are:


Reviewers Theresa Ameri Part-time/adjunct instructor, Marymount University Arlington, VA

Becky Brown, MSN, RN Full-time instructor, College of Southern Idaho Twin Falls, ID

Candace Burns, PhD, ARNP Professor, University of South Florida College of Nursing Tampa, FL

Sandra Janashak Cadena, PhD, APRN, CNE Professor, University of South Florida Tampa, FL

Margaret Decker Full-time instructor, Binghamton University Binghamton, NY

Denise Eccles, MSN/Ed, RN Professor, Miami Dade College Miami, FL

Barb Gilbert, EdD, MSN, RN, CNE Part-time/adjunct instructor, Excelsior College Albany, NY

Karen Joris, MSN, RN Assistant professor, Lorain County Community College Elyria, OH

Jean M. Klein, PhD, PMHCNS, BC Associate professor, Widener University Chester, PA

Jemimah Mitchell-Levy, MSN, ARNP Professor, Miami Dade College Miami, FL

Rorey Pritchard, EdS, MSN, RN, CNOR Full-time instructor, Chippewa Valley Technical College Eau Claire, WI

Heather Saifman, MSN, RN, CCRN Assistant professor, Nova Southeastern University

Miami Kendall, FL Linda Stone Other Cambridge, MA

Sandra Swearingen Part-time/adjunct instructor, UCF Orlando, FL

Diane Whitehead, EdD, RN, ANEF Department chair, Nova Southeastern University Fort Lauderdale, FL



Leading and managing are essential skills for all nurses in today’s rapidly changing health care arena. New graduates find themselves managing unlicensed assistive personnel, and experienced nurses are managing groups of health care providers from a variety of disciplines and educational lev- els. Declining revenues, increasing costs, demands for safe care, and health care reform legislation mandate that every organization use its resources efficiently.

Nurses today are challenged to manage effectively with fewer resources. Never has the information presented in this textbook been needed more. Effective Leadership & Management in Nursing, eighth edition, can help both stu- dent nurses and those with practice experience acquire the skills needed to ensure success in today’s dynamic health care environment.

Features of the Eighth Edition Effective Leadership & Management in Nursing has made a significant and lasting contribution to the education of nurses and nurse managers in its seven previous editions. Used worldwide, this award-winning textbook is now of- fered in an updated and revised edition to reflect changes in the current health care system and in response to sug- gestions from the book’s users. The eighth edition builds upon the work of previous contributors to provide the most up-to-date and comprehensive learning package for today’s busy students and professionals.

This book has been a success for many reasons. It com- bines practicality with conceptual understanding; is respon- sive to the needs of faculty, nurse managers, and students; and taps the expertise of contributors from a variety of dis- ciplines, especially management professionals whose work has been adapted by nurses for current nursing practice. The expertise of management professors in schools of busi- ness and practicing nurse managers is seldom incorporated into nursing textbooks. This unique approach provides students with invaluable knowledge and skills and sets the book apart from others.

Features new or expanded in the eighth edition include:

• Information about the Patient Protection and Afford- able Care Act

• An emphasis on quality initiatives, including Six Sigma, Lean Six Sigma, and DMAIC

• The use of Magnet-certified hospitals as examples of concepts

• The addition of emotional leadership concepts • The use of social media in management • An emphasis on multicratic leadership and interprofes-

sional relationships • Updated legal and legislative content • Tips on how to deal with disruptive staff behaviors,

including bullying • Guidance on preparing for emergencies and mass

casualty incidents • Information on preventing workplace violence

Student-Friendly Learning Tools Designed with the adult learner in mind, the book focuses on the application of the content presented and offers spe- cific guidelines on how to implement the skills included. To further illustrate and emphasize key points, each chapter in this edition includes these features:

• A chapter outline and preview • New MediaLink boxes introduce readers to resources

and activities on the Student Resources site through nursing.pearsonhighered.com.

• Key terms are defined in the glossary at the end of the book

• What You Know Now lists at the end of each chapter • A list of “tools,” or key behaviors, for using the skills

presented in the chapter • Questions to Challenge You to help students relate

concepts to their experiences • Up-to-date references and Web resources identified • Case Studies with a Manager’s Checklist to demonstrate

application of content

Organization The text is organized into four sections that address the es- sential information and key skills that nurses must learn to succeed in today’s volatile health care environment.

Part 1. Understanding Nursing Management and Organizations. Part 1 introduces the context for nursing management, with an emphasis on how organizations are designed, on ways that nursing care is delivered, on the concepts of leading and managing, on how to initiate and manage change, on


providing quality care, and on using power and politics— all necessary for nurses to succeed and prosper in today’s chaotic health care world.

Part 2. Learning Key Skills in Nursing Management. Part 2 delves into the essential skills for today’s manag- ers, including thinking critically, making decisions, solv- ing problems, communicating with a variety of individuals and groups, delegating, working in teams, resolving con- flicts, and managing time.

Part 3. Managing Resources. Knowing how to manage resources is vital for nurses to- day. They must be adept at budgeting fiscal resources; recruiting and selecting staff; handling staffing and sched- uling; motivating and developing staff; evaluating staff performance; coaching, disciplining and terminating staff; managing absenteeism, reducing turnover, and retaining staff; and handling disruptive staff behaviors, including bullying. In addition, collective bargaining and preparing for emergencies and preventing workplace violence are in- cluded in Part 3.

Part 4. Taking Care of Yourself. Nurses are their own most valuable resource. Part 4 shows how to manage stress and to advance in a career.

Resources for Teaching and Learning Student and Instructor Resources can be accessed by regis- tering or logging in at nursing.pearsonhighered.com.

Acknowledgments The success of previous editions of this book has been due to the expertise of many contributors. Nursing adminis- trators, management professors, and faculty in schools of nursing all made significant contributions to earlier edi- tions. I am enormously grateful to them for sharing their knowledge and experience to help nurses learn leadership and management skills. Without them, this book would not exist.

At Pearson Health Science, Acquisitions Editor Pamela Fuller and Development Editor Susan Geraghty guided this revision from start to finish. Editorial Assistant Cyn- thia Gates was also especially helpful.

Because health care continues to change, reviewers who are using the book in their management practice and in their classes provided invaluable comments and sugges- tions (see list on pages xi–xii).

I am especially grateful to experienced nurse manager and graduate student Rachel Pepper for her expert research assistance, ability to generate real-life examples, and ex- pertise in creating case scenarios to exemplify the experi- ence of nurses in management roles. She lent assistance throughout with ideas and suggestions. This book and Becoming Influential: A Guide for Nurses, 2nd edition, are better for her contributions.

To everyone who has contributed to this fine book over the years, I thank you.

Eleanor J. Sullivan, PhD, RN, FAAN www.EleanorSullivan.com



Thank You vi Preface vii

PART 1 Understanding Nursing Management and Organizations 1

CHAPTER 1 Introducing Nursing Management 1 Learning Outcomes 1


How America Pays for Health Care 2 Pay for Performance 2

DEMAND FOR QUALITY 2 Quality Initiatives 2 The Leapfrog Group 3 Benchmarking 3 Evidence-Based Practice 3 Magnet® Certification 4

EVOLVING TECHNOLOGY 4 Electronic Health Records 5 Virtual Care 5 Robotics 5 Communication Technology 5


Even More Change . . . 7 Challenges Facing Nurses and Managers 7

CHAPTER 2 Designing Organizations 11 Learning Outcomes 11


Classical Theory 12 Humanistic Theory 14 Systems Theory 14 Contingency Theory 14 Chaos Theory 15 Complexity Theory 15


Functional Structure 16 Hybrid Structure 16

Matrix Structure 16 Parallel Structure 16


Primary Care 19 Acute Care Hospitals 20 Home Health Care 20 Long-Term Care 20


Health Care Networks 21 Interorganizational Relationships 21 Diversification 22 Managed Health Care Organizations 23 Accountable Care Organizations 23


CHAPTER 3 Delivering Nursing Care 29 Learning Outcomes 29

TRADITIONAL MODELS OF CARE 30 Functional Nursing 30 Team Nursing 31 Total Patient Care 32 Primary Nursing 33

INTEGRATED MODELS OF CARE 34 Practice Partnerships 34 Case Management 34 Critical Pathways 35 Differentiated Practice 36

EVOLVING MODELS OF CARE 36 Patient-Centered Care 36 Synergy Model of Care 37 Clinical Microsystems 37 Chronic Care Model 37

CHAPTER 4 Leading, Managing, Following 40 Learning Outcomes 40



CONTEMPORARY THEORIES 42 Quantum Leadership 42 Transactional Leadership 42 Transformational Leadership 43 Shared Leadership 43 Servant Leadership 44 Emotional Leadership 44


Planning 46 Organizing 46 Directing 47 Controlling 47

NURSE MANAGERS IN PRACTICE 47 Nurse Manager Competencies 47 Staff Nurse 48 First-Level Management 48 Charge Nurse 49 Clinical Nurse Leader 50


CHAPTER 5 Initiating and Managing Change 55 Learning Outcomes 55


Assessment 58 Planning 60 Implementation 60 Evaluation 61

CHANGE STRATEGIES 61 Power-Coercive Strategies 61 Empirical–Rational Model 62 Normative–Reeducative Strategies 62


Initiating Change 64 Implementing Change 65


CHAPTER 6 Managing and Improving Quality 69 Learning Outcomes 69

QUALITY MANAGEMENT 70 Total Quality Management 70 Continuous Quality Improvement 71 Components of Quality Management 72 Six Sigma 73 Lean Six Sigma 73 DMAIC Method 74

IMPROVING THE QUALITY OF CARE 74 National Initiatives 74 How Cost Affects Quality 75 Evidence-Based Practice 75 Electronic Medical Records 75 Dashboards 76 Nurse Staffing 76 Reducing Medication Errors 76 Peer Review 76

RISK MANAGEMENT 77 Nursing’s Role in Risk Management 77 Incident Reports 78 Examples of Risk 78 Root Cause Analysis 80 Role of the Nurse Manager 80 Creating a Blame-Free Environment 81

CHAPTER 7 Understanding Power and Politics 86 Learning Outcomes 86


Image as Power 89 Using Power Appropriately 91


Nursing’s Political History 93 Using Political Skills to Influence Policies 93 Influencing Public Policies 94


PART 2 Learning Key Skills in Nursing Management 99

CHAPTER 8 Thinking Critically, Making Decisions, Solving Problems 99 Learning Outcomes 99

CRITICAL THINKING 100 Critical Thinking in Nursing 100 Using Critical Thinking 101 Creativity 101

DECISION MAKING 103 Types of Decisions 104 Decision-Making Conditions 104 The Decision-Making Process 106


Decision-Making Techniques 107 Group Decision Making 108

PROBLEM SOLVING 109 Problem-Solving Methods 109 The Problem-Solving Process 110 Group Problem Solving 112


CHAPTER 9 Communicating Effectively 117 Learning Outcomes 117

COMMUNICATION 118 Modes of Communication 118 Distorted Communication 118 Directions of Communication 120 Effective Listening 120


Gender Differences in Communication 121 Generational and Cultural Differences in Communication 121 Differences in Organizational Culture 122


Employees 123 Administrators 123 Coworkers 125 Medical Staff 125 Other Health Care Personnel 126 Patients and Families 126


CHAPTER 10 Delegating Successfully 131 Learning Outcomes 131


Benefits to the Nurse 132 Benefits to the Delegate 133 Benefits to the Manager 133 Benefits to the Organization 133

THE FIVE RIGHTS OF DELEGATION 133 The Delegation Process 134


Organizational Culture 138 Lack of Resources 138 An Insecure Delegator 138 An Unwilling Delegate 139 Underdelegation 140

Reverse Delegation 140 Overdelegation 140

CHAPTER 11 Building and Managing Teams 143 Learning Outcomes 143


Norms 147 Roles 148

BUILDING TEAMS 149 Assessment 149 Team-Building Activities 150

MANAGING TEAMS 150 Task 151 Group Size and Composition 151 Productivity and Cohesiveness 151 Development and Growth 152 Shared Governance 152


Communication 153 Evaluating Team Performance 153


Guidelines for Conducting Meetings 155 Managing Task Forces 156



Antecedent Conditions 163 Perceived and Felt Conflict 164 Conflict Behaviors 165 Conflict Resolved or Suppressed 165 Outcomes 165

MANAGING CONFLICT 165 Conflict Responses 166 Filley’s Strategies 168 Alternative Dispute Strategies 169

CHAPTER 13 Managing Time 172 Learning Outcomes 172

TIME WASTERS 173 Time Analysis 174 The Manager’s Time 175

SETTING GOALS 175 Determining Priorities 176 Daily Planning and Scheduling 176


Grouping Activities and Minimizing Routine Work 177 Personal Organization and Self-Discipline 177

CONTROLLING INTERRUPTIONS 178 Phone Calls, Voice Mail, Text Messages 179 E-Mail 180 Drop-In Visitors 181 Paperwork 181


PART 3 Managing Resources 184

CHAPTER 14 Budgeting and Managing Fiscal Resources 184 Learning Outcomes 184


Incremental Budget 186 Zero-Based Budget 187 Fixed or Variable Budgets 187

THE OPERATING BUDGET 187 The Revenue Budget 187 The Expense Budget 188


Benefits 189 Shift Differentials 190 Overtime 190 On-Call Hours 190 Premiums 190 Salary Increases 191 Additional Considerations 191


Variance Analysis 193 Position Control 195


Reimbursement Problems 195 Staff Impact on Budget 196

CHAPTER 15 Recruiting and Selecting Staff 199 Learning Outcomes 199


RECRUITING APPLICANTS 200 Where to Look 201 How to Look 202 When to Look 202 How to Promote the Organization 202 Cross-Training as a Recruitment Strategy 203


Principles for Effective Interviewing 205 Involving Staff in the Interview Process 209 Interview Reliability and Validity 209

MAKING A HIRE DECISION 210 Education, Experience, and Licensure 210 Integrating the Information 210 Making an Offer 211


CHAPTER 16 Staffing and Scheduling 217 Learning Outcomes 217

STAFFING 218 Patient Classification Systems 218 Determining Nursing Care Hours 219 Determining FTEs 219 Determining Staffing Mix 220 Determining Distribution of Staff 220

SCHEDULING 221 Creative and Flexible Staffing 221 Automated Scheduling 222 Supplementing Staff 223

CHAPTER 17 Motivating and Developing Staff 227 Learning Outcomes 227 A MODEL OF JOB PERFORMANCE 228

Employee Motivation 229 Motivational Theories 229


Orientation 231 On-the-Job Instruction 232 Preceptors 233 Mentoring 233 Coaching 234 Nurse Residency Programs 234 Career Advancement 234 Leadership Development 235



CHAPTER 18 Evaluating Staff Performance 239 Learning Outcomes 239

THE PERFORMANCE APPRAISAL 240 Evaluation Systems 241 Evidence of Performance 244 Evaluating Skill Competency 247 Diagnosing Performance Problems 247 The Performance Appraisal Interview 248

POTENTIAL APPRAISAL PROBLEMS 251 Leniency Error 251 Recency Error 251 Halo Error 252 Ambiguous Evaluation Standards 252 Written Comments Problem 252

IMPROVING APPRAISAL ACCURACY 253 Appraiser Ability 253 Appraiser Motivation 253


CHAPTER 19 Coaching, Disciplining, and Terminating Staff 257 Learning Outcomes 257


CHAPTER 20 Managing Absenteeism, Reducing Turnover, Retaining Staff 268 Learning Outcomes 268 ABSENTEEISM 269

A Model of Employee Attendance 269 Managing Employee Absenteeism 272 Absenteeism Policies 273 Selecting Employees and Monitoring Absenteeism 274 Family and Medical Leave 274

REDUCING TURNOVER 275 Cost of Nursing Turnover 275 Causes of Turnover 276 Understanding Voluntary Turnover 276

RETAINING STAFF 277 Employee Engagement 277 Healthy Work Environment 277 Improving Salaries 277 Recognizing Staff Performance 278 Additional Retention Strategies 279

CHAPTER 21 Dealing with Disruptive Staff Problems 283 Learning Outcomes 283

HARASSING BEHAVIORS 284 Bullying 284 Lack of Civility 284 Lateral Violence 285

HOW TO HANDLE PROBLEM BEHAVIORS 286 Marginal Employees 286 Disgruntled Employees 287


State Board of Nursing 289 Strategies for Intervention 289 Reentry 290 The Americans with Disabilities Act and Substance Abuse 291

CHAPTER 22 Preparing for Emergencies 294 Learning Outcomes 294


Natural Disasters 295 Man-Made Disasters 295 Levels of Disasters 295


Emergency Operations Plan 296 Disaster Triage 297 Core Competencies for Nurses 297 Continuation of Services 297 Impact on Employees 298

CHAPTER 23 Preventing Workplace Violence 302 Learning Outcomes 302

VIOLENCE IN HEALTH CARE 303 Incidence of Workplace Violence 303 Consequences of Workplace Violence 303 Factors Contributing to Violence in Health Care 303

PREVENTING VIOLENCE 304 Zero-Tolerance Policies 304 Reporting and Education 304 Environmental Controls 304

DEALING WITH VIOLENCE 305 Verbal Intervention 305 A Violent Incident 305 Other Dangerous Incidents 306 Post-Incident Follow-Up 306


CHAPTER 24 Handling Collective Bargaining Issues 310 Learning Outcomes 310


The Grievance Process 312 The Nurse Manager’s Role 312


Legal Status of Nursing Unions 313 The Future of Collective Bargaining for Nurses 314

PART 4 Taking Care of Yourself 316

CHAPTER 25 Managing Stress 316 Learning Outcomes 316


Organizational Factors 318 Interpersonal Factors 318 Individual Factors 319


Personal Methods 320 Organizational Methods 321

CHAPTER 26 Advancing Your Career 325 Learning Outcomes 325


Applying for the Position 327 The Interview 328 Accepting the Position 331 Declining the Position 331

BUILDING A RÉSUMÉ 331 Tracking Your Progress 333 Identifying Your Learning Needs 334


Finding Your Next Position 337 Leaving Your Present Position 337

WHEN YOUR PLANS FAIL 337 Taking the Wrong Job 337 Adapting to Change 338

Glossary 340 Index 348


Changes in Health Care












Cultural, Gender, and Generational Differences

Violence Prevention and Disaster Preparedness

Changes in Nursing’s Future EVEN MORE CHANGE . . .


Introducing Nursing Management 1

1. Describe the forces that are changing the health care system.

2. Discuss changes in paying for health care. 3. Explain how quality initiatives can reduce

medical errors. 4. Describe how evidence-based practice is

changing nursing. 5. Explain how to become a Magnet-certified


6. Explain what emerging technologies mean for nursing.

7. Describe how cultural, gender, and genera- tional differences affect management.

8. Explain why preparation is the best defense against violence and disasters.

9. Discuss the changes and challenges that nurses face now and into the future.

Learning Outcomes After completing this chapter, you will be able to:

Key Terms Benchmarking Electronic health records

(EHRs) Evidence-based practice Leapfrog Group

Magnet Recognition Program®

Patient Protection and Affordable Care Act (PPACA)

Quality initiatives Robotics Social media Virtual care


T oday, all nurses are managers. Whether you work in a freestanding clinic, an ambula-tory surgical center, a critical unit in an acute care hospital, or in hospice care for a home care agency, you must deal with staff, including other nurses and unlicensed as- sistive personnel, who work with you and for you. At the same time, you must be vigilant about costs. To manage well, you must understand the health care system and the organizations where you work. You need to recognize what external forces affect your work and how to influence those forces. You need to know what motivates people and how you can help create an environ- ment that inspires and sustains the individuals who work in it. You must be able to collaborate with others, as a leader, a follower, and a team member, in order to become confident in your ability to be a leader and a manager.

This book is designed to provide new graduates or novice managers with the information they need to become effective managers and leaders in health care. More than ever before, today’s rapidly changing health care environment demands highly refined management skills and superb leadership.

Changes in Health Care Today’s health care system is continuing to undergo significant changes. Costly lifesaving medi- cines, robotics, virtual care, and innovations in imaging technologies, noninvasive treatments, and surgical procedures have combined to produce the most sophisticated and effective health care ever—and the most expensive. Skyrocketing costs and inaccessibility to health care are ongoing concerns for employers, health care providers, policy makers, and the public at large. A number of factors are forcing change on the health care system.

Paying for Health Care

How America Pays for Health Care The United States spends more money on health care than any other country, and health care spending continues to rise with costs of $2.5 trillion in 2009, consuming more than 17 percent of the country’s gross domestic product (GDP) (CMS, 2011). With the goal of providing access to health care to most U.S. citizens and containing costs, Congress passed a health care reform bill known as the Patient Protection and Affordable Care Act (PPACA) that was signed into law March 23, 2010. While implementation of the bill is pending court challenges, the promise of providing adequate and affordable care to more Americans is on the horizon.

Pay for Performance In 1999, the Institute of Medicine (IOM, 1999) reported that 98,000 deaths occurred each year from preventable medical mistakes, such as falls, wrong site surgeries, avoidable infections, and pressure ulcers, among others. By 2008, researchers learned that “the effects of medical mistakes continue long after the patient leaves the hospital” (Encinosa & Hellinger, 2008, p. 2067). In spite of numerous efforts to prevent mistakes, the cost of medical errors has con- tinued to climb. Recent estimates put such costs at $19.5 billion annually (Shreve et al., 2010).

In 2008, the Centers for Medicare and Medicaid Services, the agency that oversees gov- ernment payments for care, tied payment to the quality of care by changing its reimbursement policy to no longer cover costs incurred by medical mistakes (Wachter, Foster, & Dudley, 2008). If medical mistakes occur, the hospital must absorb the costs. Thus, pay for performance became the norm, and performance is now measured by the quality of care (Milstein, 2009).

Demand for Quality

Quality Initiatives In an effort to ameliorate medical mistakes, a number of quality initiatives have emerged. Quality management is a preventive approach designed to address problems before they become crises. The quality movement actually began in post–World War II Japan, when Japanese industries adopted a


system that W. Edwards Deming designed to improve the quality of manufactured products. The philosophy of the system is that consumers’ needs should be the focus and that employees should be empowered to evaluate and improve quality. In addition to businesses in the United States and else- where, the health care industry has adopted total quality management or variations on it.

Built into the system is a mechanism for continuous improvement of products and services through constant evaluation of how well consumers’ needs are met and plans adjusted to per- fect the process. Patient satisfaction surveys are one example of how health care organizations evaluate their customers’ needs. Today, quality initiatives address all aspects of patient care and include government efforts as well as private sector endeavors.

Public reporting of heath care organizations has emerged as a strategy to improve quality (Christianson et al., 2010). To further that goal, the Agency for Healthcare Research and Quality (AHRQ)—whose mission is to improve the quality, safety, efficiency, and effectiveness of health care—funds projects that address three quality indicators: prevention, inpatient, quality, and patient safety (Dunton et al., 2011).

The Leapfrog Group Efforts by the Leapfrog Group constitute one private sector initiative to address quality. The Leapfrog Group is a consortium of public and private purchasers established to reduce prevent- able medical mistakes. The organization uses its mammoth purchasing power to leverage quality care for its consumers by rewarding health care organizations that demonstrate quality outcome measures. The quality indicators the group focuses on include ICU staffing, electronic medi- cation ordering systems, and the use of higher performing hospitals for high-risk procedures. Leapfrog estimates that if these three patient safety practices were implemented, more than 57,000 lives could be saved, more than $12 billion dollars could be saved, and more than 3 mil- lion adverse drug events could be avoided (Binder, 2010).

Benchmarking In contrast to quality management strategies that compare internal measures across comparable units, such as the Leapfrog Group, benchmarking compares an organization’s data with similar organizations. Outcome indicators are identified that can be used to compare performance across disciplines or organizations. Once the results are known, health care organizations can address areas of weakness and enhance areas of strength (Nolte, 2011). Interestingly, one study found that hospital size didn’t affect the ability of institutions to compare results (Brown et al., 2010).

Evidence-Based Practice Evidence-based practice has emerged as a strategy to improve quality by using the best avail- able knowledge integrated with clinical experience and the patient’s values and preferences to provide care (Houser & Oman, 2010).

Similar to the nursing process, the steps in EBP are:

1. Identify the clinical question.

2. Acquire the evidence to answer the question.

3. Evaluate the evidence.

4. Apply the evidence.

5. Assess the outcome.

Research findings with conflicting results puzzle consumers daily, and nurses are no excep- tion, especially when they search for practice evidence. Hader (2010) suggests that evidence falls into several categories:

● Anecdotal—derived from experience ● Testimonial—reported by an expert in the field


● Statistical—built from a scientific approach ● Case study—an in-depth analysis used to translate to other clinical situations ● Nonexperimental design research—gathering factors related to a clinical condition ● Quasi-experimental design research—a study limited to one group of subjects ● Randomized control trial—uses both experimental and control groups to determine the

effectiveness of an intervention

While all forms of evidence are useful for clinical decision making, a randomized control design and statistical evidence are the most rigorous (Hader, 2010).

Magnet® Certification The Magnet Recognition Program® designates organizations that “recognize health care orga- nizations that provide nursing excellence” (ANCC, 2011). To qualify for recognition as a mag- net hospital the organization must demonstrate that they are:

● Promoting quality in a setting that supports professional practice ● Identifying excellence in the delivery of nursing services to patients/residents ● Disseminating “best practices” in nursing services.

Becoming a magnet hospital requires a significant investment of time and financial resources. Research shows, however, that patient safety is improved when nurse staffing meets Magnet standards (Lake et al., 2010).

Systems involving participatory management and shared governance create organizational environments that reward decision making, creativity, independence, and autonomy. These orga- nizations retain and recruit independent, accountable professionals. Organizations that empower nurses to make decisions will better meet consumer requests. As the health care environment continues to evolve, more and more organizations are adopting consumer-sensitive cultures that require accountability and decision making from nurses.

Magnet hospitals are those institutions that have met the stringent guidelines for nurses and are credentialed by the American Nurses Credentialing Center. Characteristics common in mag-

net hospitals include:

● Higher ratios of nurses to patients ● Flexible schedules ● Decentralized administration ● Participatory management ● Autonomy in decision making ● Recognition ● Advancement opportunities

To retain the current workforce and attract other nurses, health care organizations can take from the magnet program characteristics to improve work-life conditions for nurses. Encourag- ing nurses to be full participants and to share a vested interest in the success of the organization can help alleviate the nursing shortage in those organizations and in the profession.

See Chapter 6 , Managing and Improving Quality, to learn more about improving quality in health care.

Evolving Technology Rapid changes in technology seem, at times, to overwhelm us. Hospital information systems (HIS); electronic health records (EHR); point-of-care data entry (POC); provider order entry; bar-code medication administration; dashboards to manage, report, and compare data across plat- forms; virtual care provided from a distance; and robotics—to name a few of the many evolving technologies—both fascinate and frighten us simultaneously. At the same time, communication


technology—from smartphones to social media—continues to march into the future. It is no wonder that people who work in health care complain that they can’t keep up! The rapidity of technological change promises, unfortunately, to continue unabated.

Electronic Health Records Electronic health records (EHRs) represent a technology destined for rapid expansion. While banks, retailers, airlines, and other industries began to rely on fully integrated systems to man- age communication and reduce redundancies, health care was still continuing to rely on volu- minous paper records duplicated in multiple locations. Keeping data safe continues to worry health care organizations, consumers, and policy makers, but the benefits of integrated systems outweigh the risks (Trossman, 2009a).

EHRs reduce redundancies, improve efficiency, decrease medical errors, and lower health care costs. Continuity of care, discharge planning and follow-up, ambulatory care collaboration, and patient safety are just a few of the additional advantages of EHRs. Furthermore, fully integrated systems allow for collective data analysis across clinical conditions, health care organizations, or worldwide and sup- port evidence-based decision making. With the federal government funding health systems to upgrade to EHRs, the current 12 percent of hospitals with EHRs is expected to increase (Gomez, 2010).

Virtual Care Virtual care, previously known as telemedicine and now more commonly called telehealth, has evolved as technologies to assess, intervene, and monitor patients remotely improved. Both communication technology (i.e., audio and video) and improvements in mobile care technology contribute to the ability of health care professionals to provide care from a distance. Nurses, for example, can watch banks of video screens monitoring ICU patients’ vitals signs miles away from the hospital. Electronic equipment, such as a stethoscope, can be accessed by a health care provider in a distant location. Such systems are especially useful in providing expert consulta- tion for specialty care (Zapatochny-Rufo, 2010).

Robotics Another technological advance is robotics. In the hospital, supplies can be ordered electroni- cally, and then laser-guided robots can fill the order in the pharmacy or central supply and de- liver the requested supplies to nursing units via their own elevators more efficiently, accurately, and in less time than individuals can. Mobile robots can also monitor patients, report changes and conditions, and allow caregivers to communicate from a distance (Markoff, 2010) via a wireless connection to a laptop or a smart phone. Robot functionality will continue to expand, limited only by resources and ingenuity.

Communication Technology Just as rapidly as clinical and data technology are evolving, so are communication technolo- gies, changing forever the ways people keep informed and interact (Sullivan, 2013). Informa- tion (accurate or inaccurate) is disseminated with lightening speed while smartphones capture real-time events and broadcast images instantaneously.

Social media has revolutionized communication beyond the realm of possibilities from just a few years ago (Kaplan & Haenlein, 2010). Social media connects diverse populations and en- courages collaboration, the exchange of images, ideas, opinions, and preferences in networking Web sites, online forums, Web blogs, social blogs, wikis, podcasts, RSS feeds, photos, video content communities, social bookmarking, online chat rooms, microblogs, such as Twitter, and online communities, such as Facebook and LinkedIn (Sullivan, 2013).

Similar to other enterprises, most health care organizations have an online presence with a Web site and social media sites, such as Facebook, Twitter, and blogs. Units within the organiza- tion may have Facebook pages as well, with staff who post on those sites. These opportunities


for information sharing and relationship building also come with risks (Raso, 2010; Trossman, 2010b). Patient confidentiality, the organization’s reputation, and recruiting efforts can be en- hanced or put in jeopardy by posts to the site (Sullivan, 2013).

Cultural, Gender, and Generational Differences According to the U.S. Census Bureau, the minority population in the U.S. increased from 31 to 36 percent from 2000 to 2010 (U.S. Census, 2011). The largest minority population is Hispanic, and that population increased to 50 million (16 percent of the total U.S. population) in 2010. The Asian population grew to 14 million (5 percent) in the same time period, and the African American population stands at 42 million (14 percent).

The cultural diversity seen in the general population is also reflected in nursing. The Health Resources and Services Administration (HRSA, 2011) reports that 16 percent of nurses are Asian, African American, Hispanic, or other ethnic minorities, an increase from 12 percent in 2004.

The gender mix found in nursing, however, differs from the general population, with men greatly outnumbered by women. Of the population of more than 3 million nurses in the U.S., only 6 percent are men, although changes suggest the ratio is improving. The proportion of men to women has risen to 1 in 10 in the decades since 1990 (HRSA, 2011). Both cultural diversity and gender diversity challenge the nurse manager to consider such differences when working with staff, colleagues, and administrators as well as mediating conflicts between individuals.

Generational differences in the nursing population is unprecedented, with four generational cohorts working together (Keepnews et al., 2010). Referred to as traditionals, baby boomers, Generation X, and Generation Y, each generational group has different expectations in the work- place. Traditionals value loyalty and respect authority. Baby boomers value professional and personal growth and expect that their work will make a difference.

Generation X members strive to balance work with family life and believe that they are not rewarded given their responsibilities (Keepnews et al., 2010). Generation Y (also called milleni- als) are technically savvy and expect immediate access to information electronically.

Similar to dealing with cultural and gender differences, the challenge for managers is to avoid stereotyping within the generations, to value the unique contributions of each generation, to encourage mutual respect for differences, and to leverage these differences to enhance team work (Chambers, 2010).

Violence Prevention and Disaster Preparedness Sadly, violence invades workplaces, and health care is no exception. Moreover, nearly 500,000 nurses are victims of workplace violence (Trossman, 2010c). In addition, recent disasters (e. g., the earthquake and tsunami in Japan, tornadoes in the U.S.) and the threats of terrorism and pan- demics challenge health care organizations to prepare for the unthinkable.

Extensive staff training is required (AHRQ, 2011). Techniques include computer simula- tions, video demonstrations, disaster drills, and a clear understanding of communication sys- tems and the incident command center. A natural disaster, an attack of terrorism, an epidemic, or other mass casualty events may, and probably will, occur at some time. All health care organizations must be prepared to care for a surge in casualties while reducing the impact on patients and staff.

Changes in Nursing’s Future Nurses will face many changes in the future, including an increasing demand for nurses as the population ages, a worsening shortage as nurses age, and recommendations for changes to prac- tice and education. The aging population is surviving previously fatal diseases and conditions


due to ever-evolving health care technologies. These patients often require ongoing care for chronic illnesses as well as for acute episodes of illness.

Just as the population is aging and requiring more and more care, nurses too are growing older. The average age of the registered nurse is 46 years, although the number of RNs under age 30 is increasing at a faster pace than before (HRSA, 2011).

Slightly more than 3 million nurses are currently licensed as registered nurses in the U.S., and 85 percent of them practice full- or part-time in the profession (HRSA, 2011). Jobs for nurses, however, are expected to grow to 3.2 million by 2018, much faster than the average for all occupations (U.S. Department of Labor, 2011). Also, with implementation of health care reform, increases in the demand for nurses in primary care and acute care settings are expected.

The Institute of Medicine’s report on the future of nursing makes sweeping recommenda- tions for nursing’s future, including that “nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States” (IOM, 2010, p. 3). In addition, IOM posits that today’s health care environment necessitates better-educated nurses and recommends that 80 percent of nurses be prepared at the baccaluareate or higher level by 2020.

At the same time, the Carnegie Foundation recommends radically transforming nursing education (Benner et al., 2009). Its recommendations include:

1. Focus on how to apply knowledge, not only acquire it.

2. Integrate clinical and classroom teaching, rather than separately.

3. Emphasize clinical reasoning, not only critical thinking.

4. Emphasize formation, rather than socialization and role taking (Benner et al., 2009).

Even More Change . . . What does the future hold for health care? Change is the one constant. Quality of care will continue to be monitored and reported with accompanying demands to tie pay to performance. Technology of care, communication, and data management will become more and more com- plex as computer processing power and storage capacity expand (Clancy, 2010) and equipment becomes smaller and more mobile. Access to care and how to pay for it will continue to drive policy and funding decisions. Everyone in health care must learn to live with ambiguity and be flexible enough to adapt to the changes it brings.

Challenges Facing Nurses and Managers Every nurse must be prepared to manage. Specific training in management skills is needed in nursing school as well as in the work setting. Most important, however, is that nurses be able to transfer their newly acquired skills to the job itself. Thus, nurse managers must be experienced in management themselves and be able to assist their staff in developing adequate management skills. Management training for nurses at all levels is essential for any organization to be effi- cient and effective in today’s cost-conscious and competitive environment.

The challenge for nurse managers and administrators is how to manage in a constantly changing system. Working with teams of administrators and providers to deliver quality health care in the most cost-effective manner offers opportunity as well. Nurses’ unique skills in communication, negotiation, and collaboration position them well for the system of today and for the future.

Nurse managers today are challenged to monitor and improve quality care, manage with limited resources, help design new systems of care, supervise teams of professionals and nonprofessionals from a variety of cultures, and, finally, teach personnel how to function well in


the new system. This is no small task. It requires that nurses and their managers be committed, involved, enthusiastic, flexible, and innovative; above all else, it requires that they have good mental and physical health. Because the nurse manager of today is responsible for others’ work, the nurse manager must also be a coach, a teacher, and a facilitator. The manager works through others to meet the goals of individuals, of the unit, and of the organization. Most of all, the man- ager must be a leader who can motivate and inspire.

Nurse managers must address the interests of administrators, colleagues in other disciplines, and employees. All want the same result—quality care. Administrators, however, must focus on cost and efficiency in order for the organization to compete and survive. Colleagues want col- laborative and efficient systems of care. Employees want to be supported in their work with ad- equate staffing, supplies, equipment, and, most of all, time. Therein lies the conflict. Between all of them is the nurse manager, who must balance the needs of all. Being a nurse manager today is the most challenging opportunity in health care. This book is designed to prepare you to meet these challenges.

What You Know Now • Health care is radically changing and is expected to continue to change in the foreseeable future. • The tension between providing adequate nursing care and paying for that care will continue to dominate

health policy decisions. • Reducing medical errors is the goal of quality initiatives. • Cultural, gender, and generational diversity will continue to shape the nursing workforce. • Evidence-based practice will guide nursing decisions into the future. • Electronic health records, robotics, and virtual care are just a few of the many technologies continuing to

evolve. • Expansion in communication technologies will continue to offer opportunities and challenges to health

care organizations. • Threats of natural disasters, terrorism, and pandemics require all health care organizations to plan and

prepare for mass casualties. • The nurse manager is challenged to manage in a constantly changing environment.

Questions to Challenge You 1. Name three changes that you would suggest to reduce the cost of health care without compromising

patients’ health and safety. Talk about how you could help make these changes. 2. What mechanisms could you suggest to improve and ensure the quality of care? (Don’t just suggest

adding nursing staff!) 3. How could you help reduce medical errors? What can you suggest that a health care organization

could do? 4. Do your clinical decisions rely on evidence-based practice? If you answer no, why not? 5. What are some ways that nurses could take advantage of emerging technologies in health care and

information systems? Think big. 6. Have you participated in a disaster drill? Did you notice ways to improve the organization’s readi-

ness for mass casualties? Name at least one. 7. What steps can you take to transfer the knowledge and skills you learn in this book into your work



Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

Agency for Healthcare Research and Quality. (2011). AHRQ disaster response tools and resources. Retrieved May 25, 2011 from http://www.ahrq. gov/research/altstand

American Nurses Credential- ing Center (2011). Magnet Recognition Program. Retrieved April 27, 2011 from http://www. nursecredentialing.org/ Magnet.aspx

Benner, P., Sutphen, M., Leonard, V., and Day, L. (2009). Educating nurses: A call for radical trans- formation. San Francisco: Jossey-Bass.

Binder, L. (2010). Leapfrog: Unique and salient mea- sures of hospital quality and safety. Prescriptions for Excellence in Health Care, 8, 1–2.

Brown, D. S., Aydin, C. E., Donaldson, N., Fridman, M., & Sandhu, M. (2010). Benchmarking for small hospitals: Size didn’t mat- ter! Journal of Healthcare Quality, 32(4), 50–60.

Centers for Medicare and Medic- aid Services (CMS) (2011). National health expenditure data. Retrieved April 25, 2011 from https://www. cms.gov/NationalHealth- ExpendData/25_NHE_Fact_ Sheet.asp

Chambers, P. D. (2010). Tap the unique strengths of the mil- lennial generation. Nursing

Management, 41(3), 37–39.

Christianson, J. B., Volmar, K. M., Alexander, J., & Scanlon, D. P. (2010). A report card on provider report cards: Current status of the health care transpar- ency movement. Journal of General Internal Medicine, 25(11), 1235–1241.

Clancy, T. R. (2010). Technology and complexity: Trouble brewing? Journal of Nurs- ing Administration, 40(6), 247–249.

Dunton, N., Gonnerman, D., Montalvo, I., & Schumann, M. J. (2011). Incorporating nursing quality indicators in public reporting and value- based purchasing initiatives. American Nurse Today, 6(1), 14–18.

Encinosa, W. E., & Hellinger, F. J. (2008). The impact of medical errors on ninety- day costs and outcomes: An examination of sur- gical patients. Health Services Research, 43(6), 2067–2085.

Hader, R. (2010). The evident that isn’t . . . interpreting research. Nursing Manage- ment, 41(9), 23–26.

Health Resources and Services Administration (HRSA) (2011). The registered nurse population: Findings from the 2008 national sample survey of registered nurses. Retrieved April 26, 2011

from http://bhpr.hrsa.gov/ healthworkforce/ rnsurvey2008.html

Houser, J., & Oman, K. S. (2010). Evidence-based practice: An implementa- tion guide for healthcare organizations. Sudbury, MA: Jones & Bartlett.

Gomez, R. (2010). Automation: HER upgrade consider- ations. Nursing Manage- ment, 41(2), 35–37.

Institute of Medicine (1999). To err is human: Build- ing a safer health system. Washington, DC: National Academy Press.

Institute of Medicine (2010). The future of nursing: Leading change, advancing health. Retrieved April 26, 2011 from http://www. thefutureofnursing.org/ IOM-Report

Kaplan, A. M., & Haenlein, M. (2010). Users of the world, unite! The challenges and opportunities of social media. Business Horizons, 53(1), 59–68.

Keepnews, D. M., Brewer, C. S., Kovner, C. T., & Shin, J. H. (2010). Genera- tional differences among newly licensed registered nurses. Nursing Outlook, 58(3), 155–163.

Lake, E. T., Shang, J., Klaus, S., & Dunton, N. E. (2010). Patient falls: Association with hospi- tal magnet status and nursing unit staffing. Research in



Nursing & Health, 33(5), 413–425.

Markoff, J. (2010, September 4). The boss is robotic, and rolling up behind you. New York Times. Retrieved April 28, 2011 from http://www.nytimes. com/2010/09/05/ science/05robots.html

Milstein, A. (2009). Encing extra payment for “never events”—Stronger incen- tives for patients’ safety. New England Journal of Medicine, 360(23), 2388–2390.

Nolte, E. (2011). International benchmarking of healthcare quality: A review of the literature. The Rand Corpo- ration. Retrieved April 26, 2011 from http://www.rand. org/pubs/technical_reports/ TR738.html

Raso, R. (2010). Social media for nurse managers: What does it all mean? Nursing Management, 41(8), 23–25.

Shreve, J., Van Den Bos, J., Gray, T., Halford, M., Rustagi, K., & Ziemkiewicz, E. (2010). The economic measurement of medical errors. Society of Actuaries. Retrieved April 28, 2011 from http:// www.soa.org/files/ pdf/research- econ-measurement.pdf

Sullivan, E. J. (2013). Becom- ing influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall Health.

Trossman, S. (2009a). Issues up close: No peeking allowed. American Nurse Today, 4(2), 31–32.

Trossman, S. (2010b). Sharing too much? Nurses nation- wide need more informa- tion on social networking pitfalls. American Nurse Today, 5(11), 38–39.

Trossman, S. (2010c, November/ December). Not “part of the job”: Nurses seek an end

to workplace violence. The American Nurse, p. 1, 6.

U.S. Census Bureau (2011, March 24). 2010 Census shows America’s diversity. Retrieved April 29, 2011 from http://2010.census. gov/news/releases/ operations/cb11-cn125.html

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Wachter, R. M., Foster, N. E., & Dudley, R. A. (2008). Medi- care’s decision to withhold payment for hospital errors: The devil is in the details. Joint Commission Journal on Quality and Patient Safety, 34(2), 116–123.

Zapatochny-Rufo, R. J. (2010). Good-better-best: The virtual ICU and beyond. Nursing Management, 41(2), 38–41.


Traditional Organizational Theories







Traditional Organizational Structures





Service-Line Structures

Shared Governance

Ownership of Health Care Organizations

Health Care Settings PRIMARY CARE




Complex Health Care Arrangements HEALTH CARE NETWORKS





Redesigning Health Care

Strategic Planning

Organizational Environment and Culture

Designing Organizations 2

1. Discuss how organizational theories differ.

2. Describe the different types of health care organizations.

3. Explain how health care organizations are structured.

4. Discuss various ways that health care is provided.

5. Demonstrate how strategic planning guides the organization’s future.

6. Discuss how the organizational environment and culture affect workplace conditions.

Learning Outcomes After completing this chapter, you will be able to:

Key Terms Accountable care organization Bureaucracy Capitation Chain of command Diversification Goals Hawthorne effect Horizontal integration Integrated health care networks Line authority

Logic model Medical home Mission Objectives Organization Organizational culture Organizational environment Philosophy Redesign Retail medicine

Service-line structures Shared governance Span of control Staff authority Strategic planning Strategies Throughput Values Vertical integration Vision statement


A n organization is a collection of people working together under a defined structure to achieve predetermined outcomes using financial, human, and material resources. The justification for developing organizations is both rational and economic. Coordinated efforts capture more information and knowledge, purchase more technology, and produce more goods, services, opportunities, and securities than individual efforts. This chapter discusses or- ganizational theory, structures, and functions.

Traditional Organizational Theories The earliest recorded example of organizational thinking comes from the ancient Sumerian civi- lization, around 5000 b.c. The early Egyptians, Babylonians, Greeks, and Romans also gave thought to how groups were organized. Later, Machiavelli in the 1500s and Adam Smith in 1776 established the management principles we know as specialization and division of labor. Never- theless, organizational theory remained largely unexplored until the Industrial Revolution during the late 1800s and early 1900s, when a number of approaches to the structure and management of organizations developed. The early philosophies are traditionally labeled classical theory and humanistic theory while later approaches include systems theory, contingency theory, chaos theory, and complexity theory.

Classical Theory The classical approach to organizations focuses almost exclusively on the structure of the formal organization. The main premise is efficiency through design. People are seen as operating most productively within a rational and well-defined task or organizational design. Therefore, one designs an organization by subdividing work, specifying tasks to be done, and only then fitting people into the plan. Classical theory is built around four elements: division and specialization of labor, organizational structure, chain of command, and span of control.

Division and Specialization of Labor Dividing the work reduces the number of tasks that each employee must carry out, thereby increasing efficiency and improving the organization’s product. This concept lends itself to proficiency and specialization. Therefore, division of work and specialization are seen as economically beneficial. In addition, managers can standardize the work to be done, which in turn provides greater control.

Organizational Structure Organizational structure describes the arrangement of the work group. It is a rational approach for designing an effective organization. Classical theorists developed the concept of departmentaliza- tion as a means to maintain command, reinforce authority, and provide a formal system for commu- nication. The design of the organization is intended to foster the organization’s survival and success.

Characteristically, the structure takes shape as a set of differentiated but interrelated func- tions. Max Weber (1958) proposed the term bureaucracy to define the ideal, intentionally ratio- nal, most efficient form of organization. Today this word has a negative connotation, suggesting long waits, inefficiency, and red tape.

Chain of Command The chain of command is the hierarchy of authority and responsibility within the organization. Authority is the right or power to direct activity, whereas responsibility is the obligation to attain objectives or perform certain functions. Both are derived from one’s position within the organi- zation and define accountability. The line of authority is such that higher levels of management delegate work to those below them in the organization.

One type of authority is line authority, the linear hierarchy through which activity is directed. Another type is staff authority, an advisory relationship; recommendations and advice


are offered, but responsibility for the work is assigned to others. In Figure 2-1, the relationships among the chief nurse executive, nurse manager, and staff nurse are examples of line authority. The relationship between the acute care nurse practitioner and the nurse manager illustrates staff authority. Neither the acute care nurse practitioner nor the nurse manager is responsible for the work of the other; instead, they collaborate to improve the efficiency and productivity of the unit for which the nurse manager is responsible.

Span of Control Span of control addresses the pragmatic concern of how many employees a manager can effec- tively supervise. Complex organizations usually have numerous departments that are highly spe- cialized and differentiated; authority is centralized, resulting in a tall organizational structure with many small work groups. Less complex organizations have flat structures; authority is decentral- ized, with several managers supervising large work groups. Figure 2-2 depicts the differences.

In the professional bureaucracy, the operating core of professionals is the dominant feature. Decision making is usually decentralized, and the technostructure is underdeveloped. The sup- port staff, however, is well developed. Most hospitals are professional bureaucracies.

Chief nurse executive

Staff nurse Staff nurse Staff nurse

Acute care nurse practitioner

Nurse manager

Nurse manager

Nurse manager

Figure 2-1 • Chain of authority.



Figure 2-2 • Contrasting spans of control. From Longest, B. B., Rakich, J. S., & Darr, K. (2000). Managing health services organizations and systems (4th ed.). Baltimore: Health Professions Press, p. 124. Reprinted by permission.


Organizational theories suggest organizational structures. Traditional structures (described later in the chapter) operationalize the tenets of classical theory.

Humanistic Theory Criticism of classical theory led to the development of humanistic theory, an approach identified with the human relations movement of the 1930s. A major assumption of this theory is that peo- ple desire social relationships, respond to group pressures, and search for personal fulfillment. This theory was developed as the result of a series of studies conducted by the Western Electric Company at its Hawthorne plant in Chicago. The first study was conducted to examine the effect of illumination on productivity. However, this study failed to find any relationship between the two. In most groups, productivity varied at random, and in one study productivity actually rose as illumination levels declined. The researchers concluded that unforeseen psychological factors were responsible for the findings.

Further studies of working conditions, such as rest breaks and the length of the workweek, still failed to reveal a relationship to productivity. The researchers concluded that the social set- ting created by the research itself—that is, the special attention given to workers as part of the research—enhanced productivity. This tendency for people to perform as expected because of special attention became known as the Hawthorne effect.

Although the findings are controversial, they led organizational theorists to focus on the so- cial aspects of work and organizational design. (See Chapter 17 for a description of motivational theories.) One important assertion of this school of thought was that individuals cannot be co- erced or bribed to do things they consider unreasonable; formal authority does not work without willing participants.

Systems Theory Organizational theorists who maintain a systems perspective view productivity as a function of the interplay among structure, people, technology, and environment. Like nursing theories based on systems theory (such as those of Roy and Neuman), organizational theory defines system as a set of interrelated parts arranged in a unified whole. Systems can be closed or open. Closed systems are self-contained and usually can be found only in the physical sciences. An open sys- tem, in contrast, interacts both internally and with its environment, much like a living organism.

An organization is a complex, sociotechnical, open system. This theory provides a frame- work by which the interrelated parts of the system and their functions can be studied. Resources, or input, such as employees, patients, materials, money, and equipment, are imported from the environment. Within the organization, energy and resources are utilized and transformed; work, a process called throughput, is performed to produce a product. The product, or output, is then exported to the environment. An organization, then, is a recurrent cycle of input, throughput, and output. Each health care organization—whether a hospital, ambulatory surgical center, or a home care agency, and so on—requires human, financial, and material resources. Each also provides a variety of services to treat illness, restore function, provide rehabilitation, and protect or promote wellness.

Throughput today is commonly associated with moving patients into and out of the sys- tem. Hospitals everywhere are focused on throughput of patients, such as if emergency depart- ments are on diversion, how long a patient has to wait for a bed, and the number of readmissions (Handel et al., 2010). Using information technology, bed management systems have emerged as a strategy to identify bed availability in real time (Gamble, 2009). Joint Commission accreditation standards now require hospitals to show data “throughput” statistics (Joint Commission, 2011).

Contingency Theory Contingency theory posits that organizational performance can be enhanced by matching an organization’s structure to its environment. The environment is defined as the people, objects,


and ideas outside the organization that influence the organization. The environment of a health care organization includes patients and potential patients; third-party payers, including the gov- ernment; regulators; competitors; and suppliers of physical facilities, personnel (such as schools of nursing and medicine), equipment, and pharmaceuticals.

Health care organizations are unique with respect to the kinds of products and services they offer. However, like all other organizations, health care organizations are shaped by external and internal forces. These forces stem from the economic and social environment, the technologies used in patient care, organizational size, and the abilities and limitations of the personnel involved in the delivery of health care, including nurses, physicians, technicians, administrators, and, of course, patients.

Given the variety of health care services and patients served today, it should come as no sur- prise that organizations differ with respect to the environments they face, the levels of training and skills of their caregivers, and the emotional and physical needs of patients. It is naive to think that the form of organization best for one type of patient in one type of environment is appropriate for another type of patient in a completely different environment. Think about the differences in the environment of a substance abuse treatment center compared to a women’s health clinic. Thus, the optimal form of the organization is contingent on the circumstances faced by that organization.

Chaos Theory Chaos theory, which was inspired by the finding of quantum mechanics, challenges us to look at organizations and the nature of relationships and proposes that nature’s work does not follow a straight line. The elements of nature often move in a circular, ebbing fashion; a stream destined for the ocean, for example, never takes a straight path. In fact, very little in life operates as a straight line; people’s relationships to each other and to their work certainly do not. This notion challenges traditional thinking regarding the design of organizations. Organizations are living, self-organizing systems that are complex and self-adaptive.

The life cycle of an organization is fully dependent on its adaptability and response to changes in its environment. The tendency is for the organization to grow. When it becomes a large entity, it tends to stabilize and develop more formal standards. From that point, however, the organization tends to lose its adaptability and responsiveness to its environment.

Chaos theory suggests that the drive to create permanent organizational structures is doomed to fail. The set of rules that guided the industrial notions of organizational function and integrity must be discarded, and newer principles that ensure flexibility, fluidity, speed of adaptability, and cultural sensitivity must emerge. The role of leadership in these changing organizations is to build resilience in the midst of change and to maintain a balance between tension and order, which promotes creativity and prevents instability. This theory requires us to abandon our at- tachment to any particular model of design and to reflect instead on creative and flexible formats that can be quickly adjusted and changed as the organization’s realities shift.

Complexity Theory Complexity theory originated in the computational sciences when scientists noted that random events interfered with expectations. The theory is useful in health care because the environment is rife with randomness and complex tasks. Patients’ conditions change in an instant; necessary staff are not available; or equipment fails, all without warning. Tasks involve intricate interactions between and among staff, patients, and the environment. Managing in such ambiguous circumstances requires considering every aspect of the system as it interacts and adapts to changes. Complexity theory ex- plains why health care organizations, in spite of concerted efforts, struggle with patient safety.

Traditional Organizational Structures The optimal organizational structure integrates organizational goals, size, technology, and envi- ronment. Various organizational structures have been utilized over time. Examples include func- tional structures, hybrid structures, matrix structures, and parallel structures.


Functional Structure In functional structures, employees are grouped in departments by specialty, with similar tasks being performed by the same group, similar groups operating out of the same depart- ment, and similar departments reporting to the same manager. In a functional structure, all nursing tasks fall under nursing service; the same is true of other functional areas. Functional structures tend to centralize decision making because the functions converge at the top of the organization.

Functional structures have several weaknesses. Coordination across functions is poor. Decision-making responsibilities can pile up at the top and overload senior managers, who may be uninformed regarding day-to-day operations. Responses to the external environment that re- quire coordination across functions are slow. General management training is limited because most employees move up the organization within functional departments. Functional structures are uncommon in today’s rapidly changing health care environment.

Hybrid Structure When an organization grows, it typically organizes both self-contained units and functional units; the result is a hybrid organization. The hybrid structure can provide simultaneous coordi- nation within product divisions, can improve alignment between corporate and service or prod- uct goals, and foster adaptation to the environment while still maintaining efficiency.

The weakness of hybrid structures is conflict between top administration and managers. Managers often resent administrators’ intrusions into what they see as their own area of respon- sibility. Over time, organizations tend to accumulate large corporate staffs to oversee divisions in an attempt to provide functional coordination across service or product structures.

Matrix Structure The matrix structure is unique and complex; it integrates both product and functional structures into one overlapping structure. In a matrix structure, different managers are responsible for func- tion and product. For example, the nurse manager for the oncology clinic may report to the vice president for nursing as well as the vice president for outpatient services.

Matrices tend to develop where there are strong outside pressures for a dual organizational focus on product and function. The matrix is appropriate in a highly uncertain environment that changes frequently but also requires organizational expertise.

A major weakness of the matrix structure is its dual authority, which can be frustrating and confusing for departmental managers and employees. Excellent interpersonal skills are required from the managers involved. A matrix organization is time-consuming because frequent meetings are required to resolve problems and conflicts; the structure will not work unless participants can see beyond their own functional area to the big organizational picture. Finally, if one side of the matrix is more closely aligned with organizational objectives, that side may become dominant.

Parallel Structure Parallel structure is a structure unique to health care. It is the result of complex relationships that exist between the formal authority of the health care organization and the authority of its medi- cal staff. In a parallel structure, the medical staff is separate and autonomous from the organiza- tion. The result is an organizational dilemma: two lines of authority. One line extends from the governing body to the chief executive officer and then to the managerial structure; the other line extends from the governing body to the medical staff. These two intersect in departments such as nursing because decision making involves both managerial and clinical elements.

Parallel structures are found in health care institutions with a functional structure and sepa- rate medical governance structure. Parallel structures are becoming less successful as health care organizations integrate into newer models that incorporate physician practice under the organi- zational umbrella.


Service-Line Structures More common in health care organizations today are service-line structures (Nugent et al., 2008). Service-line structures also are called product-line or service-integrated structures. In a service-line structure, clinical services are organized around patients with specific conditions (Figure 2-3).

Integrated structures are preferred in large and complex organizations because the same ac- tivity (for example, hiring) is assigned to several self-contained units, which can respond rapidly to the unit’s immediate needs. This is appropriate when environmental uncertainty is high and the organization requires frequent adaptation and innovation.

One of the strengths of the service-line structure is its potential for rapid change in a chang- ing environment. Because each division is specialized and its outputs can be tailored to the situa- tion, client satisfaction is high. Coordination across function (nursing, dietary, pharmacy, and so on) occurs easily; work partners identify with their own service and can compromise or collabo- rate with other service functions to meet service goals and reduce conflict. Service goals receive priority under this organizational structure because employees see the service outcomes as the primary purpose of their organization.

The major weaknesses of service-integrated structures include possible duplication of resources (such as ads for new positions) and lack of in-depth technical training and specialization. Coordination across service categories (oncology, cardiology, and the burn unit, for example) is difficult; services operate independently and often compete. Each service category, which is independent and autono- mous, has separate and often duplicate staff and competes with other service areas for resources. In addition, some service lines (e. g., pediatrics, obstetrics, bariatric surgery, and transplant centers) pres- ent special challenges due to low usage or the need for specialized personnel (Page, 2010).

Service-line structures are the most common structures found in Magnet-certified organiza- tions (Kaplow & Reed, 2008). Such structures, however, present a challenge to nursing adminis- trators and managers to maintain nursing standards across service lines (Hill, 2009). Armstrong, Laschinger, and Wong (2009) found improved patient safety in Magnet hospitals was related to nurses’ perception of empowerment. This can be explained, possibly, by Magnet standards that encourage staff participation in decision making.

Shared Governance Shared governance is a process for empowering nurses in the practice setting. It is based on a philosophy that nursing practice is best determined by nurses. Participative decision making is the hallmark of shared governance and a standard for Magnet certification. Interdependence and

Nursing Dietary



Pharmacy Storeroom

Nursing Dietary Pharmacy Storeroom


Nursing Dietary

Burn unit

Pharmacy Storeroom

Figure 2-3 • Service line structure.


accountability are the basis for constructing a network of making nursing practice decisions in a decentralized environment. As a result, nurses gain significant control over their practice, ef- ficiency and accountability are improved, and feelings of powerlessness are mitigated.

The ultimate outcome of shared governance is that nurses participate in an accountable fo- rum to control their own practice within the health care organization. The assumption is that nursing staffs, like medical staffs, will predetermine the clinical skills of staff nurses and moni- tor the work of each through peer review while deciding on other practice issues through ac- countable forums or councils.

Shared governance allows staff nurses significant control over major decisions about nurs- ing practice. Most shared governance systems are similar to and reflect the principles often found in academic or medical governance models. As shown in the example in Figure 2-4, nurses par- ticipate in unit-based councils that interface with divisional councils, specialty councils, and a leadership council, consisting of nurse managers and administrators.

Decisions are made by consensus, rather than by the manager’s order or majority rule, a process that allows staff nurses an active voice in the decision. In the example in Figure 2-4, unit councils make decisions that directly affect the unit, divisional councils address issues that affect more than one unit, and a hospital-wide council determines overall issues.

The hospital-wide council consists of specific councils that address particular issues. The practice council, for example, is responsible for patient care standards. The professional development council maintains educational standards and competency assessments. The quality council monitors patient care quality. The research council assists in implementing evidence- based practice.

Although nursing practice councils have been operational for several decades, changes in health care and in organizational structures often require restructuring the councils, a process not without difficulty (Moore & Wells, 2010). Staffing shortages, patient demands and unfamiliarity with the process or its benefits may discourage participation.

Furthermore, not all shared governance models are successful (Ballard, 2010). Human fac- tors, such as lack of leadership, lack of staff or manager understanding of shared governance, or the absence of knowledgeable mentors, can impede the implementation of the model. Structural factors, such as a known structure for decision making, time available for meetings, and staffing support for attendance also can affect the success of shared governance.

With shared governance a Magnet standard, efforts to implement, refine and restructure the model in health care organizations is expected to continue (McDowell et al., 2010).

Ownership of Health Care Organizations Today’s health care organizations differ in ownership, role, activity, and size. Ownership can be either private or government, voluntary (not for profit) or investor-owned (for profit), and sectarian or non- sectarian (Figure 2-5). Private organizations are usually owned by corporations or religious entities,

Unit-based councils

Divisional council

Leadership council

Practice council

Professional development


Quality council

Research council

Figure 2-4 • Shared governance model. Adapted from McDowell, J. B., Williams, R. L., Kautz, D. D., Madden, P., Heilig, A., & Thompson, A. (2010). Shared governance: 10 years later. Nursing Management, 41(7), 32–37.


whereas government organizations are operated by city, county, state, or federal entities, such as the Indian Health Service. Voluntary organizations are usually not for profit, meaning that surplus mon- ies are reinvested into the organization. Investor-owned, or for-profit corporations, distribute surplus monies back to the investors, who expect a profit. Sectarian agencies have religious affiliations.

Health Care Settings Organizations are further divided by the setting in which they deliver care. These include pri- mary care, acute care hospitals, home health care, and long-term care organizations.

Primary Care Primary care is considered the patient’s first encounter with the health care system. Primary care is deliv- ered in physician’s offices, emergency rooms, public health clinics, and in sites known as retail medicine.


Voluntary (not for profit)

Roman Catholic, Salvation Army, Lutheran, Methodist, Baptist, Presbyterian, Latter-day Saints, Jewish


Industrial (railroad, lumber, union) Kaiser-Permanente Plan Shriners hospitals

Investor- owned (for profit)

Individual owner partnership corporation

Single hospital (Investor-owned hospitals)





State Long-term psychiatric, chronic, and other State university medical centers

Army Navy Air Force

Public Health Service Indian Health Service Other


Hospital district or authority County City-county City

Department of Defense

Department of Veterans Affairs

Department of Health and Human Services

Department of Justice—prisons

Figure 2-5 • Types of ownership in health care organizations. From Longest, B. S., Rakich, J. S., & Darr, K. (2000). Managing Health Services Organizations and Systems (4th ed.). Baltimore: Health Professions Press, p. 173. Reprinted by permission.


Retail medicine describes walk-in clinics that provide convenient services for low-acuity illnesses without scheduled appointments. Staffed by nurse practitioners with physician backup, these clinics seem a natural expectation of today’s fast food, 24/7 public mindset. The Ameri- can Medical Association, however, has questioned the quality of care provided in these clinics (Costello, 2008).

Rohrer, Angstman, and Furst (2009) addressed quality of care in their study. They com- pared the reutilization rates of patients seen in a retail clinic with those in a large group physician practice. They surmised that if clinic patients had no higher return visits or emer- gency room visits for the same condition than physician office patients, then the quality of care could be assumed to be comparable in both settings. That is exactly what they found. So, according to this study, patients not only benefitted from the convenience of a walk-in clinic, but the quality of care they received was comparable to a private physician’s office visit. In addition, the cost of care was much lower than either physician offices or emer- gency rooms.

Another model of primary care is the logic model. The logic model is a practice-based re- search network (PBRN) that provides a framework for planning and evaluation of primary care (Hayes, Parchman, & Howard, 2011). The goal of this model is to improve the health outcomes of patients. Primary care outcomes are seldom evaluated. The logic model offers one way to determine if efforts and resources are used in the most productive way and if subjective outcomes, such as pa- tient satisfaction and easy access are achieved.

Acute Care Hospitals Hospitals are frequently classified by length of stay and type of service. Most hospitals are acute (short-term or episodic) care facilities, and they may be classified as general or special care fa- cilities, such as pediatric, rehabilitative, and psychiatric facilities. Many hospitals also serve as teaching institutions for nurses, physicians, and other health care professionals.

The term “teaching hospital” commonly designates a hospital associated with a medical school that maintains a house staff of residents on call 24 hours a day. Nonteaching hospitals, in contrast, have only private physicians on staff. Because private physicians are less accessible than house staff, the medical supervision of patient care differs, as may the role of the nurse. This designation is changing dramatically as new forms of physician groups and allied practices emerge in partnerships with hospitals and medical schools. Some organizations hire hospitalists, physicians who provide care only to hospital inpatients; those who care for patients in intensive care are known as intensivists.

Home Health Care Home health care is the intermittent, temporary delivery of health care in the home by skilled or unskilled providers. With shortened lengths of hospital stay, more acutely ill patients are dis- charged to recuperate at home. Furthermore, more people are surviving life-threatening illnesses or trauma and require extended care. The primary service provided by home care agencies is nursing care; however, larger home care agencies also offer other professional services, such as physical or occupational therapy, and durable medical equipment, such as ventilators, hospital beds, home oxygen equipment, and other medical supplies. Hospice care for the final days of a patient’s terminal illness may be provided by a home care agency or a hospital.

An outgrowth of the home health care industry is the temporary service agency. These agencies provide nurses and other health care workers to hospitals that are temporarily short- staffed; they also provide private duty nurses to individual patients either at home or in the hospital.

Long-Term Care Long-term care facilities provide professional nursing care and rehabilitative services. They may be freestanding, part of a hospital, or affiliated with a health care organization. Usually, length of


stay is limited. Residential care facilities, also known as nursing homes, are sheltered environ- ments in which long-term care is provided by nursing assistants with supervision from licensed professional or registered nurses.

As the population ages and the frail elderly account for more and more of the nation’s citi- zens, care in long-term care facilities is growing (Weaver et al., 2008). These organizations pose different problems for staff. Ageism and infantilism permeate many settings (Ryvicker, 2009). In addition, patients often transition between the nursing home and the hospital, and that care may be fragmented and lead to poor outcomes (Naylor, Kurtzman, & Pauly, 2009). Challenges in providing care to the elderly include addressing the tendency to stigmatize older, frail adults and to provide continuity of care across settings.

Complex Health Care Arrangements Health Care Networks Integrated health care networks emerged as organizations struggled to find ways to survive in today’s cost-conscious environment. Integrated systems encompass a variety of model organiza- tional structures, but certain characteristics are common. Network systems

● Deliver a continuum of care; ● Provide geographic coverage for the buyers of health care services; and ● Accept the risk inherent in taking a fixed payment in return for providing health care for

all persons in the selected group, such as all employees of one company.

To provide such services, networks of providers evolved to encompass hospitals and physi- cian practices. Most importantly, the focal point for care is primary care rather than the hospital. The goal is to keep patients healthy by treating them in the setting that incurs the lowest cost and thereby reducing expensive hospital treatments. The former goal—to keep hospital beds filled— has been replaced with a new goal: to keep patients out of them!

A variety of other arrangements have emerged, varying from loose affiliations between hos- pitals to complete mergers of hospitals, clinics, and physician practices. These arrangements continue to move and shift as alliances fail, return to separate entities, and form new affiliations. Changes in health care payments offer possibilities for nurses to practice in expanding primary care networks are anticipated.

Interorganizational Relationships With increased competition for resources and public and governmental pressures for better efficiency and effectiveness, organizations have been forced to establish relationships with one another for their continued survival. Multihospital systems and multiorganizational ar- rangements, both formal and informal, are mechanisms by which these relationships have formed.

Arrangements between or among organizations that provide the same or similar services are examples of horizontal integration. For instance, all hospitals in the network provide compa- rable services, as shown in Figure 2-6.

Vertical integration, in contrast, is an arrangement between or among dissimilar but re- lated organizations to provide a continuum of services. An affiliation of a health maintenance organization with a hospital, pharmacy, and nursing facility represents vertical integration (see Figure 2-7).

Numerous arrangements using horizontal and vertical integration can be found, and these models likely will become the common structure for delivery of health care. Examples of such arrangements include affiliations, consortia, alliances, mergers, and consolidations. An assort- ment of health care agencies under the umbrella of a corporate network is shown in the example in Figure 2-8.


Hospital A

Hospital B

Hospital C

Hospital D

Hospital E

Hospital F

Hospital G

Figure 2-6 • Horizontal integration.

Acute care hospital

Long-term care facility

Home health agency

Ambulatory care clinic

Sports medicine clinic

Hospice care

Figure 2-7 • Vertical integration.

Hospital Imaging center

Home care services

Medical group


Skilled nursing facility

Ambulatory surgical center

Long-term care

Corporate board

Figure 2-8 • Corporate health care network.

Diversification Diversification provides another strategy for survival in today’s economy. Diversification is the expansion of an organization into new arenas. Two types of diversification are common: concen- tric and conglomerate.

Concentric diversification occurs when an organization complements its existing services by expanding into new markets or broadening the types of services it currently has available. For example, a children’s hospital might open a day-care center for developmentally delayed children or offer drop-in facilities for sick child care.

Conglomerate diversification is the expansion into areas that differ from the original product or service. The purpose of conglomerate diversification is to obtain a source of income that will support the organization’s product or service. For example, a long-term care facility might develop real estate or purchase a company that produces durable medical equipment.

Another type of diversification common to health care is the joint venture. A joint venture is a partnership in which each partner contributes different areas of expertise, resources, or services to create a new product or service. In one type of joint venture, one partner (general partner) finances and manages the venture, whereas the other partner (limited partner) pro- vides a needed service. Joint ventures between health care organizations and physicians are becoming increasingly common. Integrated health care organizations, hospitals, and clinics seek physician and/or practitioner groups they can bond (capture) in order to obtain more referrals. The health care organization as financier and manager is the general partner, and physicians are limited partners.


Managed Health Care Organizations The managed health care organization is a system in which a group of providers is responsible for delivering services (that is, managing health care) through an organized arrangement with a group of individuals (for example, all employees of one company, all Medicaid patients in the state). Different types of managed-care organizations exist: health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-service plans (POS).

An HMO is a geographically organized system that provides an agreed-on package of health maintenance and treatment services provided to enrollees at a fixed monthly fee per enrollee, called capitation. Patients are required to choose providers within the network.

In a PPO, the managed-care organization contracts with independent practitioners to pro- vide enrollees with established discounted rates. If an enrollee obtains services from a nonpar- ticipating provider, significant copayments are usually required.

Point-of-service (POS) is considered to be an HMO–PPO hybrid. In a POS, enrollees may use the network of managed-care providers to go outside the network as they wish. However, use of a pro- vider outside the network usually results in additional costs in copayments, deductibles, or premiums.

Accountable Care Organizations Effective January 2012, accountable care organizations have been able to contract with Medicare to provide care to a group of Medicare recipients (Ansel & Miller, 2010). Strong incentives to reduce cost, share information across networks and improve quality are included in the provisions for reimbursement.

An accountable care organization consists of a group of health care providers that provide care to a specified group of patients. Various structures can be used in accountable care organiza- tions from loosely affiliated groups of providers to integrated delivery systems. An accountable care organization is more flexible than a HMO because consumers are free to choose providers from outside the network. Cognizant of the potential for Medicare contracts and, later, reim- bursement by other third-party payers, health care providers and organizations are scrambling to establish collaborative arrangements and networks.

Redesigning Health Care Health care is a dynamic environment with multiple factors impinging on continuity and stability. Implementation of accountable care organizations, demands for safe, quality care, Magnet standards that promote decentralized organizational structures and an aging population with multiple chronic conditions are just two of the factors that make redesigning health care a reality today.

Redesign includes strategies to better provide safe, efficient, quality health care. Some ex- amples of redesign strategies include adopting a patient-centered care model, focusing on spe- cific service lines, applying lean thinking to the system, and establishing a flat, decentralized organizational structure.

The Institute of Medicine’s 2001 report, Crossing the Quality Chasm, recommended ways to improve health care. One of those was to adopt a patient-centered care model (IOM, 2001). Success in implementing a patient- and family-centered care model has been reported in the lit- erature (Zarubi, Reiley & McCarter, 2008).

Another patient-centered model is the medical home (Berenson et al., 2008). Centered by a primary care provider (primary care physician or nurse practitioner), a medical home links all care providers in the “home.” The goal is to provide continuous, accessible, and comprehen- sive care. Challenges for coordinating care in a medical home include communication (e.g., ab- sence of electronic medical records for all providers), the multiple needs of patients with chronic health problems, discomfort of patients and providers to use electronic communication of data and information, and compensation for primary care. To offset some of these challenges are sev- eral suggestions (Berenson et al., 2008). These include implementing electronic medical records


using nurse practitioners to manage patients with chronic conditions, encouraging patients to self-manage chronic conditions, and persuading providers to use electronic communication with patients.

To meet both quality and cost-effective goals, the health care organization may decide to concentrate on specific service lines. Called big-dot focus areas, an organization selects a few major initiatives. They might, for example, put resources into building cardiology, cancer, and neuroscience while maintaining other services as is.

Another strategy is to adopt the quality concepts of lean thinking to redesign (Joosten, Bongers, & Janssen, 2009). Lean thinking focuses on the system rather than on individuals, concentrates on interventions that improve outcomes and disregards those that have little or no effect. A flat, decentralized organizational structure centers decision making closest to the problem. It promotes unit-based decision making and empowers staff to implement process improvements in a timely manner (Kramer, Schmalenberg, & Maguire, 2010). Furthermore, a decentralized structure encourages communication and collaboration and provides a quality im- provement infrastructure.

Redesigning an organization presents numerous challenges. Staff may be concerned that their jobs will change or may disappear. Administrators may complain that loss of authority will result in poor performance. Everyone may worry that cost effective measures may diminish the quality of care. Significant stress is to be expected (Lavoie-Tremblay et al., 2010).

Nurse managers are key players in the redesign efforts. They are expected not only to initi- ate change while reducing costs, maintaining or improving quality of care, coaching and men- toring, and team building, but also to do so in an ever-changing environment full of ambiguities while their own responsibilities are expanded.

Strategic Planning Successful organizations know that they must focus their resources on their unique strengths, and health care is no exception. Organizations that focus on a few strategic initiatives, as dis- cussed previously, do so after an intensive planning process. The competitive health care en- vironment and limited resources require organizations to respond to public demands for safe, accessible quality health care.

This is a time-consuming and demanding process and should not be undertaken hurriedly. Put in use, however, a well-thought-out strategic plan guides the organization toward its goals, helps all the staff stay directed, and prevents the organization from responding to inappropriate requests.

A strategic plan projects the organization’s goals and activities into the future, usually two to five years ahead (Schaffner, 2009). Based on the organization’s philosophy and leaders’ as- sessment of their organization and the environment, strategic planning guides the direction the organization is to take.

The philosophy is a written statement that reflects the organizational values, vision, and mission (Conway-Morana, 2009). Values are the beliefs or attitudes one has about people, ideas, objects, or actions that form a basis for behavior. Organizations use value statements to identify those beliefs or attitudes esteemed by the organizational leaders.

A vision statement describes the goal to which the organization aspires. The vision state- ment is designed to inspire and motivate employees to achieve a desired state of affairs. “Our vision is to be a regional integrated health care delivery system providing premier health care services, professional and community education, and health care research” is an example of a vision statement for a health care system.

The mission of an organization is a broad, general statement of the organization’s reason for existence. Developing the mission is the necessary first step to designing a strategic plan. “Our mission is to improve the health of the people and communities we serve” is an example of a mission statement that guides decision making for the organization. Purchasing a medical equipment company, for example, might not be considered because it fails to meet the mission of improving the community’s health.


The strategic plan is based on the organization’s philosophy, vision, and mission. The first steps in strategic planning are:

● Appoint a strategic planning committee ● Interview key stakeholders ● Conduct a SWOT (strengths, weaknesses, opportunities, and threats) analysis ● Develop the plan ● Communicate the plan

People who are enthusiastic, experienced, and committed to the organization are the best representatives to serve on the planning committee. Naysayers can be included once some parts of the plan are formulated. Everyone in the organization must be involved even peripherally. “Buy-in” is critical to the plan’s success.

Stakeholders include physicians, administrators, nurses, ancillary and support staff, and community representatives. They will have differing opinions about what the organization can and should do and provide valuable information unavailable elsewhere.

The SWOT analysis includes assessment of the external and internal environment (Kalisch & Curley, 2008). Data is collected from multiple sources, including stakeholder information.

To develop the plan:

● Determine goals, objectives and strategies ● Assess the projected costs ● Assign responsible units or individuals ● Identify outcome measures and expected dates of completion

Goals are specific statements of what outcome is to be achieved. Goals describe outcomes that are measurable and precise. “Every patient will be satisfied with his or her care” is an example of a goal.

Goals apply to the entire organization, whereas objectives are specific to an individual unit. A nursing objective to meet the above goal might be “Provide appropriate information and ed- ucation to patients from preadmission to discharge.” Strategies follow objectives and specify what actions will be taken. “Implement patient education classes for prenatal patients” is an example of a strategy to meet the patient satisfaction objective.

Other categories in a strategic plan include identifying the personnel responsible for each activity, determining the projected cost, establishing criteria to recognize that the goal has been met, and deciding the expected date of completion.

Strategic planning is an ongoing process, not an end in itself. It requires meticulous atten- tion to how the organization is meeting its goals and, if goals are not met, what the reasons are for the variance. Maybe the goal needs to change, or possibly other personnel should be assigned to the task. Perhaps a change in the environment (reimbursement) or within the organization (shortage of key personnel) requires the goal to be abandoned. Continual evaluation will help the organization target its resources best.

Organizational Environment and Culture The terms organizational environment and organizational culture both describe internal con- ditions in the work setting. Organizational environment is the systemwide conditions that con- tribute to a positive or negative work setting. In 2005, the American Association of Critical-Care Nurses identified six characteristics of a healthy work environment, characteristics that the orga- nization continues to promote (AACN, 2011 ). The characteristics are:

● Skilled communication ● True collaboration ● Effective decision making ● Appropriate staffing ● Meaningful recognition ● Authentic leadership.


One way to assess the organizational environment is to evaluate the qualities of those hired for key positions in the organization. An organization in which nursing leaders are in- novative, creative, and energetic will tend to operate in a fast-moving, goal-oriented fashion. If humanistic, interpersonal skills are sought in candidates for leadership positions, the or- ganization will focus on human resources, employees, and patient advocacy (Hersey, 2011).

Organizational culture, on the other hand, are the basic assumptions and values held by members of the organization (Sullivan, 2013). These are often known as the unstated “rules of the game.” For example, who wears a lab coat? When is report given? To whom? Is tardiness tolerated? How late is acceptable?

Like environment, organizational culture varies from one institution to the next and subcul- tures and even countercultures, groups whose values and goals differ significantly from those of the dominant organization, may exist. A subculture is a group that has shared experiences or like interests and values. Nurses form a subculture within health care environments. They share a common language, rules, rituals, dress, and have their own unstated rules. Individual units also can become subcultures.

Systems involving participatory management and shared governance create organizational environments that reward decision making, creativity, independence, and autonomy (Kramer, Schmalenberg, & Maguire, 2010). These organizations retain and recruit independent, ac- countable professionals. Organizations that empower nurses to make decisions will better meet consumer requests. As the health care environment continues to evolve, more and more organi- zations are adopting consumer-sensitive cultures that require accountability and decision mak- ing from nurses.

What You Know Now • The schools of organizational theory include classical theory, humanistic theory, systems theory, contin-

gency theory, chaos theory, and complexity theory. • Organizations can be viewed as social systems consisting of people working in a predetermined pattern of

relationships who strive toward a goal. The goal of health care organizations is to provide a particular mix of health services.

• Traditional organizational structures include functional, hybrid, matrix, and parallel structures. • Service-line structures organize clinical services around specific patient conditions. • Shared governance provides the framework for empowerment and partnership within the health care

organization. • Accountable care organizations are recent additions to health care design. They can contract with a payer

to provide care to a specific group of patients. • The medical home is one of the patient-centered models where all services are provided by a group of

health care professionals. • Strategic planning is a process used by organizations to focus their resources on a limited number of

activities. • Organizational environment and culture affect the internal conditions of the work setting.

Questions to Challenge You 1. Secure a copy of the organizational chart from your employment or clinical site. Would you describe

the organization the same way the chart depicts it? If not, redraw a chart to illustrate how you see the organization.

2. What organizational structure would you prefer? Think about how you might go about finding an organization that meets your criteria.

3. Organizational theories explain how organizations function. Which theory or theories describes your organization’s functioning? Do you think it is the same theory your organization’s administrators would use to describe it? Explain.


4. Have you been involved in strategic planning? If so, explain what happened and how well it worked in directing the organization’s activities.

5. Using the six characteristics of a healthy work environment in the chapter, evaluate the organiza- tion where you work or have clinicals. How well does it rate? What changes would improve the environment?

American Association of Criti- cal Care Nurses (AACN). (2011). AACN standards for establishing and sustaining healthy work environments. Retrieved May 5, 2011 from http://www.aacn. org/WD/HWE/Docs/ HWEStandards.pdf

Ansel, T. C., & Miller, D. W. (2010). Reviewing the land- scape and defining the core competencies needed for a successful accountable care organization. Louisville, KY: Healthcare Strategy Group.

Armstrong, K., Laschinger, H., & Wong, C. (2009). Work- place empowerment and Magnet hospital characteris- tics as predictors of patient safety climate. Journal of Nursing Care Quality, 24(1), 55–62.

Ballard, N. (2010). Factors as- sociated with success and breakdown of shared gov- ernance. Journal of Nursing Administration, 40(10), 411–416.

Berenson, R. A., Hammons, T., Gans, D. H., Zuckerman, S., Merrell, K., Underwood, W. S., & Williams, A. F. (2008). A house is not a home: Keeping patients at the center of practice

redesign. Health Affairs, 27(5), 1219–1230.

Conway-Morana, P. L. (2009). Nursing strategy: What’s your plan? Nursing Man- agement, 40(3), 25–29.

Costello, D. (2008). Report from the field: A checkup for retail medicine. Health Af- fairs, 27(5), 1299–1303.

Gamble, K. H. (2009). Con- necting the dots: Patient flow systems are being leveraged to increase throughput, improve com- munication, and provide a more complete view of care. Healthcare Informat- ics, 25(13), 27–29.

Handel, D. A., Hilton, J. A., Ward, M. J., Rabin, E., Zwemer, F. L., & Pines, J. M. (2010). Emergency department throughput, crowding, and financial outcomes for hospitals. Academic Emergency Medicine, 17(8), 840–847.

Hayes, H., Parchman, M. L., & Howard, R. (2011). A logic model framework for evaluation and planning in a primary care practice-based research network (PBRN). Journal of the American Board of Family Medicine, 24(5), 576–582.

Hersey, P. H. (2011). Management of organizational behavior (10th ed.). Upper Saddle River, NJ: Prentice Hall.

Hill, K. S. (2009). Service line structures: Where does this leave nursing? Journal of Nursing Administration, 39(4), 147–148.

Institute of Medicine (2001). Crossing the quality chasm: A new health sys- tem for the 21st century. Retrieved October 24, 2011 from http://www. iom.edu/Reports/2001/ Crossing-the-Quality- Chasm-A-New-Health- System-for-the-21st- Century.aspx

Joint Commission (2011). Edition standards. Retrieved May 12, 2011 from http:// www.jcrinc.com/ E-dition-Home/Joosten, T., Bongers, I., & Janssen, R. (2009). Application of lean thinking to health care: Issues and observations. International Journal of Quality in Health Care, 21(5), 341–347.

Kalisch, B. J., and Curley, M. (2008). Transforming a nursing organization. Jour- nal of Nursing Administra- tion, 38(2), 76–83.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!



Kaplow, R., & Reed, K. D. (2008). The AACN synergy model for patient care: A nursing model as a force of magnetism. Nursing Eco- nomics, 26(1), 17–25.

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Traditional Models of Care FUNCTIONAL NURSING




Integrated Models of Care PRACTICE PARTNERSHIPS




Evolving Models of Care PATIENT-CENTERED CARE




Delivering Nursing Care 3

Chronic care model Clinical microsystems

Critical pathways Patient-centered care

Practice partnership Synergy model of care

Key Terms

1. Describe how the delivery system structures nursing care.

2. Describe what types of nursing care delivery systems exist.

3. Discuss the positive and negative aspects of different systems.

4. Describe evolving types of delivery systems that have emerged.

5. Explain characteristics of effective delivery systems.

Learning Outcomes After completing this chapter, you will be able to:


T he core business of a health care organization is providing nursing care to patients. The purpose of a nursing care delivery system is to provide a structure that enables nurses to deliver nursing care to a specified group of patients. The delivery of care

includes assessing care needs, formulating a plan of care, implementing the plan, and evaluating the patient’s responses to interventions. This chapter describes how nursing care is organized to ensure quality care in an era of cost containment.

Since World War II, nursing care delivery systems have undergone continuous and significant changes (Box 3-1). Over the years, various nursing care delivery systems have been tried and critiqued. Debates regarding the pros and cons of each method have focused on identifying the perfect delivery system for providing nursing care to patients with varying degrees of need.

In addition, a delivery system must utilize specific nurses and groups of nurses, optimizing their knowledge and skills while at the same time ensuring that patients receive appropriate care. It’s no small challenge. In fact, researchers have found that a better hospital environment for nurses is associ- ated with lower mortality rates (Aiken et al., 2008) and nurse satisfaction (Spence-Laschinger, 2008).

Traditional Models of Care Functional Nursing Functional nursing, also called task nursing, began in hospitals in the mid-1940s in response to a national nursing shortage (see Figure 3-1). The number of registered nurses (RNs) serving in the armed forces during World War II depleted the supply of nurses at home. As a result of this loss of RNs, the composition of nursing staffs in hospitals changed. Staff that had been composed almost entirely of RNs gave way to the widespread use of licensed practical nurses (LPNs) and unlicensed assistive personnel (UAPs) to deliver nursing care.

In functional nursing, the needs of a group of patients are broken down into tasks that are assigned to RNs, LPNs, or UAPs so that the skill and licensure of each caregiver is used to his or her best advantage. Under this model an RN assesses patients whereas others give baths, make beds, take vital signs, administer treatments, and so forth. As a result, the staff become very efficient and effective at performing their regular assigned tasks.

BOX 3-1 Job Description of a Floor Nurse (1887)

Developed in 1887 and published in a magazine of Cleveland Lutheran Hospital.

In addition to caring for your 50 patients, each nurse will follow these regulations:

1. Daily sweep and mop the floors of your ward, dust the patients’ furniture and window sills.

2. Maintain an even temperature in your ward by bringing in a scuttle of coal for the day’s business.

3. Light is important to observe the patient’s condi- tion. Therefore, each day fill kerosene lamps, clean chimneys, and trim wicks. Wash windows once a week.

4. The nurse’s notes are important to aiding the phy- sician’s work. Make your pens carefully. You may whittle nibs to your individual taste.

5. Each nurse on day duty will report every day at 7 A.M. and leave at 8 P.M., except on the Sabbath, on which you will be off from 12 noon to 2 P.M.

6. Graduate nurses in good standing with the Direc- tor of Nurses will be given an evening off each week for courting purposes, or two evenings a week if you go regularly to church.

7. Each nurse should lay aside from each pay a goodly sum of her earnings for her benefits during her declining years, so that she will not become a burden. For example, if you earn $30 a month you should set aside $15.

8. Any nurse who smokes, uses liquor in any form, gets her hair done at a beauty shop, or frequents dance halls will give the Director of Nurses good reason to suspect her worth, intentions, and integrity.

9. The nurse who performs her labor, serves her patients and doctors faithfully and without fault for a period of five years will be given an increase by the hospital administration of five cents a day providing there are no hospital debts that are outstanding.


Disadvantages of functional nursing include:

● Uneven continuity ● Lack of holistic understanding of the patient ● Problems with follow-up

Because of these problems, functional nursing care is used infrequently in acute care facilities and only occasionally in long-term care facilities.

Team Nursing Team nursing (Figure 3-2) evolved from functional nursing and has remained popular since the middle to late 1940s. Under this system, a team of nursing personnel provides total patient care to a group of patients. In some instances, a team may be assigned a certain number of patients; in others, the assigned patients may be grouped by diagnoses or provider services.

The size of the team varies according to physical layout of the unit, patient acuity, and nurs- ing skill mix. The team is led by an RN and may include other RNs, LPNs, and UAPs. Team members provide patient care under the direction of the team leader. The team, acting as a uni- fied whole, has a holistic perspective of the needs of each patient. The team speaks for each patient through the team leader.

Typically, the team leader’s time is spent in indirect patient care activities, such as:

● Developing or updating nursing care plans ● Resolving problems encountered by team members ● Conducting nursing care conferences ● Communicating with physicians and other health care personnel

With team nursing, the unit nurse manager consults with team leaders, supervises patient care teams, and may make rounds with all physicians. To be effective, team nursing requires that all team members have good communication skills. A key aspect of team nursing is the nursing care conference, where the team leader reviews with all team members each patient’s plan of care and progress.

Charge nurse

UAP responsible for transportation

UAP responsible for vital signs

UAP with bath duty

Treatment nurse

Medication nurse


Figure 3-1 • Functional nursing.

Charge nurse

Team/module leaderTeam/module leaderTeam/module leader


Patients Patients Patients

Figure 3-2 • Team/modular nursing.


Advantages of team nursing are:

● It allows the use of LPNs and UAPs to carry out some functions (e.g., making beds, trans- porting patients, collecting some data) that do not require the expertise of an RN.

● It allows patient care needs requiring more than one staff member, such as patient trans- fers from bed to chair, to be easily coordinated.

● The geographical boundaries of team nursing help save steps and time.

Disadvantages of team nursing are:

● A great deal of time is needed for the team leader to communicate, supervise, and coordi- nate team members.

● Continuity of care may suffer due to changes in team members, leaders, and patient assignments.

● No one person considers the total patient. ● There may be role confusion and resentment against the team leader, who staff may

view as more focused on paperwork and less directed at the physical or real needs of the patient.

● Nurses have less control over their assignments due to the geographical boundaries of the unit.

● Assignments may not be equal if they are based on patient acuity or may be monotonous if nurses continuously care for patients with similar conditions (e.g., all patients with hip replacements).

Skills in delegating, communicating, and problem solving are essential for a team leader to be effective. Open communication between team leaders and the nurse manager is also im- portant to avoid duplication of effort, overriding of delegated assignments, or competition for control or power. Problems in delegation and communication are the most common reasons why team nursing is less effective than it theoretically could be.

Total Patient Care The original model of nursing care delivery was total patient care, also called case method (Figure 3-3), in which a registered nurse was responsible for all aspects of the care of one or more patients. During the 1920s, total patient care was the typical nursing care delivery system. Student nurses often staffed hospitals, whereas RNs provided total care to the patient at home. In total patient care, RNs work directly with the patient, family, physician, and other health care staff in implementing a plan of care.

The goal of this delivery system is to have one nurse give all care to the same patient(s) for the entire shift. Total patient care delivery systems are typically used in areas requiring a high level of nursing expertise, such as in critical care units or postanesthesia recovery areas.

The advantages of a total patient care system include:

● Continuous, holistic, expert nursing care ● Total accountability for the nursing care of the assigned patient(s) for that shift ● Continuity of communication with the patient, family, physician(s), and staff from other


Charge nurse


Patients Patients Patients

Figure 3-3 • Total patient care.


The disadvantage of this system is that RNs spend some time doing tasks that could be done more cost-effectively by less skilled persons. This inefficiency adds to the expense of using a total patient care delivery system.

Primary Nursing Conceptualized by Marie Manthey and implemented during the late 1960s after two decades of team nursing, primary nursing (Figure 3-4) was designed to place the registered nurse back at the patient’s bedside (Manthey, 1980). Decentralized decision making by staff nurses is the core principle of primary nursing, with responsibility and authority for nursing care allocated to staff nurses at the bedside. Primary nursing recognized that nursing was a knowledge-based profes- sional practice, not just a task-focused activity.

In primary nursing, the RN maintains a patient load of primary patients. A primary nurse designs, implements, and is accountable for the nursing care of patients in the patient load for the duration of the patient’s stay on the unit. Actual care is given by the primary nurse and/or associate nurses (other RNs).

Primary nursing advanced the professional practice of nursing significantly because it provided:

● A knowledge-based practice model ● Decentralization of nursing care decisions, authority, and responsibility to the staff nurse ● 24-hour accountability for nursing care activities by one nurse ● Improved continuity and coordination of care ● Increased nurse, patient, and physician satisfaction.

Primary nursing also has some disadvantages, including:

● It requires excellent communication between the primary nurse and associate nurses. ● Primary nurses must be able to hold associate nurses accountable for implementing the

nursing care as prescribed. ● Because of transfers to different units, critically ill patients may have several primary care

nurses, disrupting the continuity of care inherent in the model. ● Staff nurses are neither compensated nor legally responsible for patient care outside their

hours of work. ● Associates may be unwilling to take direction from the primary nurse.

Although the concept of 24-hour accountability is worthwhile, it is a fallacy. When primary nursing was first implemented, many organizations perceived that it required an all–RN staff. This practice was viewed as not only expensive but also ineffective because many tasks could be done by less skilled persons. As a result, many hospitals discontinued the use of primary nurs- ing. Other hospitals successfully implemented primary nursing by identifying one nurse who was assigned to coordinate care and with whom the family and physician could communicate, and other nurses or unlicensed assistive personnel assisted this nurse in providing care.


Other health care providers

Primary nurse Charge nurse

Associate nurse Associate nurse

Figure 3-4 • Primary nursing.


Integrated Models of Care Practice Partnerships The practice partnership (Figure 3-5) was introduced by Marie Manthey in 1989 (Manthey, 1989). In the practice partnership model, an RN and an assistant—UAP, LPN, or less experi- enced RN—agree to be practice partners. The partners work together with the same schedule and the same group of patients. The senior RN partner directs the work of the junior partner within the limits of each partner’s abilities and within limits of the state’s nurse practice act.

The relationship between the senior and junior partner is designed to create synergistic en- ergy as the two work in concert with patients. The senior partner performs selected patient care activities but delegates less specialized activities to the junior partner. When compared to team nursing, practice partnerships offer more continuity of care and accountability for patient care. When compared to total patient care or primary nursing, partnerships are less expensive for the organization and more satisfying professionally for the partners.

Disadvantages of this model are:

● Organizations tend to increase the number of UAPs and decrease the ratio of professional nurses to nonprofessional staff. If, for example, one UAP is assigned to more than one RN, the UAP must follow the instructions of several people, making a synergistic relation- ship with any one of them difficult.

● Another problem is the potential for the junior member of the team to assume more responsibility than appropriate. Senior partners must be careful not to delegate inappropriate tasks to junior partners.

Practice partnerships can be applied to primary nursing and used in other nursing care delivery systems, such as team nursing, modular nursing, and total patient care. As organizations restructured, practice partnerships offered an efficient way of using the skills of a mix of professional and nonprofessional staff with differing levels of expertise.

Case Management Following the introduction and impact of prospective payments, nursing case management, used for decades in community and psychiatric settings, was adopted for acute inpatient care. Nursing case management (Figure 3-6) is a model for identifying, coordinating, and monitoring the implementation of services needed to achieve desired patient care outcomes within a specified period of time. Nursing case management organizes patient care by major diagnoses or diagnosis-related groups (DRGs) and focuses on attaining predetermined patient outcomes within specific time frames and resources.

Nursing case management requires:

● Collaboration of all members of the health care team ● Identification of expected patient outcomes within specific time frames ● Use of principles of continuous quality improvement (CQI) and variance analysis ● Promotion of professional practice.

Case manager

Patient caseload

Caregivers CaregiversCaregivers

Figure 3-6 • Case management.




Figure 3-5 • Practice partnerships.


In an acute care setting, the case manager has a caseload of 10 to 15 patients and follows patients’ progress through the system from admission to discharge, accounting for variances from expected progress. One or more nursing case managers on a patient care unit may coordi- nate, communicate, collaborate, problem solve, and facilitate patient care for a group of patients. Ideally, nursing case managers have advanced degrees and considerable experience in nursing.

After a specific patient population is selected to be “case managed,” a collaborative prac- tice team is established. The team, which includes clinical experts from appropriate disciplines (e.g., nursing, medicine, physical therapy) needed for the selected patient population, defines the expected outcomes of care for the patient population. Based on expected patient outcomes, each member of the team, using his or her discipline’s contribution, helps determine appropriate interventions within a specified time frame.

To initiate case management, specific patient diagnoses that represent high-volume, high- cost, and high-risk cases are selected. High-volume cases are those that occur frequently, such as total hip replacements on an orthopedic floor. High-risk cases include patients or case types who have complications, stay in a critical care unit longer than two days, or require ventilatory support. Patients also may be selected because they are treated by one particular physician who supports case management.

Whatever patient population is selected, baseline data must be collected and analyzed first. These data provide the information necessary to measure the effectiveness of case management. Essential baseline data include length of stay, cost of care, and complication information.

Five elements are essential to successful implementation of case management:

● Support by key members of the organization (administrators, physicians, nurses) ● A qualified nurse case manager ● Collaborative practice teams ● A quality management system ● Established critical pathways (see next section)

In case management, all professionals are equal members of the team; thus, one group does not determine interventions for other disciplines. All members of the collaborative practice team agree on the final draft of the critical pathways, take ownership of patient outcomes, and accept responsibility and accountability for the interventions and patient outcomes associated with their discipline. The emphasis must be on managing interdisciplinary outcomes and building consensus with physicians. In addition, outcomes must be specified in measurable terms.

Critical Pathways Successful case management relies on critical pathways to guide care. The term critical path, also called a care map, refers to the expected outcomes and care strategies developed by the col- laborative practice team. Again, interdisciplinary consensus must be reached and specific, and measurable outcomes determined.

Critical paths provide direction for managing the care of a specific patient during a specified time period. Critical paths are useful because they accommodate the unique characteristics of the patient and the patient’s condition. Critical paths use resources appropriate to the care needed and, thus, reduce cost and length of stay. Critical paths are used in every setting where health care is delivered.

A critical path quickly orients the staff to the outcomes that should be achieved for the patient for that day. Nursing diagnoses identify the outcomes needed. If patient outcomes are not achieved, the case manager is notified and the situation analyzed to determine how to modify the critical path.

Altering time frames or interventions is categorized as a variance, and the case manager tracks all variances. After a time, the appropriate collaborative practice teams analyze the vari- ances, note trends, and decide how to manage them. The critical pathway may need to be revised or additional data may be needed before changes are made.


Some features are included on all critical paths, such as specific medical diagnosis, the expected length of stay, patient identification data, appropriate time frames (in days, hours, minutes, or visits) for interventions, and patient outcomes. Interventions are presented in modality groups (medications, nursing activity, and so on). The critical path must include a means to identify variances easily and to determine whether the outcome has been met.

Differentiated Practice Differentiated practice is a method that maximizes nursing resources by focusing on the struc- ture of roles and functions of nurses according to their education, experience, and competence. Differentiated practice is designed to identify distinct levels of nursing practice based on defined abilities that are incorporated into job descriptions.

In differentiated practice, the responsibilities of RNs (mainly those with bachelor’s and as- sociate degrees) differ according to the competence and training associated with the two edu- cation levels as well as the nurses’ experience and preferences. The scope of nursing practice and level of responsibility are specifically defined for each level. Some organizations differenti- ate roles, responsibilities, and tasks for professional nurses, licensed practical nurses, and unli- censed assistive personnel, which are incorporated into their respective job descriptions.

Evolving Models of Care Recognizing the need for improving patient care, the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement established a program titled Transforming Care at the Bedside (IHI, 2009). The goal was, and continues to be, to help hospitals achieve affordable and lasting improvements to care (Lavizzo-Mourey & Berwick, 2009). One of its premises is the use of a patient-centered care model.

Patient-Centered Care Patient-centered care is a model of nursing care delivery in which the role of the nurse is broadened to coordinate a team of multifunctional unit-based caregivers. In patient-centered care, all patient care services are unit-based, including admission and discharge, diagnostic and treatment services, and support services, such as environmental and nutrition services and medical records. The focus of patient-centered care is decentralization, the promotion of efficiency and quality, and cost control.

In this model of care, the number of caregivers at the bedside is reduced, but their responsibilities are increased so that service time and waiting time are decreased. A typical team in a unit providing patient-centered care consists of:

● Patient care coordinators (RNs) ● Patient care associates or technicians who are able to perform delegated patient care tasks ● Unit support assistants who provide environmental services and can assist with hygiene

and ambulation needs ● Administrative support personnel who maintain patient records, transcribe orders,

coordinate admission and discharge, and assist with general office duties

Success using a patient-centered care model continues to be reported in the literature (Miles & Vallish, 2010; Schneider & Fake, 2010). Furthermore, lower mortality in patients with acute myocardial infarctions has been found (Meterko et al., 2010). Patients with chronic conditions are appropriate candidates for patient-centered care approaches, including the use of complementary and alternative medicine therapies (Maizes, Rakel, & Niemiec, 2009).

The nurse manager’s role in patient-centered care requires considerable time. No longer is the manager doing rounds and assisting with patient care. Instead, being responsible for a staff that is more diverse with fewer professional RN staff demands a strong leader proficient to


interview, hire, train, and motivate staff. Some organizations share assistive staff between units, also increasing the need for more communication and coordination with other managers.

Synergy Model of Care Developed by the American Association of Critical Nurses, the American Association of Critical Care Nurses conceptualizes nursing practice based on the needs and characteristics of patients (AACN, 2011). These characteristics drive nurse competencies. Patient characteristics include:

● Resiliency ● Vulnerability ● Stability ● Complexity ● Resource availability ● Participation in care ● Participation in decision making ● Predictability

These characteristics are then matched with nurse competencies, including:

● Clinical judgment ● Advocacy and moral agency ● Caring practices ● Collaboration ● Systems thinking ● Response to diversity ● Facilitation of learning ● Clinical inquiry (AACN, 2011)

When patients’ characteristics and nurses’ competencies match, synergy is the outcome. The model is useful to nurses by delineating job descriptions, evaluation formats, and advancement criteria. Furthermore, a synergy model helps meet the standards for Magnet certification (Kaplow & Reed, 2008).

Clinical Microsystems Clinical microsystems are a recent addition to care delivery structures. Clinical microsystems evolved from the belief that decision making is best given to those involved in the smallest unit of care. Thus, a clinical microsystem is a small unit of care that maintains itself over time.

Clinical microsystems include the following elements:

● Core team of caregivers ● Defined population to receive care ● Informational system for both patients and caregivers ● Support staff, equipment and facilitative environment

The clinical microsystem model has been shown to be effective in neonatal intensive care units (Reis, Scott, & Rempel, 2009) and to increase quality improvement projects among medical residents (Tess et al., 2009). Additionally, using a clinical nurse leader improved quality outcomes in a hospital using a clinical microsystem model (Hix, McKeon, & Walters, 2009).

Chronic Care Model So far our discussion of delivery systems has focused on hospital nursing care. Increasingly, however, care is being delivered in ambulatory care environments. Additionally, most of the patients cared for in those environments suffer from chronic health conditions. The chronic care model addresses these concerns.


The goal of the chronic care model is not to manage a disease but to change how daily care is delivered by clinical teams (Coleman et al., 2009). Instead of reacting to changes in the patient’s condition, the team provides proactive interventions. The model is systematic and re- quires six components. They are:

● Self-management support ● Decision support ● Delivery system design ● Clinical information systems ● Health care organization ● Community resources

Given that the population is aging and chronic conditions are expected to rise, the chronic care model is an appropriate one to consider for providing care to patients with chronic illnesses.

No delivery system is perfect. Or permanent. As health care adapts to changes in reimbursement, demands for quality, and technological advances, models for delivering care will continue to evolve.

What You Know Now • Nursing care delivery systems provide a structure for nursing care. Most organizations use a combina-

tion of nursing care delivery systems or modify one or more systems to meet their own needs. • Traditional care models include functional nursing, team nursing, total patient care, and primary nursing. • Integrated models of care include practice partnerships, case management, critical pathways, and differen-

tiated practice. • Evolving models of care include patient-centered care, a synergy model of care, clinical microsystems,

and a chronic care model. • Commonly used by Magnet-certified hospitals, the patient-centered care model provides care from admit-

ting to discharge on the unit. • The synergy model, developed by the American Association of Critical Care Nurses, matches patients’

characteristics with nurses’ competencies. • Clinical microsystems use a structure that puts decision making in small units of those who provide the care. • The chronic care model is a systemwide, proactive model designed to provide daily care to patients by

clinical teams. • As health care adapts to changes in reimbursement, demands for quality, and technological advances,

models for delivering care will continue to evolve.

Questions to Challenge You 1. Describe the patient care delivery system(s) at your place of work or clinical placement site. How

well does it work? Can you suggest a better system? 2. Pretend that you are designing a new nursing care delivery system. Select the system or combination

of systems you would use. Explain your rationale. 3. Why have different systems been used in earlier times? Would any of them be useful today? Explain what

characteristics of the health care system today would make them appropriate or inappropriate to use. 4. As a manager, which system would you prefer? Why? 5. If you were a patient, which system do you think would provide you with the best care?

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!


References Aiken, L. H., Clarke, S. P.,

Sloane, D. M., Lake, E. T., & Cheney, T. (2008). Effects of hospital care environment on patient mortality and nurse out- comes. Journal of Nursing Administration, 38(5), 223–229.

American Association of Critical Care Nurses (AACN) (2011). The AACN synergy model for patient care. Retrieved May 9, 2011 from http://www.aacn.org/ WD/Certifications/Docs/ SynergyModelforPatient- Care.pdf

Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the chronic care model in the new millennium. Health Affairs, 28(1), 75–85.

Hix, C., McKeon, L., and Walters, S. (2009). Clini- cal nurse leader impact on clinical microsystems outcomes. Journal of Nurs- ing Administration, 39(2), 71–76.

Institute for Healthcare Improvement (IHI) (2009). IHI Collaborative: Trans- forming care at the bedside. Retrieved May 9, 2011 from http://www.ihi.org/IHI/ Programs/Collaboratives/ TransformingCareatthe Bedside.htm.

Kaplow, R., & Reed, K. D. (2008). The AACN synergy model for patient care: A nursing model as a force of magnetism. Nursing Economics, 26(1), 17–25.

Lavisso-Mourey, R., & Berwick, D. M. (2009). Nurses trans- forming care. American Journal of Nursing, 109(11), 3.

Maizes, V., Rakel, D., & Niemiec, C. (2009). Integrative medicine and patient-centered care. Explore: The Journal of Science & Healing, 5(5), 277–289.

Manthey, M. (1980). The prac- tice of primary nursing. St. Louis: Mosby.

Manthey, M. (1989). Practice partnerships: The newest concept in care delivery. Journal of Nursing Associa- tion, 19(2), 33–35.

Meterko, M., Wright, S., Lin, H., Lowy, E., & Cleary, P. D. (2010). Mortality among patients with acute myocardial infarction: The influences of patient- centered care and evidence- based medicine. Health Services Research, 45(5), 1188–1204.

Miles, K. S., & Vallish, R. (2010). Creating a personal- ized professional practice framework for nursing.

Nursing Economics, 28(3), 171–189.

Reis, M. D., Scott, S. D., & Rempel, G. R. (2009). Including parents in the evaluation of clinical microsystems in the neonatal intensive care unit. Advances in Neonatal Care, 9(4), 174–179.

Schneider, M. A., & Fake, P. (2010). Implementing a relationship-based care model on a large orthopaedic/neurosurgical hospital unit. Orthopaedic Nursing, 29(6), 374–378.

Spence-Laschinger, H. K. (2008). Effect of empow- erment on professional practice environment, work satisfaction, and patient care quality: Further testing the nursing work life model. Journal of Nursing Care Quality, 23(4), 322–330.

Tess, A. V., Yang, J. J., Smith, C., Fawcett, C. M., Bates, C. K., & Reynolds, E. E. (2009). Combining clinical microsystems and an experiential quality im- provement curriculum to improve residency educa- tion in internal medicine. Academic Medicine, 84(3), 326–334.

Charge nurse Clinical nurse leader Controlling Directing Emotional intelligence First-level manager

Followership Formal [leadership] Informal [leadership] Leader Manager Organizing

Planning Quantum leadership Servant leadership Shared leadership Transactional leadership Transformational leadership

Key Terms

1. Explain why every nurse is a manager and can be a leader.

2. Differentiate between leaders and managers.

3. Discuss how different theories explain leadership and management.

4. Describe what management roles nurses fill in practice.

5. Discuss how followership is essential to leadership.

6. Describe what makes a leader successful.

Learning Outcomes After completing this chapter, you will be able to:

Leaders and Managers


Traditional Leadership Theories Contemporary Theories







Traditional Management Functions





Nurse Managers in Practice NURSE MANAGER






Followership: An Essential Component of Leadership

What Makes a Successful Leader?

Leading, Managing, Following4



M anagers are essential to any organization. A manager’s functions are vital, com-plex, and frequently difficult. They must be directed toward balancing the needs of patients, the health care organization, employees, physicians, and self. Nurse managers need a body of knowledge and skills distinctly different from those needed for nurs- ing practice, yet few nurses have the education or training necessary to be managers. Frequently, managers depend on experiences with former supervisors, who also learned supervisory tech- niques on the job. Often a gap exists between what managers know and what they need to know.

Today, all nurses are managers, not in the formal organizational sense but in practice. They direct the work of nonprofessionals and professionals in order to achieve desired outcomes in patient care. Acquiring the skills to be both a leader and a manager will help the nurse become more effective and successful in any position.

Leaders and Managers Manager, leader, supervisor, and administrator are often used interchangeably, yet they are not the same. A leader is anyone who uses interpersonal skills to influence others to accomplish a specific goal. The leader exerts influence by using a flexible repertoire of personal behaviors and strategies. The leader is important in forging links—creating connections—among an organiza- tion’s members to promote high levels of performance and quality outcomes.

The functions of a leader are to achieve a consensus within the group about its goals, main- tain a structure that facilitates accomplishing the goals, supply necessary information that helps provide direction and clarification, and maintain group satisfaction, cohesion, and performance.

A manager, in contrast, is an individual employed by an organization who is responsible and accountable for efficiently accomplishing the goals of the organization. Managers focus on coordinating and integrating resources, using the functions of planning, organizing, supervising, staffing, evaluating, negotiating, and representing. Interpersonal skill is important, but a man- ager also has authority, responsibility, accountability, and power defined by the organization. The manager’s job is to:

● Clarify the organizational structure ● Choose the means by which to achieve goals ● Assign and coordinate tasks, developing and motivating as needed ● Evaluate outcomes and provide feedback

All good managers are also good leaders—the two go hand in hand. However, one may be a good manager of resources and not be much of a leader of people. Likewise, a person who is a good leader may not manage well. Both roles can be learned; skills gained can enhance either role.

Leadership Leadership may be formal or informal. Leadership is formal when practiced by a nurse with legitimate authority conferred by the organization and described in a job description (e.g., nurse manager, supervisor, coordinator, case manager). Formal leadership also depends on personal skills, but it may be reinforced by organizational authority and position. Insightful formal lead- ers recognize the importance of their own informal leadership activities and the informal leader- ship of others who affect the work in their areas of responsibility.

Leadership is informal when exercised by a staff member who does not have a speci- fied management role. A nurse whose thoughtful and convincing ideas substantially influ- ence the efficiency of work flow is exercising leadership skills. Informal leadership depends primarily on one’s knowledge, status (e.g., advanced practice nurse, quality improvement coordinator, education specialist, medical director), and personal skills in persuading and guiding others.


Traditional Leadership Theories Research on leadership has a long history, but the focus has shifted over time from personal traits to behavior and style, to the leadership situation, to change agency (the capacity to trans- form), and to other aspects of leadership. Each phase and focus of research has contributed to managers’ insights and understandings about leadership and its development. Traditional leader- ship theories include trait theories, behavioral theories, and contingency theories.

In the earliest studies researchers sought to identify inborn traits of successful leaders. Although inconclusive, these early attempts to specify unique leadership traits provided bench- marks by which most leaders continue to be judged.

Research on leadership in the early 1930s focused on what leaders do. In the behavioral view of leadership, personal traits provide only a foundation for leadership; real leaders are made through education, training, and life experiences.

Contingency approaches suggest that managers adapt their leadership styles in relation to changing situations. According to contingency theory, leadership behaviors range from au- thoritarian to permissive and vary in relation to current needs and future probabilities. A nurse manager may use an authoritarian style when responding to an emergency situation such as a cardiac arrest but use a participative style to encourage development of a team strategy to care for patients with multiple system failure.

The most effective leadership style for a nurse manager is the one that best complements the organizational environment, the tasks to be accomplished, and the personal characteristics of the people involved in each situation.

Contemporary Theories Leaders in today’s health care environment place increasing value on collaboration and team- work in all aspects of the organization. They recognize that as health systems become more complex and require integration, personnel who perform the managerial and clinical work must cooperate, coordinate their efforts, and produce joint results. Leaders must use additional skills, especially group and political leadership skills, to create collegial work environments.

Quantum Leadership Quantum leadership is based on the concepts of chaos theory (see Chapter 2). Reality is constantly shifting, and levels of complexity are constantly changing. Movement in one part of the system reverberates throughout the system. Roles are fluid and outcome oriented. It matters little what you did; it only matters what outcome you produced. Within this framework, employees become di- rectly involved in decision making as equitable and accountable partners, and managers assume more of an influential facilitative role, rather than one of control (Porter-O’Grady & Malloch, 2010).

Quantum leadership demands a different way of thinking about work and leadership. Change is expected. Informational power, previously the purview of the leader, is now available to all. Patients and staff alike can access untold amounts of information. The challenge, however, is to assist patients, uneducated about health care, how to evaluate and use the information they have. Because staff have access to information only the leader had in the past, leadership be- comes a shared activity, requiring the leader to possess excellent interpersonal skills.

Transactional Leadership Transactional leadership is based on the principles of social exchange theory. The primary premise of social exchange theory is that individuals engage in social interactions expecting to give and receive social, political, and psychological benefits or rewards. The exchange process between leaders and followers is viewed as essentially economic. Once initiated, a sequence of exchange behavior continues until one or both parties finds that the exchange of performance and rewards is no longer valuable.


The nature of these transactions is determined by the participating parties’ assessments of what is in their best interests; for example, staff respond affirmatively to a nurse manager’s re- quest to work overtime in exchange for granting special requests for time off. Leaders are suc- cessful to the extent that they understand and meet the needs of followers and use incentives to enhance employee loyalty and performance. Transactional leadership is aimed at maintaining equilibrium, or the status quo, by performing work according to policy and procedures, maxi- mizing self-interests and personal rewards, emphasizing interpersonal dependence, and routin- izing performance (Weston, 2008).

Transformational Leadership Transformational leadership goes beyond transactional leadership to inspire and motivate fol- lowers (Marshall, 2010). Transformational leadership emphasizes the importance of interper- sonal relationships. Transformational leadership is not concerned with the status quo, but with effecting revolutionary change in organizations and human service. Whereas traditional views of leadership emphasize the differences between employees and managers, transformational lead- ership focuses on merging the motives, desires, values, and goals of leaders and followers into a common cause. The goal of the transformational leader is to generate employees’ commitment to the vision or ideal rather than to themselves.

Transformational leaders appeal to individuals’ better selves rather than these individuals’ self-interests. They foster followers’ inborn desires to pursue higher values, humanitarian ideals, moral missions, and causes. Transformational leaders also encourage others to exercise leader- ship. The transformational leader inspires followers and uses power to instill a belief that follow- ers also have the ability to do exceptional things.

Transformational leadership may be a natural model for nursing managers, because nurs- ing has traditionally been driven by its social mandate and its ethic of human service. In fact, Weberg (2010) found that transformational leadership reduced burnout among employees, and Grant et al., (2010) reports transformational leadership positively affected the practice environ- ment in one medical center. Transformational leadership can be used effectively by nurses with clients or coworkers at the bedside, in the home, in the community health center, and in the health care organization.

Shared Leadership Reorganization, decentralization, and the increasing complexity of problem solving in health care have forced administrators to recognize the value of shared leadership, which is based on the empowerment principles of participative and transformational leadership (Everett & Sitterding, 2011). Essential elements of shared leadership are relationships, dialogues, partnerships, and understanding boundaries. The application of shared leadership assumes that a well-educated, highly professional, dedicated workforce is comprised of many leaders. It also assumes that the notion of a single nurse as the wise and heroic leader is unrealistic and that many individuals at various levels in the organization must be responsible for the organization’s fate and performance.

Different issues call for different leaders, or experts, to guide the problem-solving process. A single leader is not expected always to have knowledge and ability beyond that of other mem- bers of the work group. Appropriate leadership emerges in relation to the current challenges of the work unit or the organization. Individuals in formal leadership positions and their colleagues are expected to participate in a pattern of reciprocal influence processes. Kramer, Schmalenberg, and Maguire (2010) and Watters (2009) found shared leadership common in Magnet-certified hospitals.

Examples of shared leadership in nursing include:

● Self-directed work teams. Work groups manage their own planning, organizing, schedul- ing, and day-to-day work activities.

● Shared governance. The nursing staff are formally organized at the service area and orga- nizational levels to make key decisions about clinical practice standards, quality assurance


and improvement, staff development, professional development, aspects of unit opera- tions, and research. Decision making is conducted by representatives of the nursing staff who have been authorized by the administrative hierarchy and their colleagues to make decisions about important matters.

● Co-leadership. Two people work together to execute a leadership role. This kind of lead- ership has become more common in service-line management, where the skills of both a clinical and an administrative leader are needed to successfully direct the operations of a multidisciplinary service. For example, a nurse manager provides administrative leader- ship in collaboration with a clinical nurse specialist, who provides clinical leadership. The development of co-leadership roles depends on the flexibility and maturity of both indi- viduals, and such arrangements usually require a third party to provide ongoing consulta- tion and guidance to the pair.

Servant Leadership Founded by Robert Greenleaf (Greenleaf, 1991), servant leadership is based on the premise that leadership originates from a desire to serve and that in the course of serving, one may be called to lead (Keith, 2008; The Greenleaf Center for Servant Leadership, 2011). Servant leaders embody three characteristics:

● Empathy ● Awareness ● Persuasion (Neill & Saunders, 2008)

Servant leadership appeals to nurses for two reasons. First, our profession is founded on principles of caring, service, and the growth and health of others (Anderson et al., 2010). Sec- ond, nurses serve many constituencies, often quite selflessly, and consequently bring about change in individuals, systems, and organizations.

Emotional Leadership Social intelligence (Goleman, 2007), including emotional intelligence (Bradberry & Greaves, 2009; Goleman, 2006), has gained acceptance in the business world and more recently in health care (Veronsesi, 2009). Emotional intelligence involves personal competence, which includes self-awareness and self-management, and social competence, which includes social awareness and relationship management that begins with authenticity. (See Table 4-1.)

Goleman (2007) asserts that attachment to others is an innate trait of human beings. Thus, emotions are “catching.” Consider a person having a pleasant day. Then an otherwise innocuous event turns into a negative experience that spills over into future interactions. Or the reverse. A positive experience lightens the mood and affects the next encounter. When people feel good, they work more effectively.

Emotional intelligence has been linked with leadership (Antonakis, Ashkanasy, & Dasbor- ough, 2009; Cote et al., 2010; Lucas, Spence-Laschinger, & Wong, 2008). One study, however, found no relationship between emotional intelligence and transformational leadership (Linde- baum & Cartwright, 2010).

Nurses, with their well-honed skills as compassionate caregivers, are aptly suited to this direction in leadership that emphasizes emotions and relationships with others as a primary at- tribute for success. These skills fit better with the more contemporary relationship-oriented theo- ries as well. Thus, the workplace is a more complex and intricate environment than previously suggested. The following chapters show you how to put these skills to work.

Health care environments require innovations in care delivery and therefore innovative lead- ership approaches. Quantum, transactional, transformational, shared, servant, and emotional leadership make up a new generation of leadership styles that have emerged in response to the need to humanize working environments and improve organizational performance. In practice, leaders tap a variety of styles culled from diverse leadership theories.


TABLE 4-1 AONE Five Areas of Competency


COMMUNICATION AND RELATIONSHIPS-BUILDING COMPETENCIES INCLUDE: ● Effective communication ● Relationship management ● Influence of behaviors ● Ability to work with diversity ● Shared decision making ● Community involvement ● Medical staff relationships ● Academic relationships

KNOWLEDGE OF THE HEALTH CARE ENVIRONMENT INCLUDES: ● Clinical practice knowledge ● Patient care delivery models and work design knowledge ● Health care economics knowledge ● Health care policy knowledge ● Understanding of governance ● Understanding of evidence-based practice ● Outcome measurement ● Knowledge of and dedication to patient safety ● Understanding of utilization/case management ● Knowledge of quality improvement and metrics ● Knowledge of risk management

LEADERSHIP SKILLS INCLUDE: ● Foundational thinking skills ● Personal journey disciplines ● The ability to use systems thinking ● Succession planning ● Change management

PROFESSIONALISM INCLUDES: ● Personal and professional accountability ● Career planning ● Ethics ● Evidence-based clinical and management practice ● Advocacy for the clinical enterprise and for nursing practice ● Active membership in professional organizations

BUSINESS SKILLS INCLUDE: ● Understanding of health care financing ● Human resource management and development ● Strategic management ● Marketing ● Information management and technology

Copyright © 2005 by the American Organization of Nurse Executives. Address reprint permission requests to aone@aha.org.

Traditional Management Functions In 1916, French industrialist Henri Fayol first described the functions of management as planning, organizing, directing, and controlling. These are still relevant today, however, the complexity of today’s health care systems make these functions more difficult and less certain (Clancy, 2008).


Planning Planning is a four-stage process to:

● Establish objectives (goals) ● Evaluate the present situation and predict future trends and events ● Formulate a planning statement (means) ● Convert the plan into an action statement

Planning is important on both an organizational and a personal level and may be an in- dividual or group process that addresses the questions of what, why, where, when, how, and by whom. Decision making and problem solving are inherent in planning. Numerous computer software programs and databases are available to help facilitate planning.

Organization-level plans, such as determining organizational structure and staffing or operational budgets, evolve from the mission, philosophy, and goals of the organization. The nurse manager plans and develops specific goals and objectives for her or his area of responsibility.

Antonio, the nurse manager of a home care agency, plans to establish an in-home photo- therapy program, knowing that part of the agency’s mission is to meet the health care needs of the child-rearing family. To effectively implement this program, he would need to address:

• How the program supports the organization’s mission

• Why the service would benefit the community and the organization

• Who would be candidates for the program

• Who would provide the service

• How staffing would be accomplished

• How charges would be generated

• What those charges should be

Planning can be contingent or strategic. Using contingency planning, the manager identifies and manages the many problems that interfere with getting work done. Contingency planning may be re- active, in response to a crisis, or proactive, in anticipation of problems or in response to opportunities.

What would you do if two registered nurses called in sick for the 12-hour night shift? What if you were a manager for a specialty unit and received a call for an admission, but had no more beds? Or what if you were a pediatric oncology clinic manager and a patient’s sibling exposed a number of immunocompromised patients to chickenpox? Planning for crises such as these are examples of contingency planning.

Strategic planning refers to the process of continual assessment, planning, and evaluation to guide the future (Fairholm & Card, 2009). Its purpose is to create an image of the desired future and design ways to make those plans a reality. A nurse manager might be charged, for example, with developing a business plan to add a time-saving device to commonly used equipment, pre- senting the plan persuasively, and developing operational plans for implementation, such as ac- quiring devices and training staff.

Organizing Organizing is the process of coordinating the work to be done. Formally, it involves identifying the work of the organization, dividing the labor, developing the chain of command, and assign- ing authority. It is an ongoing process that systematically reviews the use of human and material resources. In health care, the mission, formal organizational structure, delivery systems, job de- scriptions, skill mix, and staffing patterns form the basis for the organization.

In organizing the home phototherapy project, Antonio develops job descriptions and pro- tocols, determines how many positions are required, selects a vendor, and orders supplies.


Directing Directing is the process of getting the organization’s work done. Power, authority, and leader- ship style are intimately related to a manager’s ability to direct. Communication abilities, moti- vational techniques, and delegation skills also are important. In today’s health care organization, professional staff are autonomous, requiring guidance rather than direction. The manager is more likely to sell the idea, proposal, or new project to staff rather than tell them what to do. The manager coaches and counsels to achieve the organization’s objectives. In fact, it may be the nurse who assumes the traditional directing role when working with unlicensed personnel.

In directing the home phototherapy project, Antonio assembles the team of nurses to provide the service, explains the purpose and constraints of the program, and allows the team to decide how they will staff the project, giving guidance and direction when needed.

Controlling Controlling involves comparing actual results with projected results. This includes establishing standards of performance, determining the means to be used in measuring performance, evaluat- ing performance, and providing feedback. The efficient manager constantly attempts to improve productivity by incorporating techniques of quality management, evaluating outcomes and per- formance, and instituting change as necessary.

Today, managers share many of the control functions with the staff. In organizations us- ing a formal quality improvement process, such as continuous quality improvement (CQI), staff participate in and lead the teams. Some organizations use peer review to control quality of care.

When Antonio introduces the home phototherapy program, the team of nurses involved in the program identify standards regarding phototherapy and their individual performances. A subgroup of the team routinely reviews monitors designed for the program and identifies ways to improve the program.

Planning, organizing, directing, and controlling reflect a systematic, proactive approach to management. This approach is used widely in all types of organizations, health care included, but Clancy (2008) asserts that today’s rapidly changing health care environment makes it more difficult to control events and predict outcomes.

Nurse Managers in Practice Putting nursing management into practice in the dynamic health care system of today is a chal- lenge. Organizations are in flux, structures are changing, and roles and functions of nurse man- agers become moving targets.

Titles for nurse managers vary as widely as do their responsibilities. The first level manager may be titled first-line manager or unit manager. A middle manager might be deemed a depart- ment manager. The top-level nursing administrator could be named executive manager, chief nursing officer, or vice president of patient care. In addition, clinical titles might include profes- sional practice leaders who are clinical nurse specialists or nurse practitioners. Regardless of their titles, all nurse managers must hold certain competencies.

Nurse Manager Competencies The American Organization of Nurse Executives (AONE), an organization for the top nursing administrators in health care, identified five areas of competency necessary for nurses at all lev- els of management (AONE, 2005). Nurse managers must be skilled communicators and rela- tionship builders, have a knowledge of the health care environment, exhibit leadership skills, display professionalism, and demonstrate business skills (see Table 4-2). These characteristics intersect to provide a common core of leadership competencies (see Figure 4-1).


TABLE 4-2 Emotional Intelligence Domains and Associated Competencies

PERSONAL COMPETENCE: These capabilities determine how we manage ourselves.

Self-Awareness • Emotional self-awareness: Reading one’s own emotions and recogniz- ing their impact; using “gut sense” to guide decisions

• Accurate self-assessment: Knowing one’s strengths and limits • Self-confidence: A sound sense of one’s self-worth and capabilities

Self-Management • Emotional self-control: Keeping disruptive emotions and impulses under control

• Transparency: Displaying honesty and integrity; trustworthiness • Adaptability: Flexibility in adapting to changing situations or over-

coming obstacles • Achievement: The drive to improve performance to meet inner stan-

dards of excellence • Initiative: Readiness to act and seize opportunities • Optimism: Seeing the upside in events

SOCIAL COMPETENCE: These capabilities determine how we manage relationships.

Social Awareness • Empathy: Sensing others’ emotions, understanding their perspective, and taking active interest in their concerns

• Organizational awareness: Reading the currents, decision networks, and politics at the organizational level

• Service: Recognizing and meeting follower, client, or customer needs

Relationship Management

• Inspirational leadership: Guiding and motivating with a compelling vision

• Influence: Wielding a range of tactics for persuasion • Developing others: Bolstering others’ abilities through feedback and

guidance • Change catalyst: Initiating, managing, and leading in a new direction • Conflict management: Resolving disagreements • Building bonds: Cultivating and maintaining a web of relationships • Teamwork and collaboration: Cooperation and team building

From Goleman, D., Boyatsis, R., & McKee, A. Primal Leadership (2002). Boston: Harvard Business School Press, 39. Copyright © 2002 by the Harvard Business School Publishing Corporation; all rights reserved.

Staff Nurse Although not formally a manager, the staff nurse supervises LPNs, other professionals, and assistive personnel and so is also a manager who needs management and leadership skills. Com- munication, delegation, and motivation skills are indispensable.

In some organizations, shared governance has been implemented and traditional manage- ment responsibilities are allocated to the work team. In this case, staff nurses have considerable involvement in managing the unit. More information about shared governance and other innova- tive management methods is provided in Chapter 2.

First-Level Management The first-level manager is responsible for supervising the work of nonmanagerial personnel and the day-to-day activities of a specific work unit or units. With primary responsibility for motivat- ing the staff to achieve the organization’s goals, the first-level manager represents staff to upper administration, and vice versa. Nurse managers have 24-hour accountability for the management of a unit(s) or area(s) within a health care organization. In the hospital setting, the first-level


manager is usually the head nurse, nurse manager, or an assistant. In other settings, such as an ambulatory care clinic or a home health care agency, a first-level manager may be referred to as a coordinator. Box 4-1 describes a first-level manager’s day.

Charge Nurse Another role that does not fit the traditional levels of management is the charge nurse. The charge nurse position is an expanded staff nurse role with increased responsibility. The charge nurse functions as a liaison to the nurse manager, assisting in shift-by-shift coordination and promotion of quality patient care as well as efficient use of resources. The charge nurse of- ten troubleshoots problems and assists other staff members in decision making. Role modeling, mentoring, and educating are additional roles that the charge nurse often assumes. Therefore, the charge nurse usually has extensive experience, skills, and knowledge in clinical practice and is familiar with the organization’s standards and practices.

The charge nurse’s job differs, though, from that of the first-level manager. The charge nurse’s responsibilities are confined to a specific shift or task, whereas the first-level manager has 24-hour responsibility and accountability for all unit activities. Also the charge nurse has limited authority; the charge nurse functions as an agent of the manager and is accountable to the manager for any actions taken or decisions made.

Although often involved in planning and organizing the work to be done, the charge nurse has a limited scope of responsibility, usually restricted to the unit for a specific time period. In the past, the charge nurse had limited involvement in the formal evaluation of performance, but in today’s climate of efficiency, the charge nurse may be involved in evaluations as well. With the trend toward participative management, charge nurses are assuming more of the roles and functions traditionally reserved for the first-level manager.

In some organizations, the position may be permanent and assigned and thus a part of the formal management team; in other organizations, the job may be rotated among experienced staff. The charge nurse, who switches from serving as a manager one day and a staff nurse the next, is especially challenged to balance the rotating roles (Leary & Allen, 2005). In some orga- nizations, a differential amount of compensation is paid to the person performing charge duties; in others, no differential is paid because the position is shared equally among staff or represents a higher rung of a career ladder (possibly the first rung of a management ladder).

The charge nurse is often key to a unit’s successful functioning (Leary & Allen, 2005). A charge nurse usually has considerable influence with the staff and may actually have more infor- mal power than the manager. Therefore, the charge nurse is an important leader and can benefit by developing the skills considered necessary for a manager. Acting as charge nurse is often the first step toward a formal management position.

Professionalism Communication & relationship management

Business skills and principles

Knowledge of health care environment


Figure 4-1 • Core of leadership competencies. Source: Copyright © 2005 by the American Organization of Nurse Executives. Address reprint permission requests to aone@aha.org.


Clinical Nurse Leader The clinical nurse leader is not a manager, per se, but instead is a lateral integrator of care re- sponsible for a specified group of clients within a microsystem of the health care setting (AACN, 2007). The CNL role is designed to respond more effectively to challenges in today’s rapidly changing, complex technological environment (Harris & Roussel, 2009). Prepared at the mas- ter’s level, the CNL coordinates care at the bedside and supervises the health care team, among other duties (Sherman, 2010).

Use of the clinical nurse leader positions in health care organizations has improved patient outcomes and reduced costs and is expected to expand as the demand for quality continues (Hix, McKeon, & Walters, 2009; Stanley et al., 2008). Problems have emerged, however, as CNLs transition into organizations. These include being drawn into direct patient care, explaining the role to other nurses and health care providers, and acceptance by the staff (Sherman, 2010).

BOX 4-1 A Day in the Life of a First-Level Manager

As the manager for a surgical intensive care unit (SICU), Jamal Johnson is routinely responsible for supervising patient care, trouble shooting, maintain- ing compliance with standards, and giving guidance and direction as needed. In addition, he has fiscal and committee responsibilities and is accountable to the organization for maintaining its philosophies and ob- jectives. The following exemplifies a typical day.

As Jamal came on duty, he learned that there had been a multiple vehicle accident and that three of the victims were currently in the operating room and destined for the unit. The assistant manager for nights had secured more staff for days: two part-time SICU nurses and a staff nurse from the surgical floor. However, she had not had time to arrange for two more patients to be moved out of the unit. From their assigned nurses, Jamal obtained an update on the pa- tients who were candidates for transfer from the SICU to another floor and, in consultation with his assistant, made the appropriate arrangements for the transfers.

Other staffing problems were at hand: in addition to the nurse who had been pulled from the surgical floor, there were two orientees, and the staff needed to attend a safety in-service. As soon as the charge nurse came in, Jamal apprised her of the situation. Together, they reviewed the operating room schedule and identified staffing arrangements. Fortunately, Jamal had only one meeting today and would be avail- able for backup staffing. In the meantime, he would work on evaluations.

After his discussions with the charge nurse, Jamal met with each of the night nurses to get an update on the status of the other patients. Then he went to his office to review his messages and plan his day. Tamera, an RN, had just learned she was pregnant but stated that she planned to work until delivery. Jamal learned that his budget hearing had been scheduled for the following Monday at 10 A.M. A pharmaceutical

representative wanted to provide an in-service for the unit. Fortunately, there were no immediate crises.

Jamal called his supervisor to inform her of the status of affairs on the unit and learned that two other individuals in the accident had been transported to another hospital; one had since died. They discussed the ethical and legal ramifications. Jamal would need to review the policies on relations with the press and law enforcement and update his staff.

As the first patient returned from surgery, Jamal went to help admit the patient and receive a report. Learning that the patient was stable, he informed Lu- cinda, the charge nurse, that the patient they had just received was likely to be charged with manslaughter and reviewed media and legal policies with her. They also discussed how the staff were doing. There were some equipment problems in room 2110; Lucinda had temporarily placed the patient in that room on a transport monitor and was waiting for a biomedi- cal technology staff member to check the monitor. Could Jamal follow up? Jamal agreed and commended Lucinda for her problem solving. She reminded Jamal they would need backup for lunch and in-services.

As Jamal returned to his office, he noted that the alarms were turned off on one of the patients. He pulled aside the nurse assigned to the patient and re- minded her of the necessity to keep the alarms on at all times. Finally, back in his office, he called biomedical technology to ascertain their plans to check the monitor and made notes regarding the charge nurse’s problem- solving abilities and the staff nurse’s negligence.

He reviewed staffing for the next 24 hours and noted that an extra nurse was needed for both the evening and night shifts because of the increased workload. After finding staff, he was able to finish one evaluation before covering for the in-services and lunch and then attending the policy and procedure team meeting.


Questions about the differences between a clinical nurse specialist and the CNL are also raised. While the CNS is assigned hospital-wide, the CNL is unit based. Ignatius (2010) sug- gests that hospitals are designed for the 19th century with little accommodation for the coordina- tion of care needed in this century. CNLs can help bridge that gap.

Followership: An Essential Component of Leadership Leaders cannot lead without followers in much the same way that instructors need students to teach. Nor is anyone a leader all the time; everyone is a follower as well. Even the hospital CEO follows the board of directors’ instructions.

Followership is interactive and complementary to leadership, and the follower is an active participant in the relationship with the leader. A skilled, self-directed, energetic staff member is an invaluable complement to the leader and to the group. Most leaders welcome active follow- ers; they help leaders accomplish their goals and the team succeed.

Followers are powerful contributors to the relationship with their leaders. Followers can in- fluence leaders in negative ways, as government cover-ups, Medicare fraud, and corporate law- breaking attest. The reverse is also true. Poor managers can undermine good followers by direct and indirect ways, such as criticizing, belittling, or ignoring positive contributions to the team (Arnold & Pulich, 2008). To counter such behaviors, you should note incidents that you experi- ence, enlist others to help, and remain in control of yourself. (See Chapter 21 for more about handling difficult problems, such as bullying.)

Miller (2007) describes followership along two continuums: participative and thinking. Par- ticipation can vary from passive (ineffective follower) to active (successful follower). Thinking can fluctuate between dependent and uncritical to independent and critical. Courage to be active contributors to the team and to the leader characterizes the effective follower.

Followership is fluid in another way. The nurse may be a leader at one moment and become a follower soon afterward. In fact, the ability to move along the continuum of degrees of fol- lowership is a must for successful teamwork. The nurse is a leader with subordinate staff and a follower of the nurse manager, possibly at the same time.

A constructive follower has several positive characteristics:

● Self-directed ● Proactive ● Supportive ● Commitment ● Initiative

Many of these qualities are the same ones that make an excellent leader, discussed next.

What Makes a Successful Leader? Leadership success is an elusive quality. Some people seem to be natural leaders, and others struggle to attain leadership skills.

See how one nurse leader described her work:

I believe that the most important role of a nurse leader is to live the life and exemplify at all times the qualities that every professional nurse leader should. I also believe the nurse leader/manager must be the person to set the bar high and perform at the highest levels in order to inspire their staff to achieve the same.

As a nurse manager, I at all times work to be an excellent communicator, compassionate, caring, vested in my job, willing to go above and beyond, and assist people with any task or issue they just need a little extra support on. I feel that by doing this, there is never a question what I expect from them and those around me. I verbally set expectations, but by living them as a role model.


For example, at shift change two nights ago, a physician wanted to do a bedside proce- dure. I was actually planning on leaving soon after a long day. I knew it was shift change, and didn’t want the staff to be interrupted, so I volunteered to stay and do the procedure so they could continue with report and the physician and patient were not kept waiting. The staff were very appreciative, but more importantly, I think it set the right example of teamwork, being flexible, being patient focused, etc.

I think it is important for the nurse leader to provide feedback at times other than evalu- ations. The nurse leader should schedule time into the workweek to have informal conver- sations with staff on the floor about comments a patient or coworker has shared or to send an e-mail to a staff member about feedback the leader has received. I think constructive feedback needs to be timely and supportive and the need for improvement discussed long before an evaluation.

I find having conversations about “What are your goals?” or “What can I help you explore or do that you’ve been dreaming about to enhance your nursing career?” People need to feel comfortable having these conversations with their trusted nurse leader. Build- ing relationships with those you lead is important.

Leaders are skilled in empowering others, creating meaning and facilitating learning, developing knowledge, thinking reflectively, communicating, solving problems, making deci- sions, and working with others. Leaders generate excitement; they clearly define their purpose and mission. Leaders understand people and their needs; they recognize and appreciate differ- ences in people, individualizing their approach as needed.

What You Know Now • A leader employs specific behaviors and strategies to influence individuals and groups to attain goals. • Managers are responsible for efficiently accomplishing the goals of the organization. • Leadership approaches are not static; they can be adapted for different situations, tasks, individuals, and

future expectations. • Contemporary theorists assert that reality is fluid, complex, and interrelated and that interpersonal

relationships are core to successful leadership. • Traditional management functions include planning, organizing, directing, and controlling. • Both leaders and followers contribute to the effectiveness of their relationship. • Successful leaders inspire and empower others, generate excitement, and individualize their approach to

differences in people.

Tools for Leading, Managing, and Following 1. Pay attention to the context: Are you leading, managing, or following in this situation? 2. Recognize that each situation requires a specific skill set. Each is described in the chapter. 3. Notice others whose leadership style you admire and try to incorporate their behaviors in your own

leadership if the situation is appropriate. 4. Evaluate yourself at regular opportunities in order to find ways to improve your abilities to lead,

manage, and follow.

Questions to Challenge You 1. Think about people you know in management positions. Are any of them leaders as well?

Describe the characteristics that make them leaders. 2. Consider people you know who are not in management positions but are leaders nonetheless.

What characteristics do they have that make them leaders?



3. Describe the manager to whom you report. (If you are not employed, use the first-level manager on a clinical placement site.) Evaluate this person using the management functions described in the chapter.

4. Imagine yourself as a manager whether you are in a management position or not. What skills do you possess that help you? What skills would you like to improve?

5. Evaluate yourself as a follower. Find at least one characteristic listed in the chapter that you would like to develop or improve. During the next week, try to find opportunities to practice that skill.

6. Assess yourself as a leader. How would you like to improve?

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

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Bradberry, T. & Greaves, J. (2009). Emotional intel- ligence 2.0. San Diego, CA: TalentSmart.

Clancy, T. R. (2008). Control: What we can learn from complex systems science. Journal of Nursing Admin- istration, 38(6), 272–274.

Cote, S., Lopes, P. N., Salovey, P., & Miners, C. T. H. (2010). Emotional intel- ligence and leadership emergence in small groups. The Leadership Quarterly, 21(3), 496–508.

Everett, L. Q., & Sitterding, M. C. (2011). Transforma- tional leadership required to design and sustain evidence-based practice: A system exemplar. Western Journal of Nursing Re- search, 33(3), 398–426.

Fairholm, M. R., & Card, M. (2009). Perspectives of stra- tegic thinking: From control- ling chaos to embracing it. Journal of Management and Organization, 15(1), 17–30.

Goleman, D. (2006). Emotional intelligence: Why it can matter more than IQ. New York: Bantam.

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Harris, J. D., & Roussel, L. (2009). Initiating and sus- taining the clinical nurse leader role: A practical guide. Sudbury, MA: Jones & Bartlett Learning.

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Why Change?

The Nurse as Change Agent

Change Theories

The Change Process ASSESSMENT







Resistance to Change



Handling Constant Change

Initiating and Managing Change 5

Key Terms Change Change agent Driving forces

1. Explain why nurses have the opportunity to be change agents.

2. Describe how different theorists explain change.

3. Discuss how the change process is similar to the nursing process.

4. Differentiate among change strategies. 5. Discuss how to handle resistance to

change. 6. Describe the nurse’s role in change.

Learning Outcomes After completing this chapter, you will be able to:

Empirical–rational model Normative–reeducative


Power-coercive strategies Restraining forces Transitions


Why Change? Change is inevitable, if not always welcome. Organizational change is essential for adaptation; creative change is mandatory for growth (Heath & Heath, 2010). Change, though, is a continu- ally unfolding process rather than an either/or event. The process begins with the present state, is disrupted, moves through a transition period, and ultimately comes to a desired state. Once the desired state has been reached, however, the process begins again.

Leading change is never needed more in today’s rapidly evolving system of health care. Those who initiate and manage change often encounter resistance. Even when planned, it can be threatening and a source of conflict because change is the process of making something different from what it was. There is a sense of loss of the familiar, the status quo. This is particu- larly true when change is unplanned or beyond human control. Even when change is expected and valued, a grief reaction still may occur.

Although nurses should understand and anticipate these reactions to change, they need to develop and exude a different approach. They can view change as a challenge and encourage their colleagues to participate. They can become uncomfortable with the status quo and be willing to take risks.

This is a particular fortuitous time for the nursing profession (Nickitas, 2010). The Institute of Medicine’s report on the future of nursing proposes radical change for the profession (IOM, 2010). Specifically, they propose:

● Nurses should practice to the full extent of their education and training. ● Nurses should achieve higher levels of education and training through an improved

education system that promotes seamless academic progression. ● Nurses should be full partners with physicians and other health care professionals in

redesigning health care in the United States. ● Effective workforce planning and policymaking require better data collection and an

improved information infrastructure.

Furthermore, the IOM makes eight recommendations:

● Remove scope-of-practice barriers. ● Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. ● Implement nurse residency programs. ● Increase the proportion of nurses with baccalaureate degrees to 80 percent by 2020. ● Ensure nurses engage in lifelong learning. ● Prepare and enable nurses to lead change to advance health. ● Build an infrastructure for the collection and analysis of interprofessional health care

workforce data (IOM, 2010).

The Nurse as Change Agent A change agent is one who works to bring about a change. Being a change agent, however, is not easy. Although the end result of change may benefit nurses and patients alike, initially it requires time, effort, and energy, all in short supply in the high-stress environment of health care.

Several recent reports document nurses’ roles in facilitating change. Holtrop et al. (2008) found that nurse consultants improved healthy behaviors in patients served by 10 primary care practices in two health care systems. Also, MacDavitt, Cieplincki, and Walker (2011) report that small changes in communication resulted in improved patient satisfaction on a pediatric inpatient unit. Finally, McMurray et al. (2010) found that nurse managers played a key role in implementing successful change in bedside handover in two hospitals.

Changes will continue at a rapid pace with or without nursing’s expert guidance. Nurses, like organizations, cannot afford merely to survive changes. If they are to exist as a distinct pro- fession that has expertise in helping individuals respond to actual or potential health problems,


they must be proactive in shaping the future. Opportunities exist now for nurses, especially those in management positions, to change the system about which they so often complain.

Change Theories Because change occurs within the context of human behavior, understanding how change does (or doesn’t) occur is helpful in learning how to initiate or manage change. Five theories explain the change process from a social–psychological viewpoint. See Table 5-1 for a comparison.

Lewin (1951) proposes a force-field model, shown in Figure 5-1. He sees behavior as a dynamic balance of forces working in opposing directions within a field (such as an organiza- tion). Driving forces facilitate change because they push participants in the desired direction. Restraining forces impede change because they push participants in the opposite direction.

To plan change, one must analyze these forces and shift the balance in the direction of change through a three-step process: unfreezing, moving, and refreezing. Change occurs by add- ing a new force, changing the direction of a force, or changing the magnitude of any one force. Basically, strategies for change are aimed at increasing driving forces, decreasing restraining forces, or both. The image of people’s attitudes thawing and then refreezing is conceptually use- ful. This symbolism helps to keep theory and reality in mind simultaneously.

Lippitt and colleagues (1958) extended Lewin’s theory to a seven-step process and focused more on what the change agent must do than on the evolution of change itself. (See Table 5-1.) They emphasized participation of key members of the target system throughout the change pro- cess, particularly during planning. Communication skills, rapport building, and problem-solving strategies underlie their phases.

Havelock (1973) described a six-step process, also a modification of Lewin’s model. Have- lock describes an active change agent as one who uses a participative approach.

Rogers (2003) takes a broader approach than Lewin, Lippitt, or Havelock (see Table 5-1). His five-step innovation–decision process details how an individual or decision-making unit

Figure 5-1 • Lewin’s force-field model of change. Adapted from Resolving Social Conflicts and Field Theory in Social Science by K. Lewin. Copyright © 1997, by the American Psychological Association. Adapted with permission.

Restraining forces

Driving forces


Fear of job loss

Nurse manager lacks change agent skills

Entrenched director of


Present (status quo)

Force will be toward change

Budget in red (financial incentive

to change)

Administration mandates the


Interested vice-president

Need new solution (old one doesn’t work)

Some long-term employees

resist change

Almost complete turnover of staff

(many new nurses)

Restraining forces

Driving forces

(unfreezing) (Refreezing)

New equilibrium

MovingPresent equilibrium (status quo)

Restraining forces

Driving forces


passes from first knowledge of an innovation to confirmation of the decision to adopt or reject a new idea. His framework emphasizes the reversible nature of change: participants may initially adopt a proposal but later discontinue it, or the reverse—they may initially reject it but adopt it at a later time. This is a useful distinction. If the change agent is unsuccessful in achieving full implementation of a proposal, it should not be assumed the issue is dead. It can be resurrected, perhaps in an altered form or at a more opportune time.

Rogers stresses two important aspects of successful planned change: key people and policy makers must be interested in the innovation and committed to making it happen. Erwin (2009) found that organizational change in hospitals could only be successful and sustained if senior administrators were fully committed to the change.

Used primarily as a tool for patient teaching, Prochaska and DiClemente (2005) proposed a transtheoretical model of behavior change. Five stages characterize their model. The stages occur in sequence, and the person must be ready for change to occur, according to this model.

The Change Process Steps in the change process follow the same path as the nursing process: assessment, planning, implementation, and evaluation (see Table 5-2).

Assessment Emphasis is placed on the assessment phase of change for two reasons. Without data collection and analysis, planned change will not proceed past the “wouldn’t it be a good idea if” stage.

Identify the Problem or the Opportunity Change is often planned to close a discrepancy between the desired and actual state of affairs. Discrepancies may arise because of problems in reaching performance goals or because new goals have been created.

Opportunities demand change as much as (or more than) problems do, but they are often overlooked. Be it a problem or an opportunity, it must be identified clearly. If the issue is perceived differently by key individuals, the search for solutions becomes confused.

TABLE 5-1 Comparison of Change Models

Lewin Lippitt Havelock Rogers Prochaska & DiClemente

1. Unfreezing 1. Diagnose problem 1. Building a relationship 1. Knowledge 1. Precontemplation

2. Moving 2. Assess motivation 2. Diagnosing the problem 2. Persuasion 2. Contemplation

3. Refreezing 3. Assess change agent’s motivations and resources

3. Acquiring resources

4. Choosing the solution

3. Decision

4. Implementation

3. Preparation

4. Action 4. Select progressive change


5. Choose change agent role

5. Gaining acceptance

6. Stabilization and self- renewal

5. Confirmation 5. Maintenance

6. Maintain change

7. Terminate helping relationships


Start by asking the right questions, such as:

1. Where are we now? What is unique about us? What should our business be?

2. What can we do that is different from and better than what our competitors do?

3. What is the driving stimulus in our organization? What determines how we make our final decisions?

4. What prevents us from moving in the direction we wish to go?

5. What kind of change is required?

This last question generates integrative thinking on the potential effect of change on the system. Organizational change involves modifications in the system’s interacting components: technology, structure, and people.

Introducing new technology changes the structure of the organization. The physical plant may be altered if new services are added and then relationships among the people who work in the system change when the structure is changed. Surveillance cameras, cell phones, mag- netic entry cards, bar codes, and communication technology, including social media, have al- tered the care environment as much as they’ve changed our personal world. New rules and regulations, new authority structures, and new budgeting methods may emerge. They, in turn, change staffing needs, requiring people with different skills, knowledge bases, attitudes, and motivations.

Collect Data Once the problem or opportunity has been clearly defined, the change agent collects data external and internal to the system. This step is crucial to the eventual success of the planned change. All driving and restraining forces are identified so the driving forces can be emphasized and the restraining forces reduced. It is imperative to assess the political pulse. Who will gain from this change? Who will lose? Who has more power and why? Can those power bases be altered? How?

Assess the political climate by examining the reasons for the present situation. Who in control may be benefiting now? Egos, commitment of the involved people, and personal likes and dislikes are as important to assess as the formal organizational structures and processes. The innovator has to gauge the potential for resistance.

The costs and benefits of the proposed change are obvious focal points. Also assess resources—especially those the manager can control. A manager who has the respect and support of an excellent nursing staff has access to a powerful resource in today’s climate.

TABLE 5-2 Steps in the Change Process

1. Identify the problem or opportunity.

2. Collect necessary data and information.

3. Select and analyze data.

4. Develop a plan for change, including time frame and resources.

5. Identify supporters or opposers.

6. Build a coalition of supporters.

7. Help people prepare for change.

8. Prepare to handle resistance.

9. Provide a feedback mechanism to keep everyone informed of the progress of change.

10. Evaluate effectiveness of the change and, if successful, stabilize the change.


Analyze Data The kinds, amounts, and sources of data collected are important, but they are useless unless they are analyzed. The change agent should focus more energy on analyzing and summarizing the data than on just collecting it. The point is to flush out resistance, identify potential solutions and strategies, begin to identify areas of consensus, and build a case for whichever option is selected.

At a not-for-profit hospital in the process of seeking Magnet status, each service line is looking for opportunities to improve standards of care, efficiency, and patient safety. In the ambulatory surgery center, the process of providing preoperative services was often slow and inefficient. The surgery center nurses were charged with finding ways to improve efficiency.

Planning Planning the who, how, and when of the change is a key step. What will be the target system for the change? Members from this system should be active participants in the planning stage. The more involved they are at this point, the less resistance there will be later. Lewin’s unfreezing imagery is relevant here. Present attitudes, habits, and ways of thinking have to soften so mem- bers of the target system will be ready for new ways of thinking and behaving. Boundaries must melt before the system can shift and restructure.

This is the time to make people uncomfortable with the status quo. Plant the seeds of dis- content by introducing information that may make people feel dissatisfied with the present and interested in something new. This information comes from the data collected (e.g., research findings, quantitative data, and patient satisfaction questionnaires or staff surveys). Couch the proposed change in comfortable terms as far as possible, and minimize anxiety about the new change.

Managers need to plan the resources required to make the change and establish feedback mechanisms to evaluate its progress and success. Establish control points with people who will provide the feedback and work with these people to set specific goals with time frames. Develop operational indicators that signal success or failure in terms of performance and satisfaction.

Three surgery center nurses designed a flow chart of how the process could be improved. They took it to their administration and were put in charge of its implementation.

Implementation The plans are put into motion (Lewin’s moving stage). Interventions are designed to gain the nec- essary compliance. The change agent creates a supportive climate, acts as an energizer, obtains and provides feedback, and overcomes resistance. Managers are the key change-process actors. Some methods are directed toward changing individuals in an organization, whereas others are directed toward changing the group.

Methods to Change Individuals The most common method used to change individuals’ perceptions, attitudes, and values is information giving. Providing information is prerequisite to change implementation, but it is inadequate unless a lack of information is the only obstacle to effecting change. Providing infor- mation does not address the motivation to change.

Training is often considered a method to change individuals. Training combines information-giving with skill practice. Training typically shows people how they are to perform in a system, not how to change it. Therefore, it is a strategy to help make the transition to a planned change rather than a mechanism to initiate change.

Selecting and placing personnel or terminating key people often is used to alter the forces for or against change. When key supporters of the planned change are given the authority and


accountability to make the change, their enthusiasm and legitimacy can be effective in leading others to support the change. Conversely, if those opposed to the change are transferred or leave the organization, the change is more likely to succeed.

Methods to Change Groups Some implementation tactics use groups rather than individuals to attain compliance to change. The power of an organizational group to influence its members depends on its authority to act on an issue and the significance of the issue itself. The greatest influence is achieved when group members discuss issues that are perceived as important and make relevant, binding de- cisions based on those discussions. Effectiveness in implementing organizational change is most likely when groups are composed of members who occupy closely related positions in the organization.

Individual and group implementation tactics can be combined. Whatever methods are used, participants should feel their input is valued and should be rewarded for their efforts. Some people are not always persuaded before a beneficial change is implemented. Sometimes behav- ior changes first, and attitudes are modified later to fit the behavior. In this case, the change agent should be aware of participants’ conflicts and reward the desired behaviors. It may take some time for attitudes to catch up.

The surgery center nurses worked with physician offices, insurance companies, and other hospital departments to implement the new process for preoperative services.

Evaluation Evaluate Effectiveness At each control point, the operational indicators established are monitored. The change agent determines whether presumed benefits were achieved from a financial as well as a qualitative perspective, explaining the extent of success or failure. Unintended consequences and undesir- able outcomes may have occurred.

Stabilize the Change The change is extended past the pilot stage, and the target system is refrozen. The change agent terminates the helping relationship by delegating responsibilities to target system members. The energizer role is still needed to reinforce new behaviors through positive feedback.

Over the next three months, the preoperative services department was able to show a 90 percent decrease in duplicate test orders, a 50 percent decrease in patient waiting time, and an 80 percent increase in physician satisfaction with the process.

Change Strategies Regardless of the setting or proposed change, the four-step change process should be followed. However, specific strategies can be used, depending on the amount of resistance anticipated and the degree of power the change agent possesses.

Power-Coercive Strategies Power-coercive strategies are based on the application of power by legitimate authority, economic sanctions, or political clout. Changes are made through law, policy, or financial appropriations. Those in control enforce changes by restricting budgets or creating policies. Those who are not in power may not even be aware of what is happening. Even if they are aware, they have little power to stop it. Health care reform legislation, is an example of power-coercive strategy by the federal government.


Power-coercive strategies are useful when a consensus is unlikely despite efforts to stimulate participation by those involved. When much resistance is anticipated, time is short, and the change is critical for organizational survival, power-coercive strategies may be necessary.

Empirical–Rational Model In the empirical–rational model of change strategies, the power ingredient is knowledge. The assumption is that people are rational and will follow their rational self-interest if that self- interest is made clear to them. It is also assumed that the change agent who has knowledge has the expert power to persuade people to accept a rationally justified change that will benefit them.

The flow of influence moves from those who know to those who do not know. New ideas are invented and communicated or diffused to all participants. Once enlightened, rational people will either accept or reject the idea based on its merits and consequences. Empirical–rational strategies are often effective when little resistance to the proposed change is expected and the change is perceived as reasonable.

Well-researched, cost-effective technology can be implemented using these strategies. In- troducing a new technology that is easy to use, cuts nursing time, and improves quality of care might be accepted readily after in-service education and a trial use. Using bar codes to match medications to patients is another example.

The change agent can direct the change. There is little need for staff participation in the early steps of the change process, although input is useful for the evaluation and stabilization stages. The benefits of change for the staff and research documenting improved patient out- comes are the major driving forces.

Normative–Reeducative Strategies In contrast to the rational-empirical model, normative–reeducative strategies of change rest on the assumption that people act in accordance with social norms and values. Information and rational arguments are insufficient strategies to change people’s patterns of actions; the change agent must focus on noncognitive determinants of behavior as well. People’s roles and relationships, perceptual orientations, attitudes, and feelings will influence their acceptance of change.

In this mode, the power ingredient is not authority or knowledge, but skill in interpersonal relationships. The change agent does not use coercion or nonreciprocal influence, but col- laboration. Members of the target system are involved throughout the change process. Value conflicts from all parts of the system are brought into the open and worked through so change can progress.

Normative–reeducative strategies are well suited to the creative problem solving needed in nursing and health care today. With their firm grasp of the behavioral sciences and communica- tion skills, nurses are comfortable with this model. Changing from a traditional nursing system to self-governance or initiating a home follow-up service for hospitalized patients are examples of changes amenable to the normative–reeducative approach.

In most cases, the normative–reeducative approach to change will be effective in reduc- ing resistance and stimulating personal and organizational creativity. The obvious drawback is the time required for group participation and conflict resolution throughout the change process. When there is adequate time or when group consensus is fundamental to successful adoption of the change, the manager is well advised to adopt this framework.

Resistance to Change Resistance to change is to be expected for a number of reasons: lack of trust, vested interest in the status quo, fear of failure, loss of status or income, misunderstanding, and belief that change


is unnecessary or that it will not improve the situation (Yukl, 2009; Hellriegel, Jackson, & Slocum, 2007). In fact, if resistance does not surface, the change may not be significant enough.

Employees may resist change because they dislike or disapprove of the person responsible for implementing the change or they may distrust the change process. Regardless, managers continually deal with change—both the change that they themselves initiate and change initiated by the larger organization.

Resistance varies from ready acceptance to full-blown resistance. Rogers (2003) identified six responses to change:

● Innovators love change and thrive on it. ● Less radical, early adopters are still receptive to change. ● The early majority prefer the status quo, but eventually accept the change. ● The late majority are resistive, accepting change after most others have. ● Laggards dislike change and are openly antagonistic. ● Rejecters actively oppose and may even sabotage change.

The change agent should anticipate and look for resistance to change. It will be lurking somewhere, perhaps where least expected. It can be recognized in such statements as:

● We tried that before. ● It won’t work. ● No one else does it like that. ● We’ve always done it this way. ● We can’t afford it. ● We don’t have the time. ● It will cause too much commotion. ● You’ll never get it past the board. ● Let’s wait awhile. ● Every new boss wants to do something different. ● Let’s start a task force to look at it; put it on the agenda.

Expect resistance and listen carefully to who says what, when, and in what circumstances. Open resisters are easier to deal with than closet resisters. Look for nonverbal signs of resis- tance, such as poor work habits and lack of interest in the change.

Resistance prevents the unexpected. It forces the change agent to clarify information, keep in- terest level high, and establish why change is necessary. It draws attention to potential problems and encourages ideas to solve them. Resistance is a stimulant as much as it is a force to be overcome. It may even motivate the group to do better what it is doing now, so that it does not have to change.

On the other hand, resistance is not always beneficial, especially if it persists beyond the planning stage and well into the implementation phase. It can wear down supporters and redirect system energy from implementing the change to dealing with resisters. Morale can suffer.

To manage resistance, use the following guidelines:

1. Talk to those who oppose the change. Get to the root of their reasons for opposition.

2. Clarify information, and provide accurate feedback.

3. Be open to revisions but clear about what must remain.

4. Present the negative consequences of resistance (e.g., threats to organizational survival, compromised patient care).

5. Emphasize the positive consequences of the change and how the individual or group will benefit. However, do not spend too much energy on rational analysis of why the change is good and why the arguments against it do not hold up. People’s resistance frequently flows from feelings that are not rational.


6. Keep resisters involved in face-to-face contact with supporters. Encourage proponents to empathize with opponents, recognize valid objections, and relieve unnecessary fears.

7. Maintain a climate of trust, support, and confidence.

8. Divert attention by creating a different disturbance. Energy can shift to a more important problem inside the system, thereby redirecting resistance. Alternatively, attention can be brought to an external threat to create a bully phenomenon. When members perceive a greater environmental threat (such as competition or restrictive governmental policies), they tend to unify internally.

The Nurse’s Role Initiating Change Contrary to popular opinion, change often is not initiated by top-level management (Yukl, 2009), but rather emerges as new initiatives or problems are identified. Furthermore, Weiner, Amick, and Lee (2008) posit that organizational readiness is the key to initiating change.

Staff nurses often think that they are unable to initiate and create change, but that is not so.

Home health nurses were often frustrated by not having appropriate supplies with them when seeing a patient for the first time. A team of nurses completed a chart audit to iden- tify commonly used supplies and equipment that nurses were using on their home visits. Each nurse was then supplied with a small plastic container to keep in his or her car with these items. Frustration decreased and efficient use of nursing time was improved.

The manager, as well, may resist leading change. Afraid of “rocking the boat,” fearful that no one will join our efforts, recalling that past efforts at change had failed, or even the reluctance to become involved may prevent the nurse from initiating change.

Making change is not easy, but it is a mandatory skill for managers. Successful change agents demonstrate certain characteristics that can be cultivated and mastered with practice. These characteristics include:

● The ability to combine ideas from unconnected sources ● The ability to energize others by keeping the interest level up and demonstrating a high

personal energy level ● Skill in human relations: well-developed interpersonal communication, group manage-

ment, and problem-solving skills ● Integrative thinking: the ability to retain a big picture focus while dealing with each part

of the system ● Sufficient flexibility to modify ideas when modifications will improve the change, but

enough persistence to resist nonproductive tampering with the planned change ● Confidence and the tendency not to be easily discouraged ● Realistic thinking ● Trustworthiness: a track record of integrity and success with other changes ● The ability to articulate a vision through insights and versatile thinking ● The ability to handle resistance

Energy is needed to change a system. Power is the main source of that energy. Informational power, expertise, and possibly positional power can be used to persuade others.

To access optimum power, use the following strategies:

1. Analyze the organizational chart. Know the formal lines of authority. Identify informal lines as well.

2. Identify key persons who will be affected by the change. Pay attention to those immedi- ately above and below the point of change.


3. Find out as much as possible about these key people. What are their “tickle points”? What interests them, gets them excited, turns them off? What is on their personal and organiza- tional agendas? Who typically aligns with whom on important decisions?

4. Begin to build a coalition of support before you start the change process. Identify the key people who will be affected by the change. Talk informally with them to flush out possible objections to your idea and potential opponents. What will the costs and benefits be to them—especially in political terms? Can your idea be modified in ways that retain your objectives but appeals to more key people?

5. Follow the organizational chain of command in communicating with administrators. Don’t bypass anyone to avoid having an excellent proposal undermined.

This information helps you develop the most sellable idea or at least pinpoint probable resistance. It is a broad beginning to the data-collection step of the change process and has to be fine-tuned once the idea is better defined. The astute manager keeps alert at all times to monitor power struggles.

Although a cardinal rule of change is, “Don’t try to change too much too fast,” the savvy manager develops a sense of exquisite timing by pacing the change process according to the political pulse. For example, the manager unfreezes the system during a period of coalition building and high interest, while resistance is low or at least unorganized.

You may decide to stall the project beyond a pilot stage if resistance solidifies or gains a powerful ally. In this case, do whatever you can to reduce resistance. If resistance continues, two options should be considered:

● The change is not workable and should be modified to meet the strongest objections (compromise).

● The change is fine-tuned sufficiently, but change must proceed now and resistance must be overcome.

Implementing Change In addition to initiating change, nurses and nurse managers are called on to assist with change in other ways. They may be involved in the planning stage, charged with sharing information with coworkers, or they may be asked to help manage the transition to planned change.

Planning Change One Magnet-recognized hospital engaged all its nurses in planning for the desired future of clinical nursing in its organization (Capuano et al., 2007). It held a series of group events to so- licit ideas and opinions. Every nurse—executive, manager, or staff nurse—had an equal vote to approve or veto a proposed change. This process illustrates the normative–reeducative process of change.

Managing Transitions to Change Transitions are those periods of time between the current situation and the time when change is implemented (Bridges, 2009). They are the times ripe for a change agent to act. Just as initiating change is not easy, neither is transitioning to changed circumstances.

Letting go of long-term, comfortable activities is difficult. The tendency is to:

● Add new work to the old ● Make individual decisions about what to add and what to let go ● Toss out everything done before (Bridges, 2009)

Accepting loss and honoring the past with respect is essential. Passion for the work is based on results, not activities, regardless of their necessity or effectiveness.

A large national for-profit health care system purchased a new hospital clinical informa- tion system. Because all paper charting would be eliminated, nurses would be directly


affected. Their participation could spell success or failure for the new system. To help the transition occur smoothly, nurses from each department met together for a demonstration of the new clinical information system and provided feedback to the IT department about nursing process and integrating patient care with the new system. Then a few nurses on each unit were selected to be trained as experts in the new technology, and they in turn trained other staff members, communicating with the IT department when concerns arose.

A nurse manager in a home health care agency used change management strategies to over- come resistance, as shown in Case Study 5-1.

Handling Constant Change Change has always occurred; what’s different today is both the pace of change and that an initial change causes a chain reaction of more and more change (Bridges, 2009). Change, rather than an occasional event, has become the norm.

Regardless of their position in an organization, nurses find themselves constantly dealing with change. Whether they thrive in such an atmosphere is a function of both their own personal resources and the environment in which change occurs.

ENCOURAGING CHANGE Peter Beasley is the nurse manager of pediatric home care for a private home health care agency. Last year, the agency completed a pilot of wireless devices for use in documenting home visits. As nurses complete the documentation, charges for supplies and medical equip- ment are generated. The agency director informed the nurse managers that all nurses will be required to use the wireless devices within the next three months.

Charlene Ramirez has been a pediatric nurse for 18 years, working for the home health care agency for the past 5 years. Charlene has been active in updating the pediatric documentation and training staff when new paper-based documentation was implemented in the past. Although she was part of the pilot, Charlene is very opposed to using the new wireless devices. She complains that she can barely see the text. At a recent staff meeting, Charlene stated she would rather quit than learn to use the new wireless devices.

Peter empathizes with Charlene’s reluctance to use the new technology. He also recognizes how much Char- lene contributes in expertise and leadership to the de- partment. However, he knows that the new performance standards require all employees to use the wireless de- vices. After three mandatory training sessions, Charlene repeatedly tells coworkers “We’ve tried things like this before, it never works. We’ll be back on paper within six months, so why waste my time learning this stuff?” The program trainer reports that Charlene was disruptive dur- ing the class and failed her competency exam.

Peter meets privately with Charlene to discuss her resistance to the new technology. Charlene again states that she fails to see the need for wireless devices in delivering quality patient care. Peter reviews the new performance standards with Charlene, emphasizing the technology requirements. He asks Charlene if she has difficulty understanding the application or just in using the device. Charlene admits she cannot read the text on the screen and therefore cannot determine what exact- ly she is documenting. Peter informs Charlene that the agency’s health benefits include vision exams and par- tial payment for corrective lenses. He suggests that she talk with an optometrist to see if special glasses would help her see the screen. Peter also makes a note to speak with the technology specialist to see if there are aids to help staff view data on the device.

Manager’s Checklist The nurse manager is responsible for:

● Communicating openly and honestly with employees who oppose change.

● Understanding resistance to change. ● Maintaining support and confidence in staff even if

they are resistive to change. ● Emphasizing the positive outcomes from initiating

change. ● Finding solutions to problems that are obstacles to




If you don’t like the current situation, you may look forward to change. As Midwestern- ers are fond of saying when asked about the weather: “If you don’t like it today, just wait until tomorrow. It will change.”

What You Know Now • In today’s health care system, change is inevitable, necessary, and constant. • With changes proposed for the nursing profession, nurses are in a pivotal position to initiate and

participate in change. • For change to be positive for nurses, they must develop change agent skills. • Critical evaluation of change theories provides guidance and direction for initiating and managing change. • The change process is similar to the nursing process and includes assessment, planning, implementation,

and evaluation. • Resistance to change is to be expected, and it can be a stimulant as well as a force to be overcome. • The nurse may be involved in change by initiating it or participating in implementing change. • Handling constant change is a challenge in today’s health care environment.

Tools for Initiating and Managing Change 1. Communicate openly and honestly with employees who oppose change. 2. Maintain support and confidence in staff even if they are resistive to change. 3. Emphasize the positive outcomes from the change. 4. Find solutions to problems that are obstacles to change. 5. Accept the constancy of change.

Questions to Challenge You 1. Identify a needed change in the organization where you practice. Using the change process, outline

the steps you would take to initiate change. 2. Consider your school or college. What change do you think is needed? Explain how you would

change it to become a better place for learning. 3. Have you had an experience with change occurring in your organization? What was your initial

reaction? Did that change? How well did the change process work? Was the change successful? 4. Do you have a behavior you would like to change? Using the steps in the change process, describe

how you might effect that change. 5. How do you normally react to change? Choose from the following: a. I love new ideas, and I’m ready to try new things. b. I like to know that something will work out before I try it. c. I try to avoid change as much as possible. 6. Did your response to the above question alter how you would like to view change? Think about this

the next time change is presented to you. 7. Think back to your first time on a clinical unit. How did you feel? Overwhelmed? Afraid of failing?

That’s the feeling that people have when facing change. Try to remember how you felt when you encounter resistance to change.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!


Bridges, W. (2009). Managing transitions: Making the most of change. Cambridge, MA: Da Capo Press.

Capuano, T., Durishin, L. D., Millard, J. L., & Hitchings, K. S. (2007). The desired future of nursing doesn’t just happen—engaged nurses create it. Journal of Nursing Administration, 37(2), 61–63.

Erwin, D. (2009). Changing or- ganizational performance: Examining the change pro- cess. Hospital Topics: Re- search and Perspectives on Healthcare, 87(3), 28–40.

Havelock, R. (1973). The change agent’s guide to innovation in education. Englewood Liffs, NJ: Educational Tech- nology Publications.

Heath, C., & Heath, D. (2010). Switch: How to change things when change is hard. New York: Crown.

Hellriegel, D., Jackson, S. E., & Slocum, J. W. (2007). Man- agement: A competency- based approach (11th ed.). Eagan, MN: South-Western.

Holtrop, J. S., Baumann, J., Arnold, A. K., & Torres, T. (2008). Nurses as practice

change facilitators for healthy behaviors. Journal of Nursing Care Quality, 23(2), 123–131.

Institute of Medicine (2010). The future of nursing: Leading change, advancing health. Retrieved May 24, 2011 from http://www.iom. edu/Reports/2010/The- Future-of-Nursing-Leading- Change-Advancing- Health.aspx

Lewin, K. (1951). Field theory in social science. New York: Harper & Row.

Lippitt, R., Watson, J., & West- ley, B. (1958). The dynam- ics of planned change. New York: Harcourt & Brace.

MacDavitt, K., Cieplinski, J. A., & Walker, V. (2011). Implementing small tests of change to improve pa- tient satisfaction. Journal of Nursing Administration, 41(1), 5–9.

McMurray, A., Chaboyer, W., Wallis, M., & Fetherston, C. (2010). Implementing bedside handover: Strate- gies for change manage- ment. Journal of Clinical Nursing, 19(17–18), 2580–2589.

Nickitas, D. M. (2010). A vi- sion for future health care: Where nurses lead the change. Nursing Econom- ics, 28(6), 361, 385.

Prochaska, J. O. & DiClemente, C. C. (2005). The transtheo- retical approach. In: Nor- cross, J. C., & Goldfried, M. R. (Eds.), Handbook of psychotherapy integration (2nd ed.). New York: Ox- ford University Press.

Rogers, E. (2003). Diffusion of innovations (5th ed.). New York: Free Press.

Sare, M. V., & Ogilvie, L. (2009). Strategic planning for nurses: Change man- agement in health care. Sudbury, MA: Jones and Bartlett.

Weiner, B. J., Amick, H., & Lee, S. D. (2008). Conceptual- ization and measurement of organizational readiness for change: A review of the literature in health services research and other fields. Medical Care Research and Review, 65(4), 379–436.

Yukl, G. A. (2009). Leadership in organizations (7th ed.). Upper Saddle River, NJ: Prentice Hall.

Web Resources Agency for Healthcare Research and Quality. http://www.ahrq.gov/ Institute of Medicine. http://www.iom.edu/



Quality Management TOTAL QUALITY







Improving the Quality of Care NATIONAL INITIATIVES















Managing and Improving Quality 6

Key Terms Continuous quality

improvement (CQI) Dashboards DMAIC Incident reports Indicator Just culture

1. Describe how total quality management, continuous quality management, Six Sigma, Lean Six Sigma, and DMAIC address quality.

2. Describe national efforts to improve the quality of health care.

3. Explain how evidence-based practice, electronic medical records, and dashboards can improve quality.

4. Point out how nurses are involved in reducing risks.

5. Discuss how to create a blame-free environment.

Learning Outcomes After completing this chapter, you will be able to:

Outcome standards Lean Six Sigma Peer review Process standards Quality management Reportable incident Risk management

Root cause analysis Six Sigma Standards Structure standards Total quality management



I n today’s highly competitive health care environment, each member of the health care organization must be accountable for the quality and cost of health care. Concern about quality gained national attention after publication of the Institute of Medicine’s (IOM) reports on medical errors in 1999 (IOM, 1999) and their later recommendations for health pro- fessionals’ education (IOM, 2003). Additionally, concern about cost continues unabated. Both quality and cost containment are found in the concept of total quality management, which has evolved into a model of continuous quality improvement designed to improve system and process performance. Risk management is integrated within a quality management program.

Quality Management Quality management moved health care from a mode of identifying failed standards, problems, and problem people to a proactive organization in which problems are prevented and ways to improve care and quality of care are sought. This paradigm shift involves all in the organization and promotes problem solving and experimentation.

A quality management program is based on an integrated system of information and accountability. Clinical information systems can provide the data needed to enable organizations to track activities and outcomes. For example, data from clinical information systems can be used to track patient wait times from admitting to outpatient testing to admission in an inpatient care unit. Delays in the process can be identified so appropriate staff and resources are available at the right time to decrease delays and increase efficiency and patient satisfaction. Methods can be devised to discover problems in the system without blaming the “sharp end,” the last individual in the chain to act (e.g., the nurse gives a wrong medication). The system must be accepted and used by the entire staff.

Total Quality Management Total quality management (TQM) is a management philosophy that emphasizes a commitment to excellence throughout the organization. The creation of Dr. W. Edwards Deming, TQM was adopted by the Japanese after World War II and helped transform their industrial development. Dr. Deming based his system on principles of quality management that were originally applied to improve quality and performance in the manufacturing industry. They are now widely used to improve quality and customer satisfaction in a number of service industries, including health care.

TQM Characteristics Four core characteristics of total quality management are:

● Customer/client focus ● Total organizational involvement ● Use of quality tools and statistics for measurement ● Key processes for improvement identified

Customer/Client Focus. An important theme of quality management is to address the needs of both internal and external customers. Internal customers include employees and departments within the organization, such as the laboratory, admitting office, and environmental services. External customers of a health care organization include patients, visitors, physicians, managed- care organizations, insurance companies, and regulatory agencies, such as the Joint Commission, which accredits health care organizations, and public health departments.

Under the principles of TQM, nurses must know who the customers are and endeavor to meet their needs. Providing flexible schedules for employees, adjusting routines for a.m. care to meet the needs of patients, extending clinic hours beyond 5 p.m., and putting infant changing tables in restrooms are some examples. Putting the customer first requires creative and innova- tive methods to meet the ever-changing needs of internal and external customers.

Total Organizational Involvement. The goal of total quality management is to involve all employees and empower them with the responsibility to make a difference in the quality of


service they provide. This means all employees must have knowledge of the TQM philosophy as it relates to their job and the overall goals and mission of the organization. Knowledge of the TQM process breaks down barriers between departments. The phrase “That’s not my job” is eliminated. Departments work together as a team. On occasion, nursing personnel might clean a bed for a new admission from the emergency room or an administrator might transport a patient to the radiology department. Sharing processes across departments and patient care functions increases teamwork, productivity, and patient positive outcomes.

Use of Quality Tools and Statistics for Measurement. A common management adage is, “You can’t manage what you can’t (or don’t) measure.” There are many tools, formats, and designs that can be used to build knowledge, make decisions, and improve quality. Tools for data analysis and display can be used to identify areas for process and quality improvement, and then to benchmark the progress of improvements. Deming applied the scientific method to the concept of TQM to develop a model he called the PDCA cycle (Plan, Do, Check, Act) depicted in Figure 6-1.

Identification of Key Processes for Improvement. All activities performed in an organization can be described in terms of processes. Processes within a health care setting can be:

● Systems related (e.g., admitting, discharging, and transferring patients) ● Clinical (e.g., administering medications, managing pain) ● Managerial (e.g., risk management and performance evaluations).

Processes can be very complex and involve multidisciplinary or interdepartmental actions. Processes involving multiple departments must be investigated in detail by members from each department involved in the activity so that they can proactively seek opportunities to reduce waste and inefficiencies and develop ways to improve performance and promote positive outcomes.

Continuous Quality Improvement TQM is the overall philosophy, whereas continuous quality improvement (CQI) is used to im- prove quality and performance. TQM and CQI often are used synonymously. In health care orga- nizations, CQI is the process used to investigate systematically ways to improve patient care. As the name implies, continuous quality improvement is a never-ending endeavor (Hedges, 2006).

CQI means more than just meeting standards and thresholds or solving problems. It involves evaluation, actions, and a mind-set to strive constantly for excellence. This concept is sometimes difficult to grasp because patient care involves the synchronization of activities in multiple de- partments. Therefore, the importance of developing and implementing a well-thought-out pro- cess is key to a successful CQI implementation.

There are four major players in the CQI process:

● Resource group ● Coordinator




Figure 6-1 • PDCA cycle.


● Team leader ● Team

The resource group is made up of senior management (e.g., CEO, vice presidents). It estab- lishes overall CQI policy, vision, and values for the organization and actively involves the board of directors in this process, thereby ensuring that the CQI program has sufficient emphasis and is provided with the resources needed. The CQI coordinator is often appointed by the CEO to pro- vide day-to-day management of the CQI process and related activities (e.g., training programs).

CQI teams are designated to evaluate and improve select processes. They are formally established and supported by the resource group. CQI teams range in size from 5 to 10 people, representing all major functions of the process being evaluated.

Each CQI team is headed by a team leader who is familiar with the process being evaluated. The leader organizes team meetings, sets the agenda, and guides the group through the discussion, evaluation, and implementation process.

Components of Quality Management A comprehensive quality management program includes:

● A comprehensive quality management plan. A quality management plan is a systematic method to design, measure, assess, and improve organizational performance. Using a multidisciplinary approach, this plan identifies processes and systems that represent the goals and mission of the organization, identifies customers, and specifies opportunities for improvement. Critical paths, which are described in Chapter 3, are an example of a quality management plan. Critical paths identify expected outcomes within a specific time frame. Then variances are tracked and accounted for.

● Set standards for benchmarking. Standards are written statements that define a level of performance or a set of conditions determined to be acceptable by some authorities. Standards relate to three major dimensions of quality care:

a. Structure b. Process c. Outcome

Structure standards relate to the physical environment, organization, and management of an organization. Process standards are those connected with the actual delivery of care. Outcome standards involve the end results of care that has been given.

An indicator is a tool used to measure the performance of structure, process, and outcome standards. It is measurable, objective, and based on current knowledge. Once indicators are identified, benchmarking, or comparing performance using identified quality indicators across institutions or disciplines, is the key to quality improvement.

In nursing, both generic and specific standards are available from the American Nurses Association and specialty organizations; however, each organization and each patient care area must designate standards specific to the patient population being served. These standards are the foundation on which all other measures of quality are based.

An example of a standard is, “Every patient will have a written care plan within 12 hours of admission.”

● Performance appraisals. Based on requirements of the job, employees are evaluated on their performance. This feedback is essential for employees to be professionally accountable. (See Chapter 18 for more on performance appraisals.)

● A focus on intradisciplinary assessment and improvement. There will always be a need for groups to assess, analyze, and improve their own performance. Methods to assess performance should, however, focus on the CQI philosophy, which involves group or intradisciplinary performance. Peer review, discussed later in the chapter, is an example of intradisciplinary assessment.


● A focus on interdisciplinary assessment and improvement. Multidisciplinary, patient- focused teamwork emphasizing collaboration, communication, coordination, and integra- tion of care is the core of CQI in health care. It is important not to disband departmental quality functions, such as patient satisfaction, utilization review, or infection control, but rather to refocus information on improving the process.

Resources are used to collect data, such as the number of postoperative infections or the number of return clinic visits, to guide the decision-making process. Throughout the evalua- tion and implementation process, the team’s focus is the patient. Implementation is continu- ally evaluated using a patient satisfaction survey, which is just one of the methods used to monitor nursing care. For example, some organizations follow up outpatient surgery clients with direct phone calls from nursing staff to ensure patients understand discharge instructions and that pain was controlled following discharge. Any potential complications are referred to the surgeon.

Six Sigma Six Sigma is another quality management program that uses, primarily, quantitative data to monitor progress. Six Sigma is a measure, a goal, and a system of management.

● As a measure. Sigma is the Greek letter—ó—for standard, meaning how much performance varies from a standard. This is similar to how CQI monitors results against an outcome measure.

● As a goal. One goal might be accuracy. How many times, for example, is the right medication given in the right amount, to the right patient, at the right time, by the right route?

● As a management system. Compared to other quality management systems, Six Sigma involves management to a greater extent in monitoring performance and ensuring favorable results.

The system has six themes:

● Customer (patient) focus ● Data driven ● Process emphasis ● Proactive management ● Boundaryless collaboration ● Aim for perfection; tolerate failure.

The first three themes are similar to other quality management programs. The focus is on the object of the service; in nursing’s case, this is the patient. Data provide the evidence of results, and the emphasis is on the processes used in the system.

The latter three themes, however, differ from other programs. Management is actively involved and boundaries are breached (e.g., the disconnect between departments). More radically, Six Sigma tolerates failure (a necessary condition for creativity) while striving for perfection.

Lean Six Sigma Lean Six Sigma focuses on improving process flow and eliminating waste. Waste occurs when the organization provides more resources than are required. Data driven, Lean Six Sigma focuses on identifying steps that have little or no value to the care and cause unnecessary delays. Further- more, the method strives to eliminate variations in care and improve efficiencies and effective- ness. Because the goal of Lean Six Sigma is to identify and reduce waste, it provides tools that can be used with a Six Sigma management system.

Studies have shown Lean Six Sigma to be effective in reducing inappropriate hospital stays, improving the quality of care and reducing costs at the same time (Yamamoto et al., 2010).


In addition, when the method was used in one hospital, researchers found that a collaborative effort improved the care of inpatient diabetic patients (Niemeijer et al., 2010).

DMAIC Method DMAIC is a Six-Sigma process improvement method (as shown in Figure 6-2). Steps in the method are:

● Define what measures will indicate success ● Measure baseline performance ● Analyze results ● Improve performance ● Control and sustain performance (DMAIC Tools: Six Sigma Training Tools, 2011)

TQM, CQI, Six Sigma, Lean Six Sigma, and DMAIC are quantifiable systems that measure performance against set standards. The goal is to improve the quality of health care. In addition, other efforts to improve the quality of care are ongoing.

Improving the Quality of Care

National Initiatives The National Quality Forum is a nonprofit organization that strives to improve the quality of health care by building consensus on performance goals and standards for measuring and report- ing them (National Quality Forum, 2011). Additionally, the Institute of Healthcare Improvement (IHI) offers programs to assist organizations in improving the quality of care they provide (IHI, 2011). Their goals are:

● No needless deaths ● No needless pain or suffering ● No helplessness in those served or serving ● No unwanted waiting ● No waste

Joint Commission, hospitals’ accrediting body, has adopted mandatory national patient safety goals (Joint Commission, 2011). They charge hospitals to:

● Identify patients correctly ● Improve staff communication ● Use medicines safely ● Prevent infection ● Check patient medicines ● Identify patient safety risks ● Prevent mistakes in surgery



Improve Analyze

Figure 6-2 • DMAIC: The Six Sigma Method. Adapted from DMAIC tools: Six Sigma training tools. Retrieved October 21, 2011, from www.dmaictools.com


Joint Commission collects data on 57 inpatient measures; 31 of these are currently made public with others scheduled to be publicly reported soon (Chassin et al., 2010). The focus is now on maxi- mizing health benefits to patients. They recommend that quality measures be based on four criteria:

1. The measure must be based on research that shows improved outcomes. More than one research study is required for documentation.

2. Reports document that evidence-based practice has been given. Aspirin following an acute myocardial infarction is an example.

3. The process documents desired outcome. Appropriately administering medications is an example.

4. The process has minimal or no unintended adverse effects (Chassin et al., 2010)

Measured standards are used extensively in industrial settings to reveal errors. However, the same cannot be said when measuring human behavior, which can vary and still be effective. Also, if the organization embraces these systems to such an extent that all variance is discour- aged, then innovation is also suppressed. Improvement in quality is sacrificed at the expense of innovative ideas and processes; organizations fail to allow input, become stagnant, and cease to be effective. This is the danger of all living systems that depend on outside input for survival. This is not to say that quality systems are not essential. They are. Organizations must find ways to foster creativity and innovation without compromising quality management.

How Cost Affects Quality Quality measures can also reduce costs. Wasted resources is an example. These include the time nurses spend looking for missing supplies or lab results, the costs of agency nurses because of unfilled positions, and delays in patient discharge due to a lack of coordination or an adverse event (e.g., medication error).

Using the Institute for Healthcare Improvement (2009) project, Transforming Care at the Bedside (TCAB), Unruh, Agrawal, and Hassmiller (2011) found that improving quality reduces costs. Specifically, the researchers report that in a three-year period, RN overtime was reduced, RN turnover was lowered, and fewer patients suffered falls.

Evidence-Based Practice Evidence-based practice (EBP) suggests that using research to decide on clinical treatments would improve quality of care, and that might be the case. Barriers, however, prevent EBP from being widely used by nurses. Such barriers, consistent across settings, include lack of time, autonomy over their practice, ability to find and assess evidence, and support from administra- tion (Brown et al., 2008).

Furthermore, EBP is most reliable when the research study includes a rigorous design (Hader, 2010), and when more than one study has confirmed the results (Chassin et al., 2010). These are not easily surmountable hurdles due to the fast-paced clinical environment and the barriers mentioned above.

Electronic Medical Records Similar to the argument that EBP improves quality, electronic medical records (EMR) should do so as well. Instant access to identical records should improve accuracy and speed commu- nication among care providers. Kazley and Ozcan (2008), however, found limited correlation between the use of EMR and 10 quality indicators in their study of more than 4,000 hospitals in the U.S. In a review of the literature, Chan, Fowles, and Weiner (2010) could not link quality indicators and EMR. Cebul (2008), however, did find direct correlation between the use of EMR and the quality of care provided to diabetic patients. EMR use, is expected to expand and will provide more data for comparison with quality.


Dashboards Dashboards are electronic tools that can provide real-time data or retrospective data, known as a scorecard. Both are useful in assessing quality. Ease of access and the visual appearance of the dashboard make its use more likely. Dashboards may report on hospital census or patient satisfac- tion results, for example. Dashboards are also useful to guide staffing and match staffing with pa- tient outcomes (Frith, Anderson, & Sewell, 2010) and to provide accurate financial data on nurse staffing and quality (Anderson, Frith, & Caspers, 2011). As technology advances, widespread use of dashboards to aggregate data and guide decision making is expected (Hyun et al., 2008).

Nurse Staffing Evidence is growing that increased nurse staffing results in better patient outcomes (Frith, Tseng, & Anderson, 2008; Anderson, Frith, & Caspers, 2011). Earlier studies found that a higher RN-to-patient ratio resulted in reduced patient mortality, fewer infections, and shortened lengths of stay (Reeves, 2007). Needleman (2008) agrees that increasing the level of nurse staffing improves quality, but asserts that higher staffing levels also increase costs.

Reducing Medication Errors Ever since Medicare discontinued payment for hospital-based errors, pressure has increased for hospitals to prevent costly errors. In 2009, the federal government passed the Health Information Technology for Economic and Clinical Health Act (HITECH). The purpose of HITECH is to stim- ulate technology use in health care, including improving technology for medication administration.

Studies have shown that when nurses are interrupted during medication preparation, a 25 percent rate of injury-causing errors are made (Westbrook et al., 2010). One strategy to alert others that a nurse should not be interrupted is the use of a sash or vest that the nurse dons to prepare medications (Heath & Heath, 2010).

Other strategies to reduce medication errors include computerized prescriber order entry (CPOE), electronic medication administration record (eMAR), remote order review by pharma- cists, automated dispensing at the bedside, bar code administration, smart pumps, and unit doses ready to be administered (Federico, 2010). Future strategies include radio frequency identification and electronic reconciliation, both expensive technologies currently being tested (Federico, 2010).

Peer Review In addition to its value for self-evaluation and performance appraisal (Davis, Capozzoli, & Parks, 2009), peer review can be used to identify clinical standards of practice that improve the quality of care. Used for quality improvement, the peer review process is not intended to serve as a per- formance appraisal nor to be punitive. The purpose is to review the incident, determine if clinical standards were met or not, and to propose an action plan to prevent a future incident.

The peer review process is appropriate in the following situations:

● An adverse patient outcome has occurred. ● A serious risk or injury to a patient occurred. ● A failure to rescue incident occurred (Fujita et al., 2009).

A shared governance structure facilitates the peer review process, fostering peer-to-peer accountability (Fujita et al., 2009). Furthermore, the process can help determine if a breach in practice is an isolated incident or a trend occurring across a unit or throughout the organization. In a shared governance environment, unit councils or the nursing council can address unit-wide or system problems. To aggregate trends, peer review cases can be categorized as:

● Appropriate care with no adverse outcomes ● Appropriate care with adverse/unexpected outcomes ● Inappropriate care with no adverse outcomes ● Inappropriate care with adverse/unexpected outcomes (Hitchings et al., 2008)


Risk Management Risk management is a component of quality management, but its purpose is to identify, analyze, and evaluate risks and then to develop a plan for reducing the frequency and severity of accidents and injuries. Risk management is a continuous daily program of detection, education, and intervention.

A risk management program involves all departments of the organization. It must be an organization-wide program, with the board of directors’ approval and input from all depart- ments. The program must have high-level commitment, including that of the chief executive officer and the chief nurse.

A risk management program:

1. Identifies potential risks for accident, injury, or financial loss. Formal and informal communication with all organizational departments and inspection of facilities are essential to identifying problem areas.

2. Reviews current organization-wide monitoring systems (incident reports, audits, committee minutes, oral complaints, patient questionnaires), evaluates completeness, and determines additional systems needed to provide the factual data essential for risk management control.

3. Analyzes the frequency, severity, and causes of general categories and specific types of incidents causing injury or adverse outcomes to patients. To plan risk intervention strategies, it is necessary to estimate the outcomes associated with the various types of incidents.

4. Reviews and appraises safety and risk aspects of patient care procedures and new programs.

5. Monitors laws and codes related to patient safety, consent, and care.

6. Eliminates or reduces risks as much as possible.

7. Reviews the work of other committees to determine potential liability and recommend prevention or corrective action. Examples of such committees are infection, medical audit, safety/security, pharmacy, nursing audit, and productivity.

8. Identifies needs for patient, family, and personnel education suggested by all of the foregoing and implements the appropriate educational program.

9. Evaluates the results of a risk management program.

10. Provides periodic reports to administration, medical staff, and the board of directors.

Nursing’s Role in Risk Management In the organizational setting, nursing is the one department involved in patient care 24 hours a day; nursing personnel are therefore critical to the success of a risk management program. The chief nursing administrator must be committed to the program. Her or his attitude will influence the staff and their participation. After all, it is the staff, with their daily patient contact, who actu- ally implement a risk management program.

High-risk areas in health care fall into five general categories:

● Medication errors ● Complications from diagnostic or treatment procedures ● Falls ● Patient or family dissatisfaction with care ● Refusal of treatment or refusal to sign consent for treatment

Nursing is involved in all areas, but the medical staff may be primarily responsible in cases involving refusal of treatment or consent to treatment.

Medical records and incidence reports serve to document organizational, nurse, and physician accountability. For every reported occurrence, however, many more are unreported. If records are


faulty, inadequate, or omitted, the organization is more likely to be sued and more likely to lose. Incident reports are used to analyze the severity, frequency, and causes of occurrences within the five risk categories. Such analysis serves as a basis for intervention.

Incident Reports Accurate and comprehensive reporting on both the patient’s chart and in the incident report is essential to protect the organization and caregivers from litigation. Incident reporting is often the nurse’s responsibility. Reluctance to report incidents is usually due to fear of the consequences. This fear can be alleviated by:

● Holding staff education programs that emphasize objective reporting ● Omitting inflammatory words and judgmental statements ● Having a clear understanding that the purposes of the incident reporting process are

documentation and follow-up ● Never using the report, under any circumstances, for disciplinary action.

Nursing colleagues and nurse managers should not berate another employee for an incident, and never in front of other staff members, patients, or patients’ family members. Peer review analysis, however, is a valuable tool to evaluate incidents (Hitchings et al., 2008).

A reportable incident should include any unexpected or unplanned occurrence that affects or could potentially affect a patient, family member, or staff. The report is only as effective as the form on which it is reported, so attention should be paid to the adequacy of the form as well as to the data required.

Reporting incidents involves the following steps:

1. Discovery. Nurses, physicians, patients, families, or any employee or volunteer may report actual or potential risk.

2. Notification. The risk manager receives the completed incident form within 24 hours after the incident. A telephone call may be made earlier to hasten follow-up in the event of a major incident.

3. Investigation. The risk manager or representative investigates the incident immediately.

4. Consultation. The risk manager consults with the referring physician, risk management committee member, or both to obtain additional information and guidance.

5. Action. The risk manager should clarify any misinformation to the patient or family, explaining exactly what happened. The patient should be referred to the appropriate source for help and, if needed, be assured that care for any necessary service will be provided free of charge.

6. Recording. The risk manager should be sure that all records, including incident reports, follow-up, and actions taken, if any, are filed in a central depository.

Examples of Risk The following are some examples of actual events in the various risk categories.

Medication Errors A reportable incident occurs when a medication or fluid is omitted, the wrong medication or fluid is administered, or a medication is given to the wrong patient, at the wrong time, in the wrong dosage, or by the wrong route. Here are some examples.

Patient A. Weight was transcribed incorrectly from emergency room sheet. Medication dose was calculated on incorrect weight; therefore, patient was given double the dose


required. Error discovered after first dose and corrected. Second dose omitted per physician’s order.

Patient B. Tegretol dosage written in Medex as “Tegretol 100 mg chewable tab—50 mg po BID.” Tegretol 100 mg given po at 1400. Meds checked at 1430 and error noted. 50 mg Tegretol should have been given two times per day to total 100mg in 24 hours. Doctor notified. Second dose held.

Patient C. During rounds at 3:30 p.m. found .9% sodium chloride at 75 mLs per hour hanging. Order was written for D5W to run at 75 mLs per hour. Fluids last checked at 2:00 p.m. Changed to correct fluid. Doctor notified.

Diagnostic Procedure Any incident occurring before, during, or after such procedures as blood sample stick, biopsy, X-ray examination, lumbar puncture, or other invasive procedure is categorized as a diagnostic procedure incident.

Patient A. When I checked the IV site, I saw that it was red and swollen. For this reason, I discontinued the IV. When removing the tape, I noted a small area of skin breakdown where the tape had been. There was also a small knot on the medial aspect of the left antecubital above the IV insertion site. Doctor notified. Wound dressed.

Patient B. Patient found on the floor after lumbar puncture. Right side rail down. Examined by a physician, BP 120/80, T 98.6, P 72, R 18. No injury noted on exam. Patient returned to bed, side rail placed up. Will continue to monitor patient condition.

Medical–Legal Incident If a patient or family refuses treatment as ordered and prescribed or refuses to sign consent forms, the situation is categorized as a medical-legal incident.

Patient A. After a visit from a member of the clergy, patient indicated he was no longer in need of medical attention and asked to be discharged. Physician called. Doctor explained potential side effects if treatment were discontinued to patient. Patient continued to ask for discharge. Doctor explained “against medical advice” (AMA) form. Patient signed AMA form and left at 1300 without medications.

Patient B. Patient refused to sign consent for bone marrow biopsy. States side effects not understood. Doctor reviewed reasons for test and side effects three different times. Doctor informed the patient that without consent he could not perform the test. Offered to call in another physician for second opinion. Patient agreed. After doctor left, patient signed consent form.

Patient or Family Dissatisfaction with Care When a patient or family indicates general dissatisfaction with care and the situation cannot be or has not been resolved, then an incident report is filed.

Patient A. Mother complained that she had found child saturated with urine every morning (she arrived around 0800). Explained to mother that diapers and linen are changed at 0600 when 0600 feedings and meds are given. Patient’s back, buttocks, and perineal areas are free of skin breakdown. Parents continue to be distressed. Discussed with primary nurse.

Patient B. Mr. Smith appeared very angry. Greeted me at the door complaining that his wife had not been treated properly in our emergency room the night before. Wanted to speak to someone from administration. Was unable to reach the administrator on call. Suggested Mr. Smith call administrator in the morning. Mr. Smith thanked me for my time and assured me that he would call the administrator the next day.


Root Cause Analysis Root cause analysis is a method to work backwards through an event to examine every action that led to the error or event that occurred; it is a complicated process. A simplified method to conduct an event analysis follows:

● Patient—what patient factors contributed to the event? ● Personnel—what personnel actions contributed to the event? ● Policies—are there policies for this type of event? ● Procedures—are there standard procedures for this type of event? ● Place—did the workplace environment contribute to the event? ● Politics—did institutional or outside politics play a role in the event? (Weiss, 2009)

Complaints have emerged, however, that the method uses too many resources for too few improvements (Wu, Lipshutz, & Pronovost, 2008). The authors posit that most organizations try to drill down to a single cause, ignoring system failures. Furthermore, they insist that correc- tive action is seldom taken due to lack of resources, professional disagreements, and absence of management support. They recommend improving system-wide dysfunctions and examining the broader health care environment to find improvements needed across hospitals.

Role of the Nurse Manager The nurse manager plays a key role in the success of any risk management program. Nurse man- agers can reduce risk by helping their staff view health and illness from the patient’s perspective. Usually, the staff’s understanding of quality differs from the patient’s expectations and perceptions. By understanding the meaning of the course of illness to the patient and the family, the nurse will manage risk better because that understanding can enable the nurse to individualize patient care. This individualized attention produces respect and, in turn, reduces risk.

A patient incident or a patient’s or family’s expression of dissatisfaction regarding care indi- cates not only some slippage in quality of care but also potential liability. A distraught, dissatisfied, complaining patient is a high risk; a satisfied patient or family is a low risk. A risk management or liability control program should therefore emphasize a personal approach. Many claims are filed because of a breakdown in communication between the health care provider and the patient. In many instances, after an incident or bad outcome, a quick visit or call from an organization’s repre- sentative to the patient or family can soothe tempers and clarify misinformation.

In the examples given, prompt attention and care by the nurse manager protected the pa- tients involved and may have averted a potential liability claim. Once an incident has occurred, the important factors in successful risk management are:

● Recognition of the incident ● Quick follow-up and action ● Personal contact ● Immediate restitution (where appropriate)

The concerns of most patients’ and their families’ concerns can and should be handled at the unit level. When that first line of communication breaks down, however, the nurse manager needs a resource—usually the risk manager or nursing service administrator.

Handling Complaints Handling a patient’s or family member’s complaints stemming from an incident can be very difficult. These confrontations are often highly emotional; the patient or family member must be calmed down, yet have their concerns satisfied. Sometimes just an opportunity to release the anger or emotion is all that is needed.

The first step is to listen to the person to hear concerns and to help defuse the situation. Arguing or interrupting only increases the person’s anger or emotion. After the patient or fam- ily member has had his or her say, the nurse manager can then attempt to solve the problem by


asking what is expected in the form of a solution. The nurse manager should ensure that immedi- ate patient care and safety needs are met, collect all facts relevant to the incident, and if possible, comply with the patient or family member’s suggested resolution.

Sometimes, a simple apology from a staff member or moving a patient to a different room on the unit can resolve a difficult situation. If the patient and/or family member’s requested resolution exceeds the nurse manager’s authority, the nurse manager should seek the assistance of a nurse administrator or hospital legal counsel. Offering vague solutions (e.g., “everything will be taken care of”) may only lead to more problems later on if expectations as to solution and timing differ.

All incidents must be properly documented. Information on the incident form should be detailed and include all the factors relating to the incident, as demonstrated in the previous ex- amples. The documentation in the chart, however, should be only a statement of the facts and of the patient’s physical response; no reference to the incident report should be made, nor should words such as error or inappropriate be used.

When a patient receives 100 mg of Demerol instead of 50 mg as ordered, the proper documen- tation in the chart is, “100 mg of Demerol administered. Physician notified.” The remainder of the documentation should include any reaction the patient has to the dosage, such as “Patient’s vital signs unchanged.” If there is an adverse reaction, a follow-up note should be written in the chart, giving an update of the patient’s status. A note related to the patient’s reaction should be written as frequently as the status changes and should continue until the patient returns to his or her previous status.

The chart must never be used as a tool for disciplinary comments, action, or expressions of an- ger. Notes such as, “Incident would never have occurred if Doctor X had written the correct order in the first place” or “This carelessness is inexcusable” or “Paged the doctor eight times, as usual, no reply” are wholly inappropriate and serve no meaningful purpose. Carelessness and incorrect orders do indeed cause errors and incidents, but the place to address and resolve these issues is in the risk management committee or in the nurse manager’s office, not on the patient chart.

Handling a complaint without punishing a staff member is a delicate situation. The manager must determine what happened in order to prevent another occurrence, but using an incident report for discipline might result in fewer or erroneous incident reports in the future. Learn how one manager handled a situation of this kind in Case Study 6-1.

A Caring Attitude With employees, the nurse manager sets the tone that contributes to a safe and low-risk environ- ment. One of the most important ways to reduce risk is to instill a sense of confidence in both patients and families by emphasizing and recognizing that they will receive personalized atten- tion and that their needs will be attended to with competence. This confidence is created envi- ronmentally and professionally.

Examples of environmental factors include cleanliness, attention to patients’ privacy, promptly responding to patients’ and family members’ requests, an orderly looking unit, and engaging in minimal social conversations in front of patients. One example of portraying pro- fessional confidence is to provide patients and families with the name of the person in charge. A sincere visit by that person is reassuring. In addition, a thorough orientation creates indepen- dence for the patient and confidence in an efficient unit.

The nurse manager needs to foster the attitude that any mistake that does occur is perceived as an opportunity to improve a system or a process rather than to punish an individual. If the nurse manager has developed a patient-focused atmosphere in which patients believe their best interests are a priority, the potential for risk will be reduced.

Creating a Blame-Free Environment The health care environment is known to be a blame culture that “is a major source of medical errors and poor quality of patient care” (Khatri, Brown, & Hicks, 2009, p. 320). Such a culture inhibits reporting of inadequate practice, underreporting of adverse events, and inattention to possible safety problems.


A just culture, in contrast, allows for reporting of errors without fear of undue retribution (Gorzeman, 2008). Khatri, Brown, & Hicks (2009) suggest that transitioning to a just culture does more than improve reporting mechanisms or initiate training programs. A just culture provides an environment in which employees can question policies and practices, express concerns, and admit mistakes without fear of retribution. A just culture requires organizational commitment, mana- gerial involvement, employee empowerment, an accountability system, and a reporting system (Gorzeman, 2008).

Accountability for errors, however, must be maintained (Gorzeman, 2008). Errors can be categorized as:

● Human errors, such as unintentional behaviors that may cause an adverse consequence ● At-risk behaviors, such as unsafe habits, negligence, carelessness ● Reckless behaviors, such as conscious disregard for standards

A just culture is prepared to handle incidents involving human error. At-risk or reckless behaviors, however, are not tolerated.

Managing and improving quality requires ongoing attention to system-wide processes and individual actions. The nurse manager is in a key position to identify problems and encourage a culture of safety and quality.

RISK MANAGEMENT Yasmine Dubois is the nurse manager for the cardiac catheterization lab and special procedures unit in a sub- urban hospital. The hospital has an excellent reputation for its cardiac care program, including the use of cut- ting-edge technology. The cath lab utilizes a specialized computer application that records the case for the nurs- ing staff, requiring little handwritten documentation at the end of a procedure.

Last month, a 56-year-old woman was brought from the ER to the cath lab at approximately 1900 for place- ment of a stent in her left anterior descending coronary artery. During the procedure, the heart wall was perfo- rated. The patient coded and was taken in critical condi- tion to the OR, where she died during surgery.

Two days following the incident, the patient’s hus- band requested a review of his wife’s medical records. During his review, he pointed out to the medical records clerk that the documentation from the cath lab stated that his wife “. . . tolerated the procedure well and was taken in satisfactory condition to the recovery area.” The documentation was signed, dated, and timed by Elizabeth Clark, RN. The medical records director

notified the hospital’s risk manager of the error. The risk manager investigated the incident and determined that Elizabeth Clark’s charting was in error.

Following her meeting with the risk manager, Yas- mine met with Elizabeth to discuss the incident. She showed Elizabeth a copy of the cath lab report. Eliza- beth asked Yasmine if she could have the chart from medical records so she could correct her mistake. Yas- mine informed Elizabeth that she couldn’t correct her charting at this point in time. But, she could, however, write an addendum to the chart, with today’s date and time, to clarify the documentation. Yasmine also told Elizabeth that the addendum would be reviewed by the risk manager and the hospital’s attorney prior to inclusion in the chart.

To ensure compliance with the hospital’s documen- tation standards and to determine if Elizabeth or any other cath lab nurse had committed any similar charting errors, Yasmine requested charts for all patients in the past 12 months who had been sent to surgery from the cath lab due to complications during a procedure. She conducted a retrospective audit and determined that this had been an isolated incident.



What You Know Now • Total quality management is a philosophy committed to excellence throughout the organization. • Continuous quality improvement is a process to improve quality and performance. • Six Sigma is another quality management program that uses measures, has goals, and is a management

system. • Lean Six Sigma provides tools to improve flow and eliminate waste. • DMAIC is a Six Sigma process improvement method to define, measure, analyze, improve, and control

performance. • A culture of safety and quality permeates efforts at the national level. • Cost may increase or decrease with quality initiatives. • Evidence-based practice, electronic medical records, and dashboards can be used to improve and monitor

quality. • Reducing medication errors is a priority for health care organizations and policy makers. • A risk management program focuses on reducing accidents and injuries and intervening if either occurs. • A caring attitude and prompt attention to complaints help to reduce risk. • A just culture is more likely to encourage reporting of adverse events, including near misses, as well as

point out unsafe practices.

Tools for Managing and Improving Quality 1. Remember: Quality management is a system. When something goes wrong, it is usually due to a

flaw in the system. 2. Become familiar with standards and outcome measures and use them to guide and improve your

practice. 3. Strive for perfection, but be prepared to tolerate failure in order to encourage innovation. 4. Be sure that performance appraisals and incident reports are not used for discipline but rather are the

bases for improvements to the system and/or development of individuals. 5. Remind yourself and your colleagues that a caring attitude is the best prevention of problems.

Following an incident:

1. Meet with the risk manager and hospital attorney to review documentation and determine which staff will be interviewed regarding the incident.

2. Provide any requested information to administration in a timely manner. 3. Audit documentation and processes to determine if an incident is part of a pattern or an isolated

incident. 4. Provide the results of any audits or discussions with staff to appropriate administrators. 5. Educate staff as appropriate. 6. Determine if disciplinary action is required. 7. Follow up with risk management, nursing administration, and human resources as appropriate. 8. Continue to cooperate with the hospital attorney if the incident results in litigation.

Questions to Challenge You 1. Imagine that an organization is debating among several quality management programs. What would

you recommend? Why? 2. Do you know what standards and outcome measures are used in your clinical setting? How are data

handled? Are they shared with employees? 3. What comparable groups, both internal and external, are used for benchmarking performance in

your organization? 4. Universities also use benchmarking. What institutions does your college or university use to bench-

mark its performance? Find out. 5. Have you, a family member, or a friend ever had a serious problem in a health care organization that

resulted in injury? What was the outcome? Is this how you would have handled it? What will you do in the future in a similar situation?

6. Have you or anyone you know ever made a mistake in a clinical setting? What happened? Would you assess the organization as a blame-free environment?


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Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

DMAIC: Define, Measure, Analyze, Improve, Control

DMAIC: Define, Measure, Analyze, Improve, Control


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1. Define power. 2. Describe how power is used. 3. Discuss how image is a source of power. 4. Explain how to use shared visioning

as a power tool.

5. Discuss how politics influence policy. 6. Describe how nurses can use politics

to influence policies.

Learning Outcomes After completing this chapter, you will be able to:

Power Defined

Power and Leadership

Power: How Managers and Leaders Get Things Done



Shared Visioning as a Power Tool

Power, Politics, and Policy NURSING’S POLITICAL HISTORY



Using Power and Politics for Nursing’s Future

Understanding Power and Politics7


Key Terms Coercive power Connection power Expert power Information power Legitimate power Personal power

Policy Politics Position power Power Power plays Punishment

Referent power Reward power Shared visioning Stakeholders Vision


Power Defined Power is the potential ability to influence others (Hersey, 2011). Power is involved in every human encounter, whether you recognize it or not. Power can be symmetrical when two parties have equal and reciprocal power, or it may be asymmetrical with one person or group having more control than another (Mason, Leavitt, & Chaffee, 2011). Power can be exclusive to one party or may be shared among many people or groups. To acquire power, maintain it effectively, and use it skillfully, nurses must be aware of the sources and types of power that they will use to influence and transform patient care.

Power and Leadership Real power—principle-centered power—is based on honor, respect, loyalty, and commitment. Principle-centered power is a model congruent with nursing’s values. It is based on respect, honor, loyalty, and commitment. Originally conceived by Stephen Covey (1991), the model is increasingly used by leaders in many fields (Ikeda, 2009). Power sharing evolves naturally when power is centered on one’s values and principles. In fact, the notion that power is something to be shared seems to contradict the usual belief that power is something to be amassed, protected, and used for one’s own purposes.

Leadership power comes from the ability to sustain proactive influence, because followers trust and respect the leader to do the right thing for the right reason. As leaders in health care, nurses must understand and select behaviors that activate principle-centered leadership:

● Get to know people. Understanding what other people want is not always simple. ● Be open. Keep others informed. Trust, honor, and respect spread just as equally as fear,

suspicion, and deceit. ● Know your values and visions. The power to define your goals is the power to choose. ● Sharpen your interpersonal competence. Actively listen to others and learn to express your

ideas well. ● Use your power to enable others. Be attentive to the dynamics of power and pay attention

to ground rules, such as encouraging dissenting voices and respecting disagreement. ● Enlarge your sphere of influence and connectedness. Power sometimes grows out of

someone else’s need.

Power: How Managers and Leaders Get Things Done Classically, managers relied on authority to rouse employees to perform tasks and accomplish goals. In contemporary health care organizations, managers use persuasion, enticement, and inspiration to mobilize the energy and talent of a work group and to overcome resistance to change.

A leader’s use of power alters attitudes and behavior by addressing individual needs and motivations. There are seven generally accepted types of interpersonal power used in organizations to influence others (Hersey, 2011):

1. Reward power is based on the inducements the manager can offer group members in exchange for cooperation and contributions that advance the manager’s objectives. The degree of compliance depends on how much the follower values the expected benefits. For example, a nurse manager may grant paid educational leave as a way of rewarding a staff nurse who agreed to work overtime. Reward power often is used in relation to a manager’s formal job responsibilities.

2. Coercive power is based on the penalties a manager might impose on an individual or a group. Motivation to comply is based on fear of punishment (coercive power) or withholding of rewards. For example, the nurse manager might make undesirable job assignments, mete out


a formal reprimand, or recommend termination for a nurse who engages in disruptive behavior. Coercion is used in relation to a manager’s perceived authority to determine employment status.

3. Legitimate power stems from the manager’s right to make a request because of the author- ity associated with job and rank in an organizational hierarchy. Followers comply because they accept a manager’s prerogative to impose requirements, sanctions, and rewards in keeping with the organization’s mission and aims. For instance, staff nurses will com- ply with a nurse manager’s directive to take time off without pay when the workload has dropped below projected levels because they know that the manager is charged with main- taining unit expenses within budget limitations.

4. Expert power is based on possession of unique skills, knowledge, and competence. Nurse man- agers, by virtue of experience and advanced education, are often the best qualified to determine what to do in a given situation. Employees are motivated to comply because they respect the manager’s expertise. Expert power relates to the development of personal abilities through edu- cation and experience. Newly graduated nurses might ask the nurse manager for advice in learn- ing clinical procedures or how to resolve conflicts with coworkers or other health professionals.

5. Referent power is based on admiration and respect for an individual. Followers comply because they like and identify with the manager. Referent power relates to the manager’s likeability and success. For example, a new graduate might ask the advice of a more expe- rienced and admired nurse about career planning.

6. Information power is based on access to valued data. Followers comply because they want the information for their own needs. Information power depends on a manager’s or- ganizational position, connections, and communication skills. For example, the nurse man- ager is frequently privy to information about pending organizational changes that affect employees’ work situations. A nurse manager may exercise information power by sharing significant information at staff meetings, thereby improving attendance.

7. Connection power is based on an individual’s formal and informal links to influential or prestigious persons within and outside an area or organization. Followers comply because they want to be linked to influential individuals. Connection power also relates to the status and visibility of the individual as well. If, for example, a nurse manager is a neighbor of an organization’s board member, followers may believe that connection will protect or ad- vance their work situation.

Managers have both personal and position power. Position power is determined by the job description, assigned responsibilities, recognition, advancement, authority, the ability to with- hold money, and decision making. Legitimate, coercive, and reward power are positional because they relate to the “right” to influence others based on rank or role. The extent to which managers mete out rewards and punishment is usually dictated by organizational policy. Information and legitimate power are directly related to the manager’s role in the organizational structure.

Expert, referent, information, and connection power are based, for the most part, on personal traits. Personal power refers to one’s credibility, reputation, expertise, experience, control of resources or information, and ability to build trust. The extent to which one may exercise expert, referent, information, and connection power relates to personal skills and positive interpersonal relationships as well as employees’ needs and motivations. Box 7-1 illustrates how nurses can learn to use power in organizations.

Using Power Despite an increase in pride and self-esteem that comes with using power and influence, some nurses still consider power unattractive. Power grabbing, which has been the tradition- ally accepted means of relating to power for one’s own self-interests and use, is how nurses


often think of power. Rather, nurses tend to be more comfortable with power sharing and empowerment: power “with” rather than power “over” others.

Image as Power A major source of power for nurses is an image of power. Even if one does not have actual power from other sources, the perception by others that one is powerful bestows a degree of power. The same is true for the profession as a whole. If the public sees the profession of nursing as powerful, the profession’s ability to achieve its goals and agendas is enhanced.

Images emerge from interactions and communications with others. If nurses present themselves as caring and compassionate experts in health care through their interactions and communications with the public, then a strong, favorable image develops for both the individual nurse and the profession. Nurses, as the ambassadors of care, must understand the importance and benefits of positive therapeutic communications and image. Developing a positive image of power is important for both the individual and the profession.

BOX 7-1 Guidelines for the Use of Power in Organizations

Guidelines for Using Legitimate Authority

● Make polite, clear requests.

● Explain the reasons for a request.

● Don’t exceed your scope of authority.

● Verify authority if necessary.

● Follow proper channels.

● Follow-up to verify compliance.

● Insist on compliance if appropriate.

Guidelines for Using Reward Power ● Offer the type of rewards that people desire.

● Offer rewards that are fair and ethical.

● Don’t promise more than you can deliver.

● Explain the criteria for giving rewards and keep it simple.

● Provide rewards as promised if requirements are met.

● Use rewards symbolically (not in a manipulative way).

Guidelines for Using Coercive Power ● Explain rules and requirements and ensure that

people understand the serious consequences of violations.

● Respond to infractions promptly and consistently without showing any favoritism to particular individuals.

● Investigate to get the facts before using repri- mands or punishment and avoid jumping to con- clusions or making hasty accusations.

● Except for the most serious infractions, provide sufficient oral and written warnings before resorting to punishment.

● Administer warnings and reprimands in private and avoid making rash threats.

● Stay calm and avoid the appearance of hostility or personal rejection.

● Express a sincere desire to help the person com- ply with role expectations and thereby avoid punishment.

● Invite the person to suggest ways to correct the problem and seek agreement on a concrete plan.

● Maintain credibility by administering punishment if noncompliance continues after threats and warnings have been made.

Guidelines for Using Expert Power ● Explain the reasons for a request or proposal and

why it is important. ● Provide evidence that a proposal will be successful. ● Don’t make rash, careless, or inconsistent

statements. ● Don’t exaggerate or misrepresent the facts. ● Listen seriously to the person’s concerns and

suggestions. ● Act confidently and decisively in a crisis.

Ways to Acquire and Maintain Referent Power ● Show acceptance and positive regard. ● Act supportive and helpful. ● Use sincere forms of ingratiation. ● Defend and back up people when appropriate. ● Do unsolicited favors. ● Make self-sacrifices to show concern. ● Keep promises.

Adapted from Yukl, G. (2007). Leadership in organizations (6th ed.) (pp. 150–156). Upper Saddle River, NJ: Prentice Hall. Reprinted by permission.


Individual nurses can promote an image of power by a variety of means, such as:

1. Appropriately introducing yourself by saying your name, making eye contact, and shaking hands can immediately establish you as a powerful person. If nurses introduce themselves by first name to the physician, Dr. Smith, they have immediately set forth an unequal power relationship unless the physician also uses his or her first name. Although women are not socialized to initiate handshakes, it is a power strategy in male-dominated circles, including health care organizations. In Western cultures, eye contact conveys a sense of confidence and connection to the individual to whom one is speaking. These seemingly minor behaviors can have a major impact on how competent and powerful the nurse is perceived.

2. Attire can symbolize power and success (Sullivan, 2013). Although nurses may believe that they are limited in choice of attire by uniform codes, it is in fact the presentation of the uniform that can hold the key to power. For example, a nurse manager needs a powerful image both with unit staff and with administrators and other professionals who are setting organizational policy. An astute nurse manager might wear a suit rather than a uniform to work on the day of a high-level interdisciplinary committee meeting. Certainly, attention to details of grooming and uniform selection can enhance the power of the staff nurse as well.

3. Conveying a positive and energetic attitude sends the message that you are a “doer” and someone to be sought out for involvement in important issues. Chronic complaining con- veys a sense of powerlessness, whereas solving problems and being optimistic promote a “can do” attitude that suggests power and instills confidence in others.

4. Pay attention to how you speak and how you act when you speak. Nonverbal signs and signals say more about you than words. Stand erect and move energetically. Speak with an even pace and enunciate words clearly. Make sure your words are reflected in your body language. Keep your facial expression consistent with your message.

5. Use facts and figures when you need to demonstrate your point. Policy changes usually evolve from data presented in a compelling story. Positioning yourself as a powerful player requires the ability to collect and analyze data. Technology facilitates data retrieval. For example, Chapter 6 lists various quality initiatives that yield useful data, including bench- marks and dashboards. Remember that power is a matter of perception; therefore, you must use whatever data are available to support your judgment.

6. Knowing when to be at the right place at the right time is crucial to gain access to key per- sonnel in the organization. This means being invited to events, meetings, and parties not necessarily intended for nurses. It means demanding to sit at the policy table when decisions affecting staffing and patient care are made. Influence is more effective when it is based on personal relationships and when people see others in person: “If I don’t see you, I can’t ask you for needed information, analysis, and alternative recommendations.” Become vis- ible. Be available. Offer assistance. You can be invaluable in providing policy makers with information, interpreting data, and teaching them about the nursing side of health care.

7. In dealing with people outside of nursing, it is important to develop powerful partnerships. Learn how to share both credit and blame. When working on collaborative projects, use “we” instead of “they,” and be clear about what is needed. If something isn’t working well, say so. Never accept another’s opinion as fact. Facts can be easily manipulated to fit one’s personal agenda. Learn how to probe and obtain additional information. Don’t assume you have all the information. Beware of unsolicited commentary. Don’t be fearful of giving strong criticism, but always put criticisms in context. Before giving any criticism, give a compliment, if appropriate. Also, make sure your partners are ready to hear all sides of the issue. It’s never superfluous to ask, “Do you want to talk about such and such right now?” Once an issue is decided—really decided—don’t raise it again.


8. Make it a point to get to know the people who matter in your sphere of influence. Become a part of the power network so that when people are discussing issues or seeking people for important appointments of leadership, your name comes to mind. Be sure to deal with senior people. The more contact you have with the “power brokers,” the more support you can generate in the future should the need arise. The more power you use, the more you get.

9. Know who holds the power. Identify the key power brokers. Develop a strategy for gaining access to power brokers through joining alliances and coalitions. Learn how to question others and how to become part of the organizational infrastructure. There is an art to de- termining when, what, and how much information is exchanged and communicated at any one time and to determining who does so. Powerful people have a keen sense of timing. Be sure to position yourself to be at the right place at the right time. Any strategy will involve a good deal of energy and effort. Direct influence and efforts toward issues of highest prior- ity or when greatest benefits are likely to result.

10. Use power appropriately to promote consensus in organizational goals, develop common means to achieve these goals, and enhance a common culture to bind organizational mem- bers together. As the health care providers closest to the patient, nurses best understand patients’ needs and wants. In the hospital, nurses are present on the first patient contact and thereafter for 24 hours a day, 7 days a week. In the clinic, the nurse may be the person the patient sees first and most frequently. By capitalizing on the special relationship that they have with patients, nurses can use marketing principles to enhance their position and image as professional caregivers.

Nursing as a profession must market its professional expertise and ability to achieve the objectives of health care organizations. From a marketing perspective, nursing’s goal is to ensure that identified markets (e.g., patients, physicians, other health professionals, community members) have a clear understanding of what nursing is, what it does, and what it is going to do. In doing so, nursing is seen as a profession that gives expert care with a scientific knowledge base.

Nursing care often is seen as an indicator of an organization’s overall quality. Regardless of the setting, quality nursing care is something that is desired and valued. Through understanding patients’ needs and preferences for programs that promote wellness and maintain and restore health, nurses become the organization’s competitive edge to enhancing revenues. Marketing an image of expertise linked with quality and cost can position nursing powerfully and competi- tively in the health care marketplace.

Using Power Appropriately Using power not only affects what happens at the time, but also has a lasting effect on your re- lationships. Therefore, it is best to use the least amount of power necessary to accomplish your goals. Also, use power appropriate to the situation (Sullivan, 2013). Table 7-1 lists rules for us- ing power.

Improper use of power can destroy a manager’s effectiveness. Power can be overused or un- derused. Overusing power occurs when you use excessive power relative to the situation. If you fail to use power when it is needed, you are underusing your power. In addition to the immediate loss of influence, you may lose credibility for the future.

Power plays are another way that power is used inappropriately. Power plays are attempts by others to diminish or demolish their opponents. Typical power plays include:

“Let’s be fair.” “Can you prove that?” “It’s either this or that; which is it? Take your pick.” “But you said . . . and now you say. . . .”


Such statements engender feelings of insecurity, incompetence, confusion, embarrassment, and anger. You do not need to respond directly in these situations but, rather, you can simply restate your initial point in a firm manner. Keep your expression neutral, ignore accusations, and restate your position, if appropriate. If you refuse to respond to these thinly veiled attacks, your opponent is unable to intimidate and manipulate you.

Nursing must perceive power for what it really is—the ability to mobilize and focus energy and resources. What better position can nurses be in but to assume power to face new problems and re- sponsibilities in reshaping nursing practice to adapt to environmental changes? Power is the means, not the end, to seek new ways for doing things in this uncertain and unsettling time in health care.

Shared Visioning as a Power Tool Shared visioning is a powerful tool to influence the organization’s future. Shared visioning is an interactive process in which both leaders and followers commit to the organization’s goals (Kantabutra, 2009; Pearce, Conger, & Locke, 2008). A vision is a mental model of a possible future (Kantabutra, 2008). It should inspire and challenge both leaders and followers to accom- plish the organization’s goals set forth in the vision.

Top-down management is an out-of-date concept (Pearce, Conger, & Locke, 2008). Today’s leaders recognize that their power must be shared and that integrated leadership styles—bottom-up and lateral—are essential for success. Consensus about the organization’s future can motivate leaders and employees alike to envision their preferred future and do their best to achieve it. In addition, a shared vision makes implementing the necessary, and often difficult, changes easier.

Kantabutra (2009) posits that the leader is not a passive participant in the visioning process. The leader should be an active group member, leading the group toward the desired vision in a participative fashion. The leader helps guide the group toward consensus.

Furthermore, innovation is necessary for organizations to effect positive change (McKeown, 2008). Innovation requires employee buy-in to flourish (Melnyk & Davidson, 2009). Shared visioning is a strategy that encourages innovation.

Power, Politics, and Policy While power is the potential ability to influence others, politics is the art of influencing others to achieve a goal (Mason, Chaffee, & Leavitt, 2011).

TABLE 7-1 Rules for Using Power

1. Use the least amount of power you can to be effective in your interactions with others.

2. Use power appropriate to the situation.

3. Learn when not to use power.

4. Focus on the problem, not the person.

5. Make polite requests, never arrogant demands.

6. Use coercion only when other methods don’t work.

7. Keep informed to retain your credibility when using your expert power.

8. Understand you may owe a return favor when you use your connection power.

From Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall. Reprinted by permission.



● Is an interpersonal endeavor—uses communication and persuasion ● Is a collective activity—requires the support and action of many people ● Calls for analysis and planning—requires an assessment of the issue and a plan to resolve it ● Involves image—hinges on the image people have of change makers

Nursing’s Political History Nurses’ political activities began with Florence Nightingale, continued with the emergence of nursing schools and women’s suffrage, and improved with the establishment of nursing organizations and the feminist movement (Sullivan, 2013). Establishing the National Center for Nursing Research (later changed to the National Institute of Nursing Research) within the National Institutes of Health is an example of nurses’ powerful political action.

A Brief History of the National Institute of Nursing Research

After the Institute of Medicine report recommended a federal nursing research entity as part of the mainstream scientific community in the early 1980s, nursing leaders in the United States began promoting establishment of a nursing institute at the National Insti- tutes of Health. This effort involved lobbying Congress, the Reagan administration, and the other institutes at NIH—a formidable task. A few members of Congress were interested in the potential that nursing science had for improving health, but the administration was not in favor of another institute at NIH, and the other institutes seemed puzzled as to why nursing would need its own institute to do research. Couldn’t nurse researchers receive funding through existing institutes? Medicine did so without a separate institute.

Step by step, nursing leaders persuaded (harassed?) institute directors and Congress, insisting that nursing research would improve human response to illness and assist in maintaining and enhancing health. A bill was born. Concern about cost and increasing bureaucracy emerged and was overcome. The bill passed only to be vetoed by President Reagan. Then a funny thing happened. Nursing made an unprecedented move. The profession came together, united with one goal: to override President Reagan’s veto (none had been successfully overridden before).

One by one, across the country, nurses called their senators and congressional represen- tatives urging support for a nursing institute, explaining that nurses were represented only among a few funded researchers at other institutes who did not understand the impact of nursing interventions on health and recovery. A modest investment, they explained, would yield exponentially greater results. Thanks to a few persuasive members of Congress, a compromise was negotiated and the National Center for Nursing Research was estab- lished in 1985. Through a statutory revision in 1993, the Center became an Institute.

Similarly, Georgia nurses successfully changed that state’s practice act to include prescrip- tive authority for advanced practice nurses, overcoming fierce opposition from the medical as- sociation (Beall, 2007). Working in concert with each other and with consumers and the media, they generated a letter-writing campaign that countered every obstacle the medical association tried. Georgia became the last state to grant prescribing privileges to nurse practitioners.

Policy, on the other hand, is the decision that determines action. Policies result from political action.

Using Political Skills to Influence Policies Political skill, per se, is not included in nursing education (nor is it tested on state board exams), yet it is a vital skill for nurses to acquire. To improve your political skill:

● Learn self-promotion—report your accomplishments appropriately. ● Be honest and tell the truth—say what you mean and mean what you say. ● Use compliments—recognize others’ accomplishments.


● Discourage gossip—silence is the best response. ● Learn and use quid pro quo—do and ask for favors. ● Remember: appearance matters—attend to grooming and attire. ● Use good manners—be courteous. (Green & Chaney, 2006)

Health care involves multiple special-interest groups all competing for their share of a limited pool of resources. The delivery of nursing services occurs at many levels in health care organizations. The effectiveness of care delivery is linked to the application of power, politics, and marketing. Nurses belong to a complex organization that is continually confronted with limited resources and is in competition for those resources.

How politically savvy are you? Ask yourself the following questions:

● Do you get credit for your ideas? ● Do you know how to deal with a difficult colleague? ● Do you have a mentor? ● Are you “in the loop”? ● Can you manage and influence others’ perceptions of you and your work? ● Are you able to convert enemies to friends? ● Do your ideas get a fair hearing? ● Do you know when and how to present them? (Reardon, 2011)

To take action, first decide what you want to accomplish. Is it realistic? Will you have supporters? Who will be the detractors? The steps in political action are shown in Table 7-2.

Try to find out what other people involved, called stakeholders, want. Maybe you could piggyback on their ideas. Members of Congress do this all the time by adding amendments to proposed bills in an attempt to satisfy their opponents.

Start telling your supporters about your idea and see if they will join with you in a coalition. This is not necessarily a formal group but allows you to know who you can count on in the discussions.

Find out exactly what objections your opponents have. Try to figure out a way to alter your plan accordingly or help your opponents understand how your proposal might help them. Political action is never easy, but the most politically astute people accomplish goals far more often than those who don’t even try.

A case study that exemplifies a nurse using organizational politics is shown in Case Study 7-1.

Influencing Public Policies What happens in the workplace both depends on and influences what is happening in the larger community, professional organizations, and government. Developing influence in each of these three groups takes time and a long-range plan of action. Although the nurse’s first priority should be to establish influence in the workplace, the nurse can gradually increase connections and in- fluence with other groups and, later on, make these other groups a priority.

TABLE 7-2 Steps in Political Action

1. Determine what you want. 2. Learn about the players and what they want. 3. Gather supporters and form coalitions. 4. Be prepared to answer opponents. 5. Explain how what you want can help them.

From Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall. Reprinted by permission.


In order to influence public policies, nurses need to know how to work with the public officials who enact those policies. Table 7-3 lists guidelines for working with public officials.

First, be respectful. Public officials have many constituents and demands on their support. Build relationships with officials. Don’t just contact them when you have a request. Keep in touch at other times.

Communicating with Elected Officials Nurses often wish to contact elected officials to support or oppose legislation. You can call, e-mail, tweet, or write to public officials. (Links to state legislators and contact information for federal government officials are listed in the Web resources for this chapter.)

Here’s how to contact state or federal elected officials. Call the official’s staff and ask to speak to the person who handles the issue that concerns you. Tell the aide that you support or oppose a certain bill and state the reasons why. Name the bill by number.

USING ORGANIZATIONAL POLITICS FOR PERSONAL ADVANTAGE Juanita Pascheco has been nurse manager of medical and surgical ICUs in a large, urban, for-profit hospital for the past seven years. Two years ago, Juanita completed her master’s degree in nursing administration. Her the- sis research centered on the acceptance of standardized and computerized documentation methods for critical care units. Juanita is well respected in her current role and is a member of several key committees addressing the need for a replacement health information system (HIS) for the hospital. She reports directly to the director of critical care services.

Although Juanita enjoys her work as nurse man- ager, she believes she is ready to assume additional responsibilities at the director level. Through her work on the hospital’s HIS selection team and as the nursing representative to the physician’s technology committee, Juanita identifies the need for a clinical informatics di- rector role. One of Juanita’s responsibilities on the HIS selection team is to identify talent from clinical areas who could support the HIS implementation. Juanita has also agreed to chair several working committees that will assist in determining required clinical functionality for the HIS.

During her tenure at the hospital, Juanita has cul- tivated solid working relationships with several key de- cision makers within the organization. The human re- sources director, Ken Harding, has worked with Juanita on several large projects over the past two years, in- cluding implementation of multidisciplinary teams in the ICUs. Juanita schedules a lunch with Ken to discuss growth opportunities in the information technology department, the process for creating new roles, and in particular, who will determine the need for and ap- proval of new information technology positions. Using this knowledge and her experience on the HIS selection

team and the physicians’ technology committee, Juanita develops a proposal for the clinical informatics director position.

As the HIS selection team draws closer to selecting a final vendor for the computerized health information system and an implementation timeline is established by the information technology department, Juanita ap- proaches her supervisor, Sherrie Wright, with her pro- posal. Juanita also provides Sherrie with an overview of the clinical support that will be necessary for successful implementation of the HIS product. Since the critical care units are targeted for the initial phase of imple- mentation, Sherrie is aware that Juanita’s high interest in technology and her clinical expertise in the ICU would be invaluable for successful implementation. As a strong manager, Juanita can build acceptance of this change among the nurses, physicians, and other members of the health care team.

Sherrie agrees to take Juanita’s proposal to the chief nursing officer for formal consideration.

Manager’s Checklist The nurse manager is responsible for:

● Knowing and understanding the formal lines of authority within the organization.

● Identifying key decision makers and understanding their priorities and how those priorities affect any new initiatives.

● Recognizing the importance of timing when initiating change.

● Being ready to take advantage of new opportunities. ● Building strong and credible working relationships

with decision makers. ● Being willing to take on new and challenging tasks

that may lead to more responsibility.



E-mail or write directly to the official. Identify the bill in question, state your position on the bill, and explain why you support or oppose it. Keep your comments brief, and address only one issue per correspondence. Hand-written letters get more attention than form letters distributed by organizations.

Use this format to address members of the U.S. Senate:

The Honorable (full name of senator) __(Rm.#)__(name of) Senate Office Building United States Senate Washington, DC 20510

Dear Senator:

To contact the member of the U.S. Congress, use a similar format.

The Honorable (full name) __(Rm.#)__(name of) House Office Building United States House of Representatives Washington, DC 20515

Dear Representative:

Meeting with Elected Officials To meet in person with an elected official, make an appointment, arrive on time, and come pre- pared. Understand the pros and cons of the issue you are bringing to the person’s attention. Be a constructive opponent. Argue for your position and be prepared with additional information and alternative suggestions. Still, be realistic. What you want may not be possible, or it may not be likely at the present time. Always be helpful. Show how your issue benefits the official’s constituents and, thus, the representative.

The American Association of Critical-Care Nurses suggests pointers for working with public officials (AACN, 2010). In addition, the American Nurses Association (ANA) has legislative and government information for nurses (ANA, 2011). (See links to these organizations in the Web resources for this chapter.)

Using Power and Politics for Nursing’s Future Kelly (2007) suggests that apathy prevents nurses from using their political skills. Becoming active in professional associations, learning the legislative issues that affect nursing, gaining political skills, and being willing to advocate for nursing’s causes are necessary for the profes- sion to flex its considerable political muscles. All nurses can participate to some extent in these activities.

Nurses can have a tremendous impact on health care policy. The best impact is often made with a bit of luck and timing, but never without knowledge of the whole system. This includes

TABLE 7-3 How to Work with Public Officials

1. Be respectful. 5. Understand the issue. 2. Build relationships. 6. Be a constructive opponent. 3. Keep in touch. 7. Be realistic. 4. Arrive informed. 8. Be helpful.

From Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall. Reprinted by permission.


knowledge of the policy agenda, the policy makers, and the politics that are involved. Once you gain this knowledge, you are ready to move forward with a political base to promote nursing.

To convert your policy ideas into political realities, consider the following power points:

● Use persuasion over coercion. Persuasion is the ability to share reasons and rationale when making a strong case for your position while maintaining a genuine respect for an- other’s perspective.

● Use patience over impatience. Despite the inconveniences and failings caused by health care restructuring, impatience in the nursing community can be detrimental. Patience, along with a long-term perspective on the health care system, is needed.

● Be open-minded rather than closed-minded. Acquiring accurate information is essential if you want to influence others effectively.

● Use compassion over confrontation. In times of change, errors and mistakes are easy to pinpoint. It takes genuine care and concern to change course and make corrections.

● Use integrity over dishonesty. Honest discourse must be matched with kind thoughts and actions. Control, manipulations, and malice must be pushed aside for change to occur.

By using their political skills, nurses can improve patient care in individual institutions, help organizations survive and thrive, and influence public officials.

What You Know Now • Power is the potential ability to influence others. • Power can be positional or personal. • Types of power include reward, coercive, legitimate, expert, referent, information, and connection. • Image is a source of power. • Power can be overused, underused, or used inappropriately. To be effective, the power used must be appro-

priate to the situation. • Shared visioning is an interactive process in which both leaders and followers commit to the organiza-

tion’s goals. • Politics is the art of influencing others to achieve a goal. • Policy is the decision that determines action. Policies result from political action. • Nurses can use political action to influence policies in the organization and to influence public policies.

Tools for Using Power and Politics 1. Learn the formal lines of authority within your organization. 2. Identify key decision makers and build strong and credible relationships with them. 3. Identify decision makers’ priorities and how those affect any new initiatives. 4. Learn the rules for using power and put them into practice. 5. Offer solutions to problems and take advantage of new opportunities. 6. Exhibit a willingness to take on new and challenging tasks that may lead to more responsibility. 7. Pay attention to people who are influential and adopt their strategies if appropriate. 8. Learn strategies for working with public officials.

Questions to Challenge You 1. Consider a person you believe to have power. What are the bases of that person’s power? 2. Evaluate how the person you named uses his or her power. Is it positive or negative? 3. Have you observed people using power inappropriately? Describe what they did and what happened

as a result.


4. Assess your own power using the seven types of power discussed in the chapter. Name three ways you could increase your power.

5. How politically savvy are you? Did you discover areas to challenge you? 6. Have you been involved in developing policies in your organization or have you worked with public

officials? Explain.

References American Association of Critical

Care Nurses. (2010). Advo- cacy 101: Golden rules for those who work with public officials. Retrieved October 22, 2010 from http://www. aacn.org/wd/practice/ content/publicpolicy/ goldenrules.pcms?pid=1& mid=2874&menu=Comm unity

American Nurses Association. (2011). RN activist kit. Retrieved June 3, 2011 from www.nursingworld. org/gova

Beall, F. (2007). Overview and summary: Power to influence patient care: Who holds the keys? Online Journal of Is- sues in Nursing, 12(1). Retrieved October 22, 2010 from http://www. nursingworld.org/MainMe- nuCategories/ANAMar- ketplace/ANAPeriodicals/ OJIN/TableofContents/ Volume122007/No1Jan07/ tpc32ntr16088.aspx

Covey, S. R. (1991). Principle- centered leadership. New York: Simon & Schuster.

Green, C. G., & Chaney, L. H. (2006). The game of office politics. Supervision, 67(8), 3–6.

Hersey, P. H. (2011). Management of organizational behavior (10th ed.). Upper Saddle River, NJ: Prentice Hall.

Ikeda, J. (2009). Principle cen- tered power. Retrieved April 12, 2011 from http:// www.leadwithhonor. com/blog/2009/03/26/ principle-centered-power/

Kantabutra, S. (2008). What do we know about vision? Journal of Applied Business Research, 24(2), 323–342.

Kantabutra, S. (2009). Toward a behavioral theory of vision in organizational settings. Leadership & Organiza- tional Development Jour- nal, 30(4), 319–337.

Kelly, K. (2007). From apathy to political activism. American Nurse Today, 2(8), 55–56.

Mason, D. J., Leavitt, J. K., & Chaffee, M. W. (2011). Policy and politics in nurs- ing and health care (6th ed.). Philadelphia: W. B. Saunders.

McKeown, M. (2008). The truth about innovation. Great Britain: Pearson Education Limited.

Melnyk, B. M., & Davidson, S. (2009). Creating a culture of innovation in nursing education through shared vision, leader- ship, interdisciplinary partnerships, and positive deviance. Nursing Admin- istration Quarterly, 33(4), 288–295.

Pearce, C. L., Conger, J. A., & Locke, E. A. (2008). Shared leadership theory. The Leadership Quarterly, 19(3), 622–628.

Sullivan, E. J. (2013). Becom- ing influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall Health.

Web Resources American Association of Critical-Care Nurses: www.aacn.org American Nurses Association: www.nursingworld.org United States House of Representatives: www.house.gov United States Senate: www.senate.gov National Conference of State Legislatures: www.ncsl.org

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!













Stumbling Blocks


Thinking Critically, Making Decisions, Solving Problems


Key Terms Adaptive decisions Artificial intelligence Brainstorming Creativity Critical thinking Decision making Democratic leadership Descriptive rationality model Experimentation

1. Discuss how to use the critical-thinking process.

2. Describe ways to foster creativity. 3. Develop a plan to improve your

decision-making and problem-solving skills.

4. Compare and contrast individual and collective decision-making processes in various situations.

5. Recognize stumbling blocks to making decisions and solving problems.

6. Foster innovation in your work and that of others.

Learning Outcomes After completing this chapter, you will be able to:

Expert systems Groupthink Innovation Innovative decisions Objective probability Political decision-making

model Probability Probability analysis

Problem solving Rational decision-making

model Routine decisions Satisficing Subjective probability Trial-and-error method


N urse managers are expected to use knowledge from various disciplines to solve prob-lems with patients, staff, and the organization as well as problems in their own personal and professional lives. They must make decisions in dynamic situations, such as: ● After a position vacates should we refill it, given the tighter economy? ● Is the present policy requiring 12-hour shifts adequate for both patients and nurses? ● Which is the best staffing pattern to prevent turnover and ensure quality patient care? ● What is the best time to have staff meetings and council meetings in order to involve the

night shift too?

This chapter explains and differentiates critical thinking, decision making, and problem solv- ing and describes processes and techniques for using each.

Critical Thinking Critical thinking is the process of examining underlying assumptions, interpreting and evaluat- ing arguments, imagining and exploring alternatives, and developing a reflective criticism for the purpose of reaching a conclusion that can be justified. Critical thinking is not the same as criticism, though it does call for inquiring attitudes, knowledge about evidence and analysis, and skills to combine them.

Critical-thinking skills can be used to resolve problems rationally. Identifying, analyz- ing, and questioning the evidence and implications of each problem stimulate and illuminate critical thought processes. Critical thinking is also an essential component of decision making. However, compared to problem solving and decision making, which involve seeking a single solution, critical thinking is a higher-level cognitive process that includes creativity, problem solving, and decision making (Figure 8-1).

Critical Thinking in Nursing The need for critical thinking in nursing has long been accepted. Zori, Nosek, and Musil (2010) used the California Critical Thinking Disposition Inventory to measure critical thinking in nurses. The researchers found that the nurses supervised by managers with higher critical think- ing skills perceived their work environment to be more positive than those whose managers scored lower on critical-thinking skills.

Case scenarios and discussion of clinical experiences taught newly licensed nurses critical thinking and improved their retention rate in one facility (Ashcraft, 2010). Bittner and Gravlin (2009) studied nurses’ critical-thinking skills when delegating to assistive personnel. They found that the nurse’s lack of critical thinking more often resulted in missed or omitted routine care.

Problem solving


Decision making

Critical thinking

Figure 8-1 • Critical-thinking model.


The Carnegie Foundation’s call for reform in nursing education argues, however, that nurs- ing should move beyond critical thinking toward clinical reasoning and diverse thinking (Benner et al., 2009).

Using Critical Thinking The critical-thinking process seems abstract unless it can be related to practical experiences. One way to develop this process is to consider a series of questions when examining a specific problem or making a decision, such as:

1. What are the underlying assumptions? Underlying assumptions are unquestioned beliefs that influence an individual’s reasoning. They are perceptions that may or may not be grounded in reality. For example, some people believe the AIDS epidemic is punishment for homosexual behavior. This attitude toward people with AIDS could alter one’s approach to care for an AIDS patient.

2. How is evidence interpreted? What is the context? Interpretation of information also can be value laden. Is the evidence presented completely and clearly? Can the facts be substan- tiated? Are the people presenting the evidence using emotional or biased information? Are there any errors in reasoning?

3. How are the arguments to be evaluated? Is there objective evidence to support the arguments? Have all value preferences been determined? Is there a good chance that the arguments will be accepted? Are there enough people to support decisions? Health care organizations were able to change to smoke-free environments once societal values favored nonsmokers, and public policies reflected those values.

4. What are the possible alternative perspectives? Using different basic assumptions and paradigms can help the critical thinker develop several different views of an issue. Com- pare how a nurse manager who assumes that more RNs equal better care will deal with a budget cut with a manager who is committed to adding assistive personnel instead. What evidence supports the alternatives? What solutions do staff members, patients, physicians, and others propose? What would be the ideal alternative?

Critical-thinking skills are used throughout the nursing process (see Table 8-1). Nurses can build on the knowledge base they began acquiring in school to make the critical-thinking process a conscious one in daily activities. Learning to be a critical thinker requires a commitment over time, but the skills can be learned. The characteristics of an expert critical thinker are shown in Box 8-1.

Creativity Creativity is an essential part of the critical-thinking process. Creativity is the ability to develop and implement new and better solutions. Creativity demands a certain amount of exposure to outside contacts, receptiveness to new and seemingly strange ideas, a certain amount of free- dom, and some permissive management.

Most nurses, however, are employed in bureaucratic settings that do not foster creativity. Control is exercised over staff, and rigid adherence to formal channels of communication jeopardizes innovation. In addition, there is little room for failure, and when failures do occur they are not well tolerated. When staff are afraid of the consequences of failure, their creativity is inhibited and innovation does not take place. (See later section on innovation.)

Maintaining a certain level of creativity is one way to keep an organization alive. New employees, who are not encumbered with details of accepted practices often can make sugges- tions based on their prior experiences or insights before they get set in their ways or have their innovative ideas “turned off.” The advantages offered by new employees should be explored because all staff gain from such use of valuable human resources.


BOX 8-1 Characteristics of an Expert Critical Thinker

● Outcome-directed ● Open to new ideas ● Flexible ● Willing to change ● Innovative ● Creative ● Analytical ● Communicator ● Assertive

● Persistent ● Caring ● Energetic ● Risk taker ● Knowledgeable ● Resourceful ● Observant ● Intuitive ● “Out of the box” thinker

From Ignatavicius, D.D. (2001). Six critical thinking skills for at-the-bedside success. Nursing Management, 32(1), 37–39.

TABLE 8-1 Critical Thinking Through the Nursing Process

The Nursing Process Critical-Thinking Skills

Assessment Observing Distinguishing relevant from irrelevant data Distinguishing important from unimportant data Validating data Organizing data Categorizing data

Diagnosis Finding patterns and relationships Making inferences Stating the problem Suspending judgment

Planning Generalizing Transferring knowledge from one situation to another Hypothesizing

Implementation Applying knowledge Testing hypotheses

Evaluation Deciding whether hypotheses are correct Making criterion-based evaluations

From Wilkinson, J. (1992). Nursing process in action: A critical thinking approach. Redwood City, CA: Addison-Wesley Nursing, p. 29.

The climate must promote the survival of potentially useful ideas. The nurse manager can foster a climate of support by giving new ideas a fair and adequate hearing, and thereby reduce the tendency to discourage the creative process in individuals and within groups. The challenge for nurse managers is to know when, for whom, and to what extent control is appropriate. If cre- ativity does have a priority in the health care setting, then the reward system should be geared to and commensurate with that priority.



Steps Definition

Information gathering




Unconscious work going on

Solutions emerge

Solutions evaluated

Figure 8-2 • The creative process.

Creativity has four stages: preparation, incubation, insight, and verification. Even people who think they are not naturally creative can learn this process (Figure 8-2).

1. Preparation. A carefully designed planning program is essential. First, acquire informa- tion necessary to understand the situation. Individuals can do this on their own, or groups can work together.

The process follows this sequence:

• Pick a specific task • Gather relevant facts • Challenge every detail • Develop preferred solutions • Implement improvements

2. Incubation. After all the information available has been gathered, allow as much time as possible to elapse before deciding on solutions.

3. Insight. Often solutions emerge after a period of reflection that would not have occurred to anyone without this time lapse.

4. Verification. Once a solution has been implemented, evaluate it for effectiveness. You may need to restart the process or go back to another step and create a different solution.

Case Study 8-1 describes how one nurse manager used creativity to solve a problem.

Decision Making Considering all the practice individuals get in making decisions, it would seem they might become very good at it. However, the number of decisions a person makes does not correspond to the person’s skill at making them. The assumption is that decision making comes naturally, like breathing. It does not.

The decision-making process described in this chapter provides nurses with a system for making decisions that is applicable to any decision. It is a useful procedure for making practical choices. A decision not to solve a problem is also a decision.

Although decision making and problem solving appear similar, they are not synonymous. Decision making may or may not involve a problem, but it always involves selecting one of several alternatives, each of which may be appropriate under certain circumstances. Problem solving, on the other hand, involves diagnosing a problem and solving it, which may or may not entail deciding on one correct


solution. Most of the time, decision making is a subset of problem solving. However, some decisions are not of a problem-solving nature, such as decisions about scheduling, equipment, or in-services.

Types of Decisions The types of problems nurses and nurse managers encounter and the decisions they must make vary widely and determine the problem-solving or decision-making methods they should use. Relatively well defined, common problems can usually be solved with routine decisions, often using established rules, policies, and procedures. For instance, when a nurse makes a medica- tion error, the manager’s actions are guided by policy and the report form. Routine decisions are more often made by first-level managers than by top administrators.

Adaptive decisions are necessary when both problems and alternative solutions are some- what unusual and only partially understood. Often they are modifications of other well-known problems and solutions. Managers must make innovative decisions when problems are unusual and unclear and when creative, novel solutions are necessary.

Decision-Making Conditions The conditions surrounding decision making can vary and change dramatically. Consider the total system. Whatever solutions are created will succeed only if they are compatible with other parts of the system. Decisions are made under conditions of certainty, risk, or uncertainty.

Decision Making Under Certainty When you know the alternatives and the conditions surrounding each alternative, a state of cer- tainty is said to exist. Suppose a nurse manager on a unit with acutely ill patients wants to decrease the number of venipunctures a patient experiences when an IV is started, as well as reduce costs resulting from failed venipunctures. Three alternatives exist:

● Establish an IV team on all shifts to minimize IV attempts and reduce costs ● Establish a reciprocal relationship with the anesthesia department to start IVs when nurses

experience difficulty ● Set a standard of two insertion attempts per nurse per patient, although this does not sub-

stantially lower equipment costs

CREATIVE PROBLEM SOLVING Jeffrey was just promoted to manager of an acute care clinic, which recently expanded its hours from 6 A.M. un- til 10 P.M. He soon realizes that staff nurses are reluctant to sign up on the schedule and do quality chart audits, an important process used to review clinic operations and patients’ care. He gathers information about qual- ity improvement, reviews the literature on motivation and incentives, and discusses the issue with other nurse managers (preparation).

Jeffrey continues to manage the clinic, thinking about the information he has gathered but does not consciously make a decision or reject new ideas (incuba- tion). When working on a new problem, self-scheduling for the change in hours, he realizes a connection between the two problems. Many nurses complain that by the time they receive the schedule the day shifts are filled.

Jeffrey decides to review the chart audits. Nurses who regularly participate in quality improvement projects will receive a “perk.” They will be allowed, on a rotating basis, first choice at selecting the schedule they want to work (this is the insight stage). He discusses the plan with the staff and proposes a two-month trial period to deter- mine whether the solution is effective (verification).

Manager’s Checklist The nurse manager is responsible for:

● Identifying problem areas ● Generating ideas that might serve as possible

solutions ● Checking with others for advice ● Selecting motivators ● Implementing a solution ● Evaluating the results



The manager knows the alternatives (IV team, anesthesia department, standards) and the conditions associated with each option (reduced costs, assistance with starting IVs, minimum attempts and some cost reduction). A condition of strong certainty is said to exist and the decision can be made with full knowledge of what the payoff probably will be.

Decision Making Under Uncertainty and Risk Seldom do decision makers know everything there is to know about a subject or situation. If everything was known, the decision would be obvious for all to realize.

Most critical decision making in organizations is done under conditions of uncertainty and risk. The individual or group making the decision does not know all the alternatives, attendant risks, or possible consequences of each option. Uncertainty and risk are inevitable because of the complex and dynamic nature of health care organizations.

Here is an example: If the weather forecaster predicts a 40 percent chance of snow, the nurse manager is operating in a situation of risk when trying to decide how to staff the unit for the next 24 hours.

In a risk situation, availability of each alternative, potential successes, and costs are all as- sociated with probability estimates. Probability is the likelihood, expressed as a percentage, that an event will or will not occur. If something is certain to happen, its probability is 100 percent. If it is certain not to happen, its probability is 0 percent. If there is a 50–50 chance, its probability is 50 percent.

Here is another example: Suppose a nurse manager decides to use agency nurses to staff a unit during heavy vacation periods. Two agencies look attractive, and the manager must decide between them. Agency A has had modest growth over the past 10 years and offers the manager a three-month contract, freezing wages during that time. In addition, the unit will have first choice of available nurses. Agency B is much more dynamic and charges more but explains that the reason they have had a high rate of growth is that their nurses are the best and the highest paid in the area. The nurse manager can choose Agency A, which will pro- vide a safe, constant supply of nursing personnel, or B, which promises better care but at a higher cost.

The key element in decision making under conditions of risk is to determine the probabili- ties of each alternative as accurately as possible. The nurse manager can use a probability anal- ysis, whereby expected risk is calculated or estimated. Using the probability analysis shown in Table 8-2, it appears as though Agency A offers the best outcome. However, if the second agency had a 90 percent chance of filling shifts and a 50 percent chance of fixing costs, a completely different situation would exist.

The nurse manager might decide that the potential for increased costs was a small trade-off for having more highly qualified nurses and the best probability of having the unit fully staffed during vacation periods. Objective probability is the likelihood that an event will or will not occur based on facts and reliable information. Subjective probability is

TABLE 8-2 Probability Analysis

Probability Analysis

Agency A 60% Filling shifts 100% Fixed wages

Agency B 50% Filling shifts 70% Fixed wage


the likelihood that an event will or will not occur based on a manager’s personal judgment and beliefs.

Janeen, a nurse manager of a specialized cardiac intensive care unit, faces the task of recruiting scarce and highly skilled nurses to care for coronary artery bypass graft patients. The obvious alternative is to offer a salary and benefits package that rivals that of all other institutions in the area. However, this means Janeen will have costly special- ized nursing personnel in her budget who are not easily absorbed by other units in the organization. The probability that coronary artery bypass graft procedures will become obsolete in the future is unknown. In addition, other factors (e.g., increased competi- tion, government regulations regarding reimbursement) may contribute to conditions of uncertainty.

The Decision-Making Process The rational decision-making model is a series of steps that managers take in an effort to make logical, well-grounded rational choices that maximize the achievement of objec- tives. First identify all possible outcomes, examine the probability of each alternative, and then take the action that yields the highest probability of achieving the most desirable outcome. Not all steps are used in every decision nor are they always used in the same order. The rational decision-making model is thought of as the ideal but often cannot be fully used.

Individuals seldom make major decisions at a single point in time and often are unable to recall when a decision was finally reached. Some major decisions are the result of many small actions or incremental choices the person makes without regarding larger issues. In addition, decision processes are likely to be characterized more by confusion, disorder, and emotionality than by rationality. For these reasons, it is best to develop appropriate technical skills and the capacity to find a good balance between lengthy processes and quick, decisive action.

The descriptive rationality model, developed by Simon in 1955 and supported by research in the 1990s (Simon, 1993), emphasizes the limitations of the rationality of the decision maker and the situation. It recognizes three ways in which decision makers depart from the rational decision-making model:

● The decision maker’s search for possible objectives or alternative solutions is limited be- cause of time, energy, and money

● People frequently lack adequate information about problems and cannot control the condi- tions under which they operate

● Individuals often use a satisficing strategy

Satisficing is not a misspelled word; it is a decision-making strategy whereby the individual chooses an alternative that is not ideal but either is good enough (suffices) under existing cir- cumstances to meet minimum standards of acceptance or is the first acceptable alternative. Many problems in nursing are ineffectively solved with satisficing strategies.

Elena, a nurse manager in charge of a busy neurosurgical floor with high turnover rates and high patient acuity levels, uses a satisficing alternative when hiring replace- ment staff. She hires all nurse applicants in order of application until no positions are open. A better approach would be for Elena to replace staff only with nurse applicants who possess the skills and experiences required to care for neurosurgical patients, re- gardless of the number of applicants or desire for immediate action. Elena also should develop a plan to promote job satisfaction, the lack of which is the real reason for the vacancies.


Individuals who solve problems using satisficing may lack specific training in problem solv- ing and decision making. They may view their units or areas of responsibility as drastically sim- plified models of the real world and be content with this simplification because it allows them to make decisions with relatively simple rules of thumb or from force of habit.

The political decision-making model describes the process in terms of the particular inter- ests and objectives of powerful stakeholders, such as hospital boards, medical staffs, corporate officers, and regulatory bodies. Power is the ability to influence or control how problems and objectives are defined, what alternative solutions are considered and selected, what information flows, and, ultimately, what decisions are made (see Chapter 7).

The decision-making process begins when a gap exists between what is actually happening and what should be happening, and it ends with action that will narrow or close this gap. The simplest way to learn decision-making skills is to integrate a model into one’s thinking by break- ing the components down into individual steps. The seven steps of the decision-making process (Box 8-2) are as applicable to personal problems as they are to nursing management problems. Each step is elaborated by pertinent questions clarifying the statements, and they should be fol- lowed in the order in which they are presented.

Decision-Making Techniques Decision-making techniques vary according to the nature of the problem or topic, the decision maker, the context or situation, and the decision-making method or process. For routine decisions, choices that are tried and true can be made for well-defined, known situations or problems. Well-designed policies, rules, and standard operating procedures can produce satisfactory results with a minimum of time. Artificial intelligence, including programmed computer systems such as expert systems that can store, retrieve, and manipulate data, can diagnose problems and make limited decisions.

For adaptive decisions involving moderately ambiguous problems and modification of known and well-defined alternative solutions, there are a variety of techniques. Many types of decision grids or tables can be used to compare outcomes of alternative solutions. Decisions about units or services can be facilitated, with analyses comparing output, revenue, and costs over time or under different conditions. Analyzing the costs and revenues of a proposed new service is an example.

Regardless of the decision-making model or strategy chosen, data collection and analy- sis are essential. In many health care organizations, quality teams are using a variety of tools to gather, organize, and analyze data about their work such as decision grids, flow

BOX 8-2 Steps in Decision Making

1. Identify the purpose: Why is a decision necessary? What needs to be determined? State the issue in the broadest possible terms.

2. Set the criteria: What needs to be achieved, preserved, and avoided by whatever decision is made? The answers to these questions are the standards by which solutions will be evaluated.

3. Weigh the criteria: Rank each criterion on a scale of values from 1 (totally unimportant) to 10 (extremely important).

4. Seek alternatives: List all possible courses of action. Is one alternative more significant than another? Does one alternative have weaknesses in some areas? Can these be overcome? Can two alternatives or features of many alternatives be combined?

5. Test alternatives: First, using the same methodology as in step 3, rank each alternative on a scale of 1 to 10. Second, multiply the weight of each criterion by the rating of each alternative. Third, add the scores and compare the results.

6. Troubleshoot: What could go wrong? How can you plan? Can the choice be improved? 7. Evaluate the action: Is the solution being implemented? Is it effective? Is it costly?


charts, or cause-and-effect diagrams. Figure 8-3 illustrates a cause-and-effect diagram that a team of nurses created to help them improve the documentation process for their ambulatory oncology unit.

Another example of a decision tool is the Dynamic Network Analysis Decision Support (DyNADS) project at the University of Arizona College of Nursing (see http://www.dynads.nursing. arizona.edu). This simulation product enables the manager to predict the consequences of decisions on patient safety and quality outcomes. The tool simulates virtual nursing units, identifies potential errors, and predicts the likely result. Using the tool, the manager can discover if an innovation or a combination of innovations is likely to be successful (Effkenet al., 2010). DyNADS is a decision support tool that improves predictability in today’s complex environment.

Group Decision Making The widespread use of participative management, quality improvement teams, and shared gover- nance in health care organizations requires every nurse manager to determine when group, rather than individual, decisions are desirable and how to use groups effectively. A number of stud- ies have shown that professional people do not function well in a micromanaged environment. As an alternative, group problem solving of substantial issues casts the manager in the role of facilitator and consultant. Compared to individual decision making, groups can provide more in- put, often produce better decisions, and generate more commitment. One group decision-making technique is brainstorming.

In brainstorming, group members meet together and generate many diverse ideas about the nature, cause, definition, or solution to a problem without consideration of their relative value. The focus team whose work is shown in Figure 8-3 used brainstorming.

With brainstorming, a premium is placed on generating lots of ideas as quickly as pos- sible and on coming up with unusual ideas. Most importantly, members do not critique ideas as they are proposed. Evaluation takes place after all the ideas have been generated. Members are




Materials Methods


Staff MDs

Chart design

Lack of chart racks

Inadequate forms

Treatment nurses

Lack of focus



Poor communication

Unclear chemotherapy orders

Less than adequate nursing

documentation Patient chart movement from clinics

Lack of procedures and guidelines

Lack of appropriate documentation forms

Figure 8-3 • Brainstorming session of a nursing quality focus team.


encouraged to improve on each other’s ideas. These sessions are enjoyable but are often unsuc- cessful because members inevitably begin to critique ideas, and as a result, meetings shift to the ordinary interacting group format. Criticisms of this approach are the high cost factor, the time consumed, and the superficiality of many solutions.

Problem Solving People use problem solving when they perceive a gap between an existing state (what is going on) and a desired state (what should be going on). How one perceives the situation influences how the problem is identified or solved. Therefore, perceptions need to be clarified before prob- lem solving can occur.

Problem-Solving Methods A variety of methods can be used to solve problems. People with little management experience tend to use the trial-and-error method, applying one solution after another until the problem is solved or appears to be improving. These managers often cite lack of experience and of time and resources to search for alternative solutions.

In a step-down unit with an increasing incidence of medication errors, Max, the nurse manager, uses various strategies to decrease errors, such as asking nurses to use calcu- lators, having the charge nurse check medications, and posting dosage and medication charts in the unit. After a few months, by which time none of the methods has worked, it occurs to Max that perhaps making nurses responsible for their actions would be more effective. Max develops a point system for medication errors: When nurses accumulate a certain amount of points, they are required to take a medication test; repeated failure of the test may eventually lead to termination. Max’s solution is effective and a low level of medication errors is restored.

As the above example shows, a trial-and-error process can be time-consuming and may even be detrimental. Although some learning can occur during the process, the nurse manager risks being perceived as a poor problem solver who has wasted time and money on ineffective solutions.

Experimentation, another type of problem solving, is more rigorous than trial and error. Pilot projects or limited trials are examples of experimentation. Experimentation in- volves testing a theory (hypothesis) or hunch to enhance knowledge, understanding, or pre- diction. A project or study is carried out in either a controlled setting (e.g., in a laboratory) or an uncontrolled setting (e.g., in a natural setting such as an outpatient clinic). Data are collected and analyzed and results interpreted to determine whether the solution tried has been effective.

Lin, a nurse manager of a pediatric floor, has received many complaints from mothers of children who think the nurses are short-tempered. Lin has a hunch that 12-hour shifts, which have been recently implemented on her floor, are contributing to the problem; she believes that nurses who must interact frequently with families would perform better on eight-hour shifts. She can test her theory by setting up a small study comparing the two staffing patterns with patient satisfaction.

Experimentation may be creative and effective or uninspired and ineffective, depending on how it is used. As a major method of problem solving, experimentation may be inefficient be- cause of the amount of time and control involved. However, a well-designed experiment can be persuasive in situations in which an idea or activity, such as a new staffing system or care proce- dure, can be tried in one of two similar groups and results objectively compared.


Still other problem-solving techniques rely on past experience and intuition. Everyone has various and countless experiences. Individuals build a repertoire of these experiences and base future actions on what they considered successful solutions in the past. If a particular course of action consistently resulted in positive outcomes, the person will try it again when similar cir- cumstances occur. In some instances, an individual’s past experience can determine how much risk he or she will take in present circumstances.

The nature and frequency of the experience also contribute significantly to the effectiveness of this problem-solving method. How much the person has learned from these experiences, posi- tive or negative, can affect the current viewpoint and can result in either subjective, narrow judg- ments or wise ones. This is especially true in human relations problems. Intuition relies heavily on past experience and trial and error. The extent to which past experience is related to intuition is difficult to determine, but nurses’ wisdom, sensitivity, and intuition are known to be valuable in solving problems.

Some problems are self-solving: if permitted to run a natural course, they are solved by those personally involved. This is not to say that a uniform laissez-faire management style solves all problems. The nurse manager must not ignore managerial responsibilities, but often difficult situations become more manageable when participants are given time, resources, and support to discover their own solutions.

This typically happens, for example, when a newly graduated nurse joins a unit where most of the staff are associate degree RNs who resent the new nurse’s level of education as well as the nurse’s lack of experience. If the nurse manager intervenes, a problem that the staff might have worked out on their own becomes an ongoing source of conflict. The important skill required here is knowing when to act and when not to act. (See Chapter 12 for a discussion of conflict.)

The Problem-Solving Process Many nursing problems require immediate action. Nurses don’t have time for formalized pro- cesses of research and analysis specified by the scientific method. Therefore, learning an orga- nized method for problem solving is invaluable. One practical method for problem solving is to follow this seven-step process, which is also outlined in Box 8-3.

1. Define the problem. The definition of a problem should be a descriptive statement of the state of affairs, not a judgment or conclusion. If one begins the statement of a problem with a judgment, the solution may be equally judgmental, and critical descriptive elements could be overlooked.

Suppose a nurse manager reluctantly implements a self-scheduling process and finds that each time the schedule is posted, evenings and some weekend shifts are not adequately covered. The manager might identify the problem as the immaturity of the staff and their inability to function under democratic leadership. The causes may be lack of interest in group decision making, minimal concern over providing adequate patient coverage, or, per- haps more correctly, a few nurses’ lack of understanding of the process.

If the nurse manager defines the above problem as immaturity and reverts to making out the schedules without further fact-finding, a minor problem could develop into a major upheaval.

BOX 8-3 Steps in Problem Solving

1. Define the problem. 2. Gather information. 3. Analyze the information. 4. Develop solutions.

5. Make a decision. 6. Implement the decision. 7. Evaluate the solution.


Premature interpretation can alter one’s ability to deal with facts objectively. For example, are there other explanations for the apparent behavior that do not entail negative assumptions about the maturity of the staff?

Accurate assessment of the scope of the problem also determines whether the manager needs to seek a lasting solution or just a stopgap measure. Is this just a situational problem requiring only intervention with a simple explanation, or is it more complex, involving the leadership style of the manager? The manager must define and classify problems in order to take action.

To define a problem, ask:

• Do I have the authority to do anything about this myself? • Do I have all the information? The time? • Who else has important information and can contribute? • What benefits could be expected? A list of potential benefits provides the basis for

comparison and choice of solutions. The list also serves as a means for evaluating the solution.

2. Gather information. Problem solving begins with collecting facts. This information gath- ering initiates a search for additional facts that provides clues to the scope and solution of the problem. This step encourages people to report facts accurately. Everyone involved can contribute. Although this may not always provide objective information, it reduces misin- formation and allows everyone an opportunity to tell what he or she thinks is wrong with a situation.

Experience is another source of information—one’s own experience as well as the experience of other nurse managers and staff. The people involved usually have ideas about what should be done. Some data will be useless, some inaccurate, but some will be useful to develop innovative ideas worth pursuing.

3. Analyze the information. Analyze the information only when all of it has been sorted into some orderly arrangement as follows:

• Categorize information in order of reliability. • List information from most important to least important. • Set information into a time sequence. What happened first? Next? What came before

what? What were the concurrent circumstances? • Examine information in terms of cause and effect. Is A causing B, or vice versa? • Classify information into categories: human factors, such as personality, maturity, educa-

tion, age, relationships among people, and problems outside the organization; technical factors, such as nursing skills or the type of unit; temporal factors, such as length of ser- vice, overtime, type of shift, and double shifts; and policy factors, such as organizational procedures or rules applying to the problem, legal issues, and ethical concerns.

• Consider how long the situation has been going on.

Because no amount of information is ever complete or comprehensive enough, critical- thinking skills, discussed earlier, help the manager examine the assumptions, evidence, and potential value conflicts.

4. Develop solutions. As an individual or a group analyzes information, numerous possible solutions will suggest themselves. Do not consider only simple solutions, because that may stifle creative thinking and cause over concentration on detail. Developing alternative solu- tions makes it possible to combine the best parts of several solutions into a superior one. Also, alternatives are valuable in case the first-order solutions prove impossible to implement.

When exploring a variety of solutions, maintain an uncritical attitude toward the way the problem has been handled in the past. Some problems have had a long-standing


history by the time they reach you, and attempts may have been made to resolve them over a period of time. “We tried this before and it didn’t work” is often said and may apply—or more likely, may not apply—in a changed situation. Past experience may not always supply an answer, but it can aid the critical-thinking process and help prepare for future problem solving.

5. Make a decision. After reviewing the list of potential solutions, select the one that is most applicable, feasible, satisfactory, and has the fewest undesirable consequences. Some solutions have to be put into effect quickly; matters of discipline or compromises in patient safety, for example, need immediate intervention. You must have legitimate authority to act in an emergency and know the penalties to be imposed for various infractions.

If the problem is a technical one and its solution brings about a change in the method of doing work (or using new equipment), expect resistance. Changes that threaten individuals’ personal security or status are especially difficult. In those cases, the change process must be initiated before solutions are implemented. If the solution involves change, the manager should fully involve those who will be affected by it, if possible, or at least inform them of the process. (See Chapter 5 for discussion of the change process.)

6. Implement the decision. Implement the decision after selecting the best course of action. If unforeseen new problems emerge after implementation, evaluate these impediments. Be careful, however, not to abandon a workable solution just because a few people object; a minority always will. If the previous steps in the problem-solving process have been followed, the solution has been carefully thought out, and potential problems have been addressed, implementation should move forward.

7. Evaluate the solution. After the solution has been implemented, review the plan and compare the actual results and benefits to those of the idealized solution. People tend to fall back into old patterns of habit, only giving lip service to change. Is the solution being implemented? If so, are the results better or worse than expected? If they are better, what changes have contributed to its success? How can we ensure that the solution continues to be used and to work? Such a periodic checkup gives you valuable insight and experience to use in other situations and keeps the problem-solving process on course.

See Case Study 8-2 to learn how one nurse manager used critical thinking to solve a problem.

Group Problem Solving Traditionally, managers solved most problems in isolation. This practice, however, is outdated. Both the complexity of problems and the staff’s desire for meaningful involvement create the impetus for using group approaches to problem solving. Today consensus-based problem solv- ing, inherent in shared governance, is the norm.

Advantages of Group Problem Solving Groups collectively possess greater knowledge and information than any single member and may access more strategies to solve a problem. Under the right circumstances and with appropriate leadership, groups can deal with more complex problems than a single individual, especially if there is no one right or wrong solution to the problem. Individuals tend to rely on a small number of familiar strategies; a group is more likely to try several approaches.

Group members may have a greater variety of training and experiences and approach prob- lems from more diverse points of view. Together, a group may generate more complete, accurate, and less biased information than one person. Groups may deal more effectively with problems that cross organizational boundaries or involve change that requires support from other units or


departments. Participative problem solving has additional advantages: it increases the likelihood of acceptance and understanding of the decision, and it enhances cooperation in implementation.

Disadvantages of Group Problem Solving Group problem solving also has disadvantages: it takes time and resources and may involve con- flict. Group problem solving also can lead to the emergence of benign tyranny within the group. Members who are less informed or less confident may allow stronger members to control group discussion and problem solving. A disparity in participation may contribute to a power struggle between the nurse manager and a few assertive group members.

Also managers may resist using groups to make decisions. They may fear that they may not agree with the decision the group makes or that they will not be needed if all decisions are made by the group. Neither is the case. Some decisions are rightfully the managers’ (e.g., handling the budget), others are staff decisions (e.g., peer review, self-scheduling), and some are shared (e.g., joint hiring decisions). Figure 8-4 illustrates this.

CRITICAL THINKING AND PROBLEM SOLVING Latonia Wilson is nurse manager for a busy 20-bed telemetry unit. In addition to providing postsurgical care for cardiac patients, nurses also prepare patients for cardiac catheterization lab procedures. Latonia’s staff includes eight new graduate nurses, almost half of her nursing staff. The new nurses have attended most of the required nursing orientation for the hospital.

Three times in one month, telemetry unit patients who had orders for heparin drips were administered heparin flush instead. Premixed IV bags for heparin drips as well as heparin flush for indwelling arterial catheters are stocked on the IV solutions cart in the medication room. While no adverse patient outcomes had been re- ported, procedures have been delayed.

Geena Donati is a graduate nurse on the telem- etry unit. Recently, she took a bag of heparin drip from the IV cart and started to attach it to the IV tubing. She noticed that the label stated heparin flush in- stead of heparin. Upon returning to the med room, she checked the heparin drip bin and found heparin flush bags mixed in with the heparin drip. The phar- macy technician came into the med room and began stocking the IV cart. Geena noticed that the pharmacy technician put extra heparin drip bags in the heparin flush bin. She questioned the pharmacy technician and he told Geena that since the unit used a lot of heparin

solution, he had started bringing extra to decrease his trips to the unit.

Geena met with Latonia later during her shift. She told her manager about the extra heparin bags be- ing mixed into the wrong bins. Latonia asked Geena if she would be interested in working with two other RNs on the unit to develop new procedures to decrease heparin medication errors. Geena and the task force worked with the pharmacy department to change the label color for heparin drip and heparin flush solutions, physically separated the bins on the IV cart onto differ- ent shelves, and provided a short educational segment at the monthly staff meeting. Since the new procedures were developed, no further heparin errors have oc- curred on the telemetry unit.

Manager’s Checklist The nurse manager is responsible for:

● Tracking and identifying recurring negative perfor- mance issues on the unit

● Analyzing adverse outcomes to determine what fac- tors contributed to the outcome

● Empowering staff to improve work processes on the unit

● Understanding the organizational structure and helping staff work with other departments within the organization


Staff decisions

Shared decision making


Manager decisions

Figure 8-4 • Shared decision making goal. From Shiparski, L. (2005). Engaging in shared decision making: Leveraging staff and management expertise. Nurse Leader, 3(1), 40.


Group problem solving also can be affected by groupthink. Groupthink is a negative phenomenon that occurs in highly cohesive groups that become isolated. Through prolonged close association, group members come to think alike and have similar prejudices and blind spots, such as stereotypical views of outsiders. They exhibit a strong tendency to seek concurrence, which interferes with critical thinking about important decisions. In addition, the leadership of such groups suppresses open, free- wheeling discussion and controls what ideas will be discussed and how much dissent will be tolerated. Groupthink seriously impairs critical thinking and can result in erroneous and damaging decisions.

Also groups tend to make riskier decisions than individuals. Groups are more likely to sup- port unusual or unpopular positions (e.g., public demonstrations). Groups tend to be less con- servative than individual decision makers and frequently display more courage and support for unusual or creative solutions to problems.

Individuals who lack information about alternatives may make a safe choice, but after group dis- cussion they acquire additional information and become more comfortable with a less secure alterna- tive. The group setting also allows for the diffusion of responsibility. If something goes wrong, others also can be assigned the blame or risk. In addition, leaders may be greater risk takers than individuals, and group members may attach a social value to risk taking because they identify it with leadership.

Stumbling Blocks The leader’s personality traits, inexperience, lack of adaptability, and preconceived ideas may be obstacles to decision making and problem solving.

Personality The leader’s personality can and often does affect how and why certain decisions are made. Managers are often selected because of their expert clinical, not managerial, skills. Inexperi- enced in management, they may resort to various unproductive actions. On the one hand, a nurse manager who is insecure may base decisions primarily on approval seeking. When a truly diffi- cult situation arises, the manager, rather than face rejection from the staff, makes a decision that will placate people rather than one that will achieve the larger goals of the unit and organization.

On the other hand, a nurse manager who demonstrates an authoritative type of personality might make unreasonable demands on the staff, fail to reward staff for long hours because he or she has a “workaholic” attitude, or give the staff little control over unit decisions. Similarly, an inexperienced manager may cause a unit to flounder because the manager is not inclined to act on new ideas or solutions to problems. Optimism, humor, and a positive approach are crucial to energizing staff and promoting creativity.

Rigidity Rigidity, an inflexible management style, is another obstacle to problem solving. It may result from ineffective trial-and-error solutions, fear of risk taking, or inherent personality traits. Avoid ineffective trial-and-error problem solving by gathering sufficient information and determining a means for early correction of wrong or inadequate decisions. Also, to minimize risk in problem solving, understand alternative risks and expectations.

The person who uses a rigid style in problem solving easily develops tunnel vision—the ten- dency to look at new things in old ways and from established frames of reference. It then becomes difficult to see things from another perspective, and problem solving becomes a process whereby one person makes all of the decisions with little information or data from other sources. In today’s rapidly changing health care setting, rigidity can be a barrier to effective problem solving.

Preconceived Ideas Effective leaders do not start out with the preconceived idea that one proposed course of action is right and all others wrong. Nor do they assume that only one opinion can be voiced and others


will be silent. They start out with a commitment to find out why others disagree. If the staff, other professionals, or patients see a different reality or even a different problem, leaders need to integrate this information into developing additional problem-solving alternatives.

Innovation Innovation is a strategy to bridge the gap between an existing state and a desired state (Porter- O’Grady & Malloch, 2010). Organized nursing has recognized the importance of innovation to solve health care’s many problems (Lachman, Glasgow, & Donnelly, 2009). The American Academy of Nursing’s campaign “Raise the Voice” highlights “edge runners,” those nurses who create innovative solutions for the health care system (see www.aannet.org).

To stimulate innovation, several techniques include:

● Simulations—uses actors representing standardized patients or high-tech mannequins ● Case studies—encourages participants to use critical thinking to analyze actual patient

situations ● Problem-based learning—incorporates additional information into the case study over

time ● Debate—helps participants examine an issue from more than one viewpoint (Lachman,

Glasgow, & Donnelly, 2009)

One university has even developed a post-master’s certificate program in innovation (Dreher, 2008). Using a case-study model, Drexel University’s College of Nursing offers an online program in innovation and entrepreneurship (see www.Drexel.edu) designed to foster cre- ative thinking to solve internal and external problems (Lachman, Glasgow, & Donnelly, 2009).

Critical thinking, creativity, and innovative thinking, along with the appropriate tools and techniques, will enable nurses and their managers to make decisions and solve problems in the least time and with the best outcomes.

What You Know Now • Critical thinking requires examining underlying assumptions about current evidence, interpreting infor-

mation, and evaluating the arguments presented to reach a new and exciting conclusion. • The creative process involves preparation, incubation, insight, and verification, which can be learned by

individuals and groups. • Problem-solving and decision-making processes use critical-thinking skills. • The decision-making process may employ several models: rational, descriptive rationality, satisficing, and

political. • Decision-making techniques vary according to the problem and the degree of risk and uncertainty in the

situation. • Methods of problem solving include trial and error, intuition, experimentation, past experience, tradition,

and recognizing that some problems are self-solving. • The problem-solving process involves defining the problem, gathering information, analyzing information,

developing solutions, making a decision, implementing the decision, and evaluating the solution. • Group problem solving can be positive, providing more information and knowledge than an individual. It

can also be negative if it generates disruptive conflict or groupthink. • Stumbling blocks to making decisions and solving problems include the leader’s personality, rigidity, or

preconceived ideas. • Innovation helps bridge the gap between the existing state and the desired state.

Tools for Making Decisions and Solving Problems 1. Identify problem areas. 2. Ask questions, interpret data, and consider alternatives to make decisions and solve problems. 3. Evaluate the level of certainty, uncertainty, and risk, and consider appropriate alternatives.


4. Identify opportunities to use groups appropriately to make decisions and solve problems. 5. Follow the problem-solving process described in the chapter. 6. Challenge yourself to look for creative and innovation solutions.

Questions to Challenge You 1. Identify someone you believe has critical-thinking skills. What critical thinking attributes does this

person possess? 2. Describe a situation when you made an important decision. What content in the chapter applied to

that situation? What was the outcome? 3. Have you been involved in group decision making at school or at work? What techniques were used?

Were they effective? 4. A number of ways that problem solving might fail were discussed in the chapter. Name three

more. 5. Have you ever proposed a creative or innovative idea at work or school? Describe the idea and

explain what happened.

Web Resources DyNADS project: http://www.dynads.nursing.arizona.edu Post-Master’s Certificate Program in Innovation and Intra/Entrepreneurship: http://www.drexel.edu/

gradnursing/msn/post-MastersCertOnline/innovationEntrepreneurship/ American Academy of Nursing Edge Runners: http://www.aannet.org/edgerunners American Academy of Nursing Raise the Voice: http://www.aannet.org/raisethevoice

References Ashcraft, T. (2010). Solving the

critical thinking puzzle. Nursing Management, 41(1), 8–10.

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2009). Educating Nurses: A call for radical transformation. San Fran- cisco: Jossey-Bass.

Bittner, N. P., & Gravlin, G. (2009). Critical thinking, delegation, and missed care in nursing practice. Journal of Nursing Administration, 39(3), 142–146.

Dreher, H. M. (2008). Innova- tion in nursing education:

Preparing for the future of nursing. Holistic Nursing Practice, 22(2), 77–80.

Effken, J. A., Verrn, J. A., Logue, M. D., & Hsu, Y. C. (2010). Nurse managers’ decisions. Journal of Nurs- ing Administration, 40(4), 188–195.

Lachman, V. D., Smith Glasgow, M. E., & Donnelly, G. F. (2009). Teaching in- novation. Nursing Ad- ministration Quarterly, 33(3), 205–211.

Porter-O’Grady, T. & Mal loch, K. (2010). In novation leadership:

Creating the landscape of healthcare. Sudbury, MA: Jones & Bartlett.

Simon, H. A. (1993). Decision making: Rational, non- rational, and irrational. Education Administra- tion Quarterly, 29(3), 392–411.

Zori, S., Nosek, L. J., & Musil, C. M. (2010). Critical thinking of nurse manag- ers related to staff RNs’ perceptions of the practice environment. Journal of Nursing Scholarship, 42(3), 305–313.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!






Effects of Differences in Communication GENDER DIFFERENCES IN COMMUNICATION



The Role of Communication in Leadership EMPLOYEES






Collaborative Communication

Enhancing Your Communication Skills

Communicating Effectively 9

Key Terms Communication Diagonal communication Downward communication Fogging

1. Identify the factors that influence communication.

2. Discuss how communication can be distorted and misunderstood.

3. Choose which communication mode to use depending on the message and the relationship.

4. Explain how communication strategies vary according to the situation and those involved.

5. Improve your collaborative communication skills.

6. Develop a plan to enhance your communi- cation skills.

Learning Outcomes After completing this chapter, you will be able to:

Intersender conflict Intrasender conflict Lateral communication Metacommunications

Negative assertion Negative inquiry Upward communication


Communication Communication is a complex, ongoing, dynamic process in which the participants simulta- neously create shared meaning in an interaction. The goal of communication is to approach, as closely as possible, a common understanding of the message sent and the one received. At times, this can be difficult because both participants are influenced by past condition- ing; the present situation; each person’s purpose in the current communication; and each per- son’s attitudes toward self, the topic, and each other. It is important that participants construct messages as clearly as possible, listen carefully, monitor each other’s response, and provide feedback.

Modes of Communication Messages may be oral (face-to-face, one-on-one, or in groups; by telephone, text, voice mail or posted on a social media site; or written (handwritten or typed) and sent by mail, e-mail, or fax. The purpose of the message determines the best mode to use. In general, the more important or delicate the issue, the more intimate the mode should be. Any difficult issue should be commu- nicated face-to-face, such as terminating an individual’s employment. Conflict or confrontation also is usually best handled in person so that the individual’s response, especially nonverbal signals (discussed later), can be seen and answered appropriately.

What mode to use depends on the level of intimacy required based on the person, your rela- tionship, and the message. The levels of intimacy, in descending order, are:

● in person ● by phone ● voice mail ● text ● e-mail ● postal mail ● posting on social media sites, including blogs

Meeting someone face-to-face is the most intimate contact. The individual can see your face, see your body movements, and hear your words simultaneously. The telephone is slightly less intimate than in-person communication. Tone of voice, for instance, can be conveyed, and phone conversations can be two-way. Voice mail is the next level of communication. Voice mail is useful to convey information that is not necessarily sensitive and may or may not require a reply. The time and place of an upcoming meeting, for example, can be communicated by voice mail, which has the added advantage of avoiding “phone tag.”

E-mail is useful for information similar to that conveyed by voice mail and, like some voice mail systems, can be broadcast to large groups at once. The dates and times for a blood drive are a good example of a broadcast message. Conveying complicated information that may require thought before the receiver replies is another value of using e-mail. Texting is similar to e-mail, although briefer. Posting on social media sites or blogs is the least personal communication (Kaplan & Haenlein, 2010).

The level of formality of the communication also affects the mode used. Applying for a position requires a written format even if the letter is e-mailed rather than mailed. The relation- ship between the sender and receiver also affects the mode. If a staff nurse, for example, wants to nominate a coworker for an award given by the hospital board of directors, a written letter or e-mail is required. Memos are less formal than written messages and can be e-mailed, faxed, or mailed. Social media postings are public and impersonal (Raso, 2010; Trossman, 2010).

Distorted Communication Oral messages are accompanied by a number of nonverbal messages known as metacommuni- cations. These behaviors include head or facial agreement or disagreement; eye contact; tone,


volume, and inflection of the voice; gestures of the shoulders, arms, hands, or fingers; body pos- ture and position; dress and appearance; timing; and environment.

Nonverbal communication is more powerful than the words one speaks and can distort the meaning of the spoken words. When a verbal message is incongruent with the nonverbal message, the recipient has difficulty interpreting the intended meaning; this results in intrasender conflict. For example, a manager who states, “Come talk to me anytime,” but keeps on typing at the keyboard while you talk, sends a conflicting message to the staff. Intersender conflict occurs when a person receives two conflicting messages from differing sources. For example, the risk manager may en- courage a nurse to report medication errors, but the nurse manager follows up with discipline over the error. The nurse is caught between conflicting messages from the two managers.

Other common causes of distorted communication are:

● Using inadequate reasoning ● Using strong, judgmental words ● Speaking too fast or too slowly ● Using unfamiliar words ● Spending too much time on details

Distortion also occurs when the recipient is busy or distracted, bases understanding on pre- vious unsatisfactory experience with the sender, or has a biased perception of the meaning of the message or the messenger. Consider the example of distortion of written communication provided in Box 9-1.

BOX 9-1 Distortion in Written Communication

There is ample opportunity for distortion in the complicated process of sending, receiving, and responding to mes- sages, as demonstrated by the following correspondence between a plumber and an official of the National Bureau of Standards (Donaldson & Scannell, 1979).

Bureau of Standards Washington, D.C. Gentlemen:

I have been in the plumbing business for over 11 years and have found that hydrochloric acid works real fine for cleaning drains. Could you tell me if it’s harmless?

Sincerely, Tom Brown, Plumber

Mr. Tom Brown, Plumber Yourtown, U.S.A. Dear Mr. Brown:

The efficacy of hydrochloric acid is indisputable, but the chlorine residue is incompatible with metallic permanence!

Sincerely, Bureau of Standards

Bureau of Standards Washington, D.C. Gentlemen:

I have your letter of last week and am mightily glad you agree with me on the use of hydrochloric acid.

Sincerely, Tom Brown, Plumber

Mr. Tom Brown, Plumber Yourtown, U.S.A. Dear Mr. Brown:

We wish to inform you we have your letter of last week and advise that we cannot assume responsibility for the production of toxic and noxious residues with hydrochloric acid and further suggest you use an alter- nate procedure.

Sincerely, Bureau of Standards

Bureau of Standards Washington, D.C. Gentlemen:

I have your most recent letter and am happy to find you still agree with me.

Sincerely, Tom Brown, Plumber

Mr. Tom Brown, Plumber Yourtown, U.S.A. Dear Mr. Brown:

Don’t use hydrochloric acid, it eats the hell out of pipes!

Sincerely, Bureau of Standards

For communication among more than two people, the chance of distortion increases proportionally.


E-mail is particularly fraught with opportunities for misunderstanding. From the greeting (e.g., dear, hi, hello, or no salutation) to the sign-off (e.g., warm regards, best wishes, best, or no sign-off), the sender conveys more than the choice of words. A speedy reply is expected and en- courages a response, sometimes without adequate thought. Finally, the possibility of sending the message to the wrong person, especially the dreaded “reply to all,” is another chance for your message to be misinterpreted. Texting shares many of the same dangers as e-mail and has added pressure for a faster response.

Directions of Communication Formal or informal communication may be downward, upward, lateral, or diagonal. Downward communication (manager to staff) is often directive. The staff is told what needs to be done or given information to facilitate the job to be done. Upward communication occurs from staff to management or from lower management to middle or upper management. Upward commu- nication often involves reporting pertinent information to facilitate problem solving and deci- sion making. Lateral communication occurs between individuals or departments at the same hierarchical level (e.g., nurse managers, department heads). Diagonal communication involves individuals or departments at different hierarchical levels (e.g., staff nurse to chief of the medi- cal staff). Both lateral and diagonal communication involve information sharing, discussion, and negotiation.

An informal channel commonly seen in organizations is the grapevine (e.g., rumors and gossip). Grapevine communication is usually rapid, haphazard, and prone to distortion. It can also be useful. Sometimes the only way to learn about a pending change is through the grape- vine. One problem with grapevine communication, however, is that no one is accountable for any misinformation that is relayed. Keep in mind, too, that information gathered this way is a slightly altered version of the truth, changing as the message passes from person to person.

Effective Listening Most nurses believe they are good listeners. Observing and listening to patients are skills nurses learn early in their careers and use every day. Being a good listener, however, involves more than just hearing words and watching body language (Sullivan, 2013). Maintaining eye contact is misleading; it may or may not signal that a person is listening. Barriers to effective listening include preconceived beliefs, lack of self-confidence, flagging energy, defensiveness, and habit (Donaldson, 2007).

Preconceived Beliefs The longer your relationship with someone is, the more apt you are to think you know what the person says or means and, thus, the more likely you are to not listen. This holds true in personal as well as professional relationships and applies to groups of people (known as stereotyping). Not expecting others to have anything worthwhile to say also is an example of preconceptions about them.

Lack of Self-Confidence Listening is difficult if you are nervous, and weak self-confidence frequently is the cause. People tend to talk too much or think about what they’re planning to say next to pay attention to the per- son speaking. Often their mind is racing and they may not be listening even when they’re talking themselves.

Flagging Energy Listening takes energy and sometimes we simply don’t have enough energy to listen carefully. Too many people speaking at once, having too much to do, being worried, or being too tired can all interfere with our ability to listen.


Defensiveness Survival required that we learned to hear danger approaching, but today humans have translated defense mechanisms into a way to avoid hearing bad news. Then, we think, we don’t have to deal with it. The opposite is true, however. Only when we can hear and consider information can we handle it.

Habit Over time, many people develop the habit of thinking ahead during conversations. Thinking ahead is valuable in most aspects of life, but it’s deadly when you need to be listening. Like all behaviors that have become habits, changing this one is not easy. Reminding yourself to refocus on the speaker can help.

Effects of Differences in Communication

Gender Differences in Communication Men and women communicate differently (Feldhahn, 2009; Tannen, 2001). They have become socialized through communication patterns that reflect their societal roles. Men tend to talk more, longer, and faster, whereas women are more descriptive, attentive, and perceptive. Women tend to use tag questions (e.g., “I can take off this weekend, can’t I?”) and tend to self-disclose more than men. Women tend to ask more questions and solicit more input than their male coun- terparts. Table 9-1 lists differences in the ways that men and women communicate.

Helgeson and Johnson (2010) suggest ways that women can improve their communication at work. Neither men nor women should raise their voices no matter what the provocation. Nor should one omit important details or assume everyone knows what you mean. Not allowing questions or objections also should be avoided, and never walk away and talk at the same time (Donaldson, 2007).

Using gender-neutral language in communication helps bridge the gap between the way men and women communicate. Men and women can improve their ability to communicate with each other by following the recommendations for gender-neutral communication found in Table 9-2.

Generational and Cultural Differences in Communication Generational differences, discussed in Chapter 1, affect communication styles, patterns, and expectations. Traditionals tend to be more formal, following the chain of command without question. Baby boomers question more. They enjoy the process of group problem solving

TABLE 9-1 Gender Differences in Communication

Men tend to Women tend to

Interrupt more frequently Wait to be noticed

Talk more, longer, louder, and faster Use qualifiers (prefacing and tagging)

Disagree more Use questions in place of statements

Focus on the issue more than the person Relate personal experiences

Boast about accomplishments Promote consensus

Use banter to avoid a one-down position Withdraw from conflict

From Sullivan, E. J. (2013). Becoming influential: A guide for nurses. (2nd ed.). Upper Saddle River, NJ: Prentice Hall, p. 57. Reprinted by permission.


and decision making. Independent Generation X members are just the opposite and want decisions made without unnecessary discussion. Collegial millennials (Generation Y) expect immediate feedback to their messages. E-mail, text, or voice mail is the best way to connect with them. Mutual respect and understanding of the unique differences between and among groups will help to minimize conflict and maximize satisfaction for both managers and staff (Hahn, 2009).

Cultural attitudes, beliefs, and behaviors also affect communication (Robertson-Malt, Herrin-Griffith, & Davies, 2010). Such elements as body movement, gestures, tone, and spatial orientation are culturally defined. A great deal of misunderstanding results from a lack of under- standing of each other’s cultural expectations. For example, people of Asian descent take great care in exchanges with supervisors so that there is no conflict or “loss of face” for either person.

Understanding the cultural heritage of employees and learning to interpret cultural mes- sages is essential to communicate effectively with staff from diverse backgrounds. Personal and professional cultural enrichment training is recommended. This includes reading the literature and history of the culture; participating in open, honest, respectful communication; and explor- ing the meaning of behavior. It is important to recognize, however, that subcultures exist within all cultures; therefore, what applies to one individual will not be true for everyone else in that culture.

Differences in Organizational Culture As discussed in Chapter 2, the customs, norms, and expectations within an organization are powerful forces that shape behavior. Focusing on relevant issues regarding the organizational culture can identify failures in communication. Poor communication is a frequent source of job dissatisfaction as well as a powerful determinant of an organization’s effectiveness. Just as violation of other norms within the organization results in repercussions, so does violation of communication rules.

To discover what rules affect communication in your organization, ask yourself:

● Who has access to what information? Is information withheld? Is it shared widely? ● What modes of communication are used for which messages? Are they used

appropriately? ● How clear are the messages? Or are they often distorted? ● Does everyone receive the same information? ● Do you receive too much information? Not enough? ● How effective is the message?

TABLE 9-2 Recommendations for Gender-Neutral Communication

Men may need to Women may need to

Listen to objections and suggestions State your message clearly and concisely

Listen without feeling responsible Solve problems without personalizing them

Suspend judgment until information is in Say what you want without hinting

Explain your reasons Eliminate unsure words (“sort of”) and nonwords (“truly”)

Not yell Not cry

From Sullivan, E. J. (2013). Becoming influential: A guide for nurses. (2nd ed.). Upper Saddle River, NJ: Prentice Hall, p. 58. Reprinted by permission.


The Role of Communication in Leadership Although communication is inherent in the manager’s role, the manager’s ability to communi- cate often determines his or her success as a leader. Leaders who engage in frank, open, two-way communication and whose nonverbal communication reinforces the verbal communication are seen as informative. Communication is enhanced when the manager listens carefully and is sen- sitive to others. The major underlying factor, however, is an ongoing relationship between the manager and employees.

Successful leaders are able to persuade others and enlist their support. The most effective means of persuasion is the leader’s personal characteristics. Competence, emotional control, as- sertiveness, consideration, and respect promote trustworthiness and credibility. A participative leader is seen as a careful listener who is open, frank, trustworthy, and informative.

Employees Depending on the organization’s policies, the nurse manager’s responsibilities may include se- lecting, interviewing, evaluating, counseling, and disciplining employees; handling their com- plaints; and settling conflicts. The principles of effective communication are especially pertinent in these activities because good communication is the adhesive that builds and maintains an effective work group.

Giving direction is not, in itself, communication. If the manager receives an appropriate response from the subordinate, however, communication has occurred. To give directions and achieve the desired results, develop a message strategy. The techniques that follow can help im- prove effective responses from others.

● Know the context of the instruction. Be certain you know exactly what you want done, by whom, within what time frame, and what steps should be followed to do it. Be clear in your own mind what information a person needs to carry out your instruction, what the outcome will be if the instruction is carried out, and how that outcome can or will be eval- uated. When you have thought through these questions, you are ready to give the proper instruction.

● Get positive attention. Avoid factors that interfere with effective listening. Informing the person that the instructions will be given is one simple way to try to get positive attention. Highlighting the background, giving a justification, or indicating the importance of the instructions also may be appropriate.

● Give clear, concise instructions. Use an inoffensive and nondefensive style and tone of voice. Be precise, and give all the information receivers need to carry out your expecta- tions. Follow a step-by-step procedure if several actions are needed.

● Verify through feedback. Make sure the receiver has understood your specific request for action. Ask for a repeat of the instructions.

● Provide follow-up communication. Understanding does not guarantee performance. Fol- low up to discover if your instruction is clear and if the person has any questions.

The nurse manager is responsible both for the quality of the work life of individual em- ployees and for the quality of patient care in the entire unit. To carry out this job, acknowledge the needs of individual employees, especially if the needs of one conflict with needs of the unit, speak directly with those involved, and state clearly and accurately the rationale for the deci- sions made.

Administrators The manager’s interaction with higher administration is comparable to the interaction between the manager and an employee, except that the manager is now the subordinate. Higher ad- ministration is responsible for the consequences of decisions made for a larger area, such as all of nursing service or the entire organization. The principles used in communicating with


subordinates are equally appropriate. Managers should be organized and prepared to state their needs clearly, explain the rationale for requests, suggest benefits for the larger organization, and use appropriate channels. Listen objectively to your supervisor’s response and be willing to con- sider reasons for possible conflict with needs of other areas.

Working effectively with an administrator is important because this person directly influ- ences personal success in a career and within the organization. Managing a supervisor, or man- aging upward, is a crucial skill for nurses. To manage upward, remember that the relationship requires participation from both parties. Managing upward is successful when power and influ- ence move in both directions. Rules for managing your supervisor are found in Box 9-2.

One aspect of managing upward is to understand the supervisor’s position from her or his frame of reference. This will make it easier to propose solutions and ideas that the supervisor will accept. Understand that a supervisor is a person with even more responsibility and pressure. Learn about the supervisor from a personal perspective: What pressures, both personal and pro- fessional, does the supervisor face? How does the supervisor respond to stress? What previous experiences are liable to affect today’s issues? This assessment will allow you to identify ways to help your supervisor with his or her job and for your supervisor to help you with yours.

Influencing Your Supervisor Nurses need to approach their supervisor to exert their influence on a variety of issues and prob- lems. Support for the purchase of capital equipment, for changes in staffing, or for a new policy or procedure all require communicating with a supervisor. Your rationale, choice of form or format, and possible objections all are important factors to consider as you prepare to make such a request. Timing is critical; choose an opportunity when the supervisor has time and appears receptive. Also, consider the impact of your ideas on other events occurring at that time.

Should ideas be presented in spoken or written form? Usually some combination is used. Even if you have a brief meeting about a relatively small request, it is a good idea to follow up with an e-mail, detailing your ideas and the plans to which you both agreed. Sometimes the pro- cedure works in reverse. If you provide the supervisor with a written proposal prior to a meeting, both of you will be familiar with the idea at the start. In the latter case, careful preparation of the written material is essential.

What can be done if, in spite of careful preparation, your supervisor says no? First, make sure you have understood the objections and associated feelings. Negative inquiry (e.g., “I don’t understand”) is a helpful technique to use. Do not interrupt or become defensive or distraught; remain diplomatic. Fogging, agreeing with part of what was said, or negative assertion, accept- ing some blame, are two additional techniques that you can use.

The next step is confrontation. Keep your voice low and measured; use “I” language; and avoid absolutes, why questions, put-downs, inflammatory statements, and threatening gestures. Finally, if you feel you have lost and compromise is unlikely, table the issue by saying, “Could

BOX 9-2 Rules for Managing Your Boss

● Give immediate positive feedback for good things that the supervisor does; positive feedback is a wel- come change.

● Never let your supervisor be surprised; keep her or him informed.

● Always tell the truth. ● Find ways to compensate for weaknesses of your su-

pervisor. Fill in weak areas tactfully. Volunteer to do something the supervisor dislikes doing.

● Be your own publicist. Don’t brag, but keep your supervisor informed of what you achieve.

● Keep aware of your supervisor’s achievements and acknowledge them.

● If your supervisor asks you to do something, do it well and ahead of the deadline if possible. If appro- priate, add some of your own suggestions.

● Establish a positive relationship with the supervisor’s assistant.


we continue discussing this at another time?” Then, think through your supervisor’s reasoning and evaluate it.

Afterward ask yourself: “What new information did I get from the supervisor?” “What are ways I can renegotiate?” “What do I need to know or do to overcome objections?” Once you can answer these questions, approach your supervisor again with the new information. This behav- ior shows that the proposal is a high priority, and the new information may cause him or her to reevaluate.

Managers often succeed in influencing supervisors through persistence and repetition, espe- cially if supporting data and documentation are supplied. If the issue is important enough, you may want to take it to a higher authority. If so, tell your supervisor you would like an administra- tor at a higher level to hear the proposal. Keep an open mind, listen, and try to meet objections with suggestions of how to solve problems. Be prepared to compromise, which is better than no movement at all, or to be turned down.

Taking a Problem to Your Supervisor No one wants to hear about a problem, and your boss is no different. Nonetheless, work involves problems, and the manager’s job is to solve them. Go to your supervisor with a goal to problem solve together. Have some ideas about solving the problem in hand if you can but do not be so wedded to them that you are unable to listen to your supervisor’s ideas. Keep an open mind. Use the following steps to take a problem to your supervisor:

● Find an appropriate time to discuss a problem, scheduling an appointment if necessary. ● State the problem succinctly and explain why it is interfering with work. ● Listen to your supervisor’s response and provide more information if needed. ● If you agree on a solution, offer to do your part to solve it. If you cannot discover an

agreeable solution, schedule a follow-up meeting or decide to gather more information. ● Schedule a follow-up appointment.

By solving the problem together and, if necessary, by taking active steps together, you and your supervisor are more likely to accept the decision and be committed to it. Setting a specific follow-up date can prevent a solution from being delayed or forgotten.

If All Else Fails Sometimes no matter what you do, working with your supervisor seems nearly impossible. Some managers foster a negative work environment, and employees become dissatisfied, angry, and depressed. High absenteeism and turnover result. As a manager you are charged with sup- porting your supervisor. If working with that person is too difficult for you to manage your work satisfactorily, you may have to transfer elsewhere or leave.

Coworkers Interactions with coworkers are inevitable. Relationships can vary from comfortable and easy to challenging and complex. Coworkers often share similar concerns. Camaraderie may be present; coworkers can exchange ideas and address problems creatively. They can provide support, and the strengths of one can be developed in the other.

Conversely, there may also be competition or conflicts (e.g., battles over territory, personal- ity clashes, differences of opinion) affected by history, the organization’s mores, or generational or cultural differences. Even when there are conflicts, coworkers should interact on a profes- sional level. Chapter 12 suggests ways to handle conflict.

Medical Staff Communication with the medical staff may be difficult for the nurse manager because the re- lationship of physicians and nurses has been that of superior and subordinate (Kripalani et al., 2007). Complicating physician–nurse relationships is the employee status of the medical staff.


They may not be employees of the organization but still have considerable power because of their ability to attract patients to the organization, and, finally, the medical staff is in itself di- verse, consisting of physicians who are organizational employees, residents, physicians in pri- vate practice, and consulting physicians.

One program designed to help physicians improve their communication skills is LegacyMd (see http://legacymd.com/). Using improvisational techniques, participants practice interacting in scenes depicting workplace examples, receive feedback, and replay the scene with enhanced skills.

(See the next section on collaborative communication for how to interact more effectively with physicians.)

Other Health Care Personnel The nurse manager has the overwhelming task of coordinating the activities of a number of per- sonnel with varied levels and types of preparation and different kinds of tasks. The patient may receive regular care from a registered nurse, unlicensed assistive personnel, a respiratory thera- pist, a physical therapist, and a dietitian, among others. The nurse manager may supervise all of them. Regardless, the manager needs considerable skill to communicate effectively with diverse personnel, recognize their commonalities, and deal with their differences.

Patients and Families Nurse managers deal with many difficult issues. Patient or family complaints about the delivery of care (e.g., complaints about a staff member, violations of policy) are one example. When dealing with patient or family complaints, keep the following principles in mind:

● The patient and family are the principal customers of the organization. Treat patients and families with respect; keep communication open and honest. Dissatisfied customers fail to continue to use a service and also inform their friends and families about their neg- ative experiences. Handle complaints or concerns tactfully and expeditiously. Many times lawsuits can be avoided if the patient or family feels that someone has taken the time to listen to their complaints. (See the section on risk management in Chapter 6.)

● Most individuals are unfamiliar with medical jargon. Use words that are appropriate to the recipient’s level of understanding. However, take care not to be condescending or intimidating. It is just as important to assess the person’s knowledge base and level of un- derstanding as it is to know his or her vital signs or liver status.

● Maintain privacy and identify a neutral location for dealing with difficult interactions. ● Make special efforts to find interpreters if a patient or family does not speak English.

Have readily available a list of individuals who are able to communicate in a variety of languages. The list also should include individuals experienced in sign language and Braille. Another resource is AT&T’s language line service (800-752-6096), which pro- vides interpreters for over 140 languages 24 hours a day.

● Recognize cultural differences in communicating with patients and their families. People in some cultures do not ask questions for fear of imposing on others (Huber, 2009). Some cultures prefer interpreters from their own culture; others do not. Cultural education for the staff can help identify some of these differences and teach them appro- priate, culturally sensitive responses (Raingruber et al., 2010).

Collaborative Communication Collaboration is central to patient safety, according to a study by Vitalsmarts™ (Maxfield et al., 2005). The researchers found seven areas where health care workers found it difficult to speak up, including seeing colleagues make mistakes, perform incompetently, disrespect others, break rules, fail to support colleagues, exhibit poor teamwork, or micromanage inappropriately.



Propp and colleagues (2010) found that two processes were critical to ensuring collabora- tion with physicians and other members of the health care team. These were ensuring quality de- cisions and promoting team synergy (see Table 9-3). Developing a collaborative practice model, nurses can build their credibility with physicians and enhance the workplace environment.

Another study found that communication and role understanding crucial to collaborative practice (Suter et al., 2009). Appreciation of one another’s roles was key to improving com- munication and positive patient outcomes. Focusing educational objectives on communication and understanding others’ roles, rather than more diffuse skills, such as respect, is more likely to lead to better practices, the researchers assert.

To support greater collaboration between nurses and physicians and to improve the product of nursing service—patient care—keep these principles in mind:

● Respect physicians as persons, and expect them to respect you. ● Consider yourself and your staff equal partners with physicians in health care. ● Build your staff’s clinical competence and credibility. Ensure that your staff has the clini-

cal preparation necessary to meet required standards of care. ● Actively listen and respond to physician complaints as customer complaints. Create a

problem-solving structure. Stop blaming physicians exclusively for communication problems. ● Use every opportunity to increase your staff’s contact with physicians and to include your

staff in meetings that include physicians. Remember that limited interactions contribute to poor communication.

● Establish a collaborative practice committee on your unit whose membership is composed equally of nurses and physicians. Identify problems, develop mutually satisfactory solu- tions, and learn more about each other. Emphasize similarities and the need for quality care. Begin with those physicians who have a positive attitude toward collaboration.

● Serve as a role model to your staff in nurse–physician communication. ● Support your staff in participating in collaborative efforts by words and by your actions.

If you are confronted with power plays or intimidation, what is the best way to respond? Intimidation can be counteracted by increasing self-confidence and personal feelings of power. Four ways that generate power are:

1. With words: • Use the other person’s name frequently. • Use strong statements. • Avoid discounters, such as “I’m sorry, but . . . ?” • Avoid clichés, such as “hit the nail on the head,” “goes without saying,” “easier said than

done.” • Avoid fillers (such as “ah,” “uh,” and “um”).

TABLE 9-3 Improving Communication

1. Consider your relationship to the receiver.

2. Craft your message, including your goal and how to answer responses.

3. Decide on the medium based on your relationship, the content, and the setting.

4. Check your timing.

5. Deliver your message.

6. Attend to verbal or written responses.

7. Reply appropriately.

8. Conclude when both parties’ messages have been understood.

9. Evaluate communication process.


2. Through delivery: • Be enthusiastic. • Speak clearly and forcefully. • Make one point at a time. • Do not tolerate interruptions.

3. By listening: • Listen for facts. • Pay attention to emotions. • Listen for what is not being said (e.g., body language, mixed messages, hidden messages).

4. Through body posture and body language: • Sit next to your antagonist; turn 30 degrees toward the person when you address him or her. • Lean forward. • Expand your personal space. • Use gestures. • Stand when you talk. • Smile when you are pleased, not in order to please. • Maintain eye contact, but do not stare.

One nurse manager handled a problem with a physician as shown in Case Study 9-1. Additional techniques to counteract intimidation and threat are included in Chapters 12, 21, and 22.

COMMUNICATION Josie Randolph is nurse manager of a perioperative unit, including responsibility for the preoperative testing unit, 18 OR suites, pre-op holding, and sterile process- ing. The OR department supports the hospital’s Level I trauma service as well as all other surgical services.

Dr. Jonas Welborne is a plastic surgeon with a his- tory of aggressive behavior. He has several cases on today’s OR schedule. While he is in his first surgery, a trauma case is brought to the OR. Susan Richardson, the OR charge nurse, decides to bump Dr. Welborne’s sec- ond case out of OR #3 to make room for the trauma case. When Dr. Welborne has finished his first case, he is informed of the delay in his second case. Dr. Welborne storms into the OR scheduling office and begins yelling at Susan. The situation quickly escalates to the point where Dr. Welborne uses obscenities and throws several charts on the floor. Loretta Donnelly, an OR tech, runs to Josie’s office and asks her to come immediately to the OR scheduling office.

Susan and Dr. Welborne continue to yell at one anoth- er, in full view of patients in the pre-op area. Josie imme- diately steps between Dr. Welborne and Susan and firmly asks both of them to lower their voices. She instructs Susan to wait in the staff lounge while she speaks with Dr. Welborne. Josie asks Dr. Welborne to step into her of- fice so they can calmly discuss the situation. Dr. Welborne is still visibly agitated but agrees to discuss the problem.

After hearing his side of the story, Josie apologizes for the inconvenience, but reminds him of the OR poli- cies. Emergent cases take precedence over elective cases, and no other elective cases were on the schedule at that time. She asks Dr. Welborne if there are alternatives to scheduling his cases that would minimize delays or bumps. As they talk, Dr. Welborne becomes calmer.

Josie informs Dr. Welborne that his earlier behavior is unacceptable. Within a few minutes, he apologizes to Josie and asks to speak with Susan. He also apologizes to Susan. Josie and Susan discuss the incident and ways Susan can help diffuse similar situations in the future. As with Dr. Welborne, Josie indicates that Susan’s behav- ior was unprofessional and, as the OR charge nurse, she is always expected to act as a nursing professional and role model.

Manager’s Checklist The nurse manager is responsible for:

● Mediating conflict in a timely manner ● Knowing organizational policies and procedures that

support staff decisions ● Allowing open and complete discussion of the

problem ● Actively listening to both participants ● Using assertive communication to facilitate problem




Enhancing Your Communication Skills Communication skills can be learned. Suggestions to improve your communication skills are shown in Table 9-3.

To communicate effectively, first consider your relationship to the receiver (e.g., boss or patient). Then craft your message. Be clear about your goal in your mind so that you can com- municate it appropriately. Then think about what the other person is liable to say and consider how you might respond.

Next decide on the medium. Is this message best conveyed in person, by phone, e-mail, or text? Should you leave a message if the person isn’t available? Note the personal intimacy con- tent earlier in the chapter for guidance.

Timing plays a critical role in successful communication. Catch your boss in the midst of planning for a budget shortfall and you are less apt to get a receptive hearing.

Be prepared when you deliver your message. The best-crafted message, delivered by the appro- priate medium can misfire by a sender who fails to listen carefully, avoids responding out of fear of consequences, or undermines the message with qualifiers, such as “I don’t know if you’re interested.”

(For more information on communicating effectively, see Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall.

What You Know Now • Communication is a complex, ongoing, dynamic process. • How to deliver a message depends on the purpose, the content, and the relationship. • Messages can be distorted or misconstrued. • Gender, generation, cultural background, and the organizational culture influence communication and its

outcome. • Expert communication skills are essential for a leader to be successful. • Communication strategies vary according to the situation and the roles of people involved. • Collaborative communication is challenging, and specific skills can help. • Nurses can enhance their communication skills with effort and practice.

Tools for Communicating Effectively 1. Identify and use the appropriate method (in person, phone, voice mail, text, e-mail, letter) for your

communications. 2. Evaluate your communication skills in various situations. Think of ways to improve. 3. Practice using the skills described in specific situations, such as with your coworkers, the medical

staff, and with patients and their families. 4. Become sensitive to others’ responses, both verbal and nonverbal, and craft your messages

appropriately. 5. Gather feedback and continue to assess the effectiveness of your communications. 6. Strive to improve your communication skills.

Questions to Challenge You 1. Consider a recent interaction you witnessed.

Did the sender express the message clearly? Use the appropriate medium? Listen and respond to questions and comments? What was the outcome?

2. Now think about a recent interaction where you were the sender using the above criteria. If you could replay the interaction, what would you do differently?

3. How well does communication function in your workplace, school, or clinical site? 4. To improve your communication, practice the skills described in the chapter by role playing or

recording yourself (Sullivan, 2013).



Donaldson, M. C. (2007). Nego- tiating for dummies (2nd ed.). New York: Wiley Publishing.

Feldhahn, S. (2009). The male factor: The unwritten rules, misperceptions, and secret beliefs of men in the work- place. New York: Crown Business.

Hahn, J. (2009). Effectively manage a multigenerational staff. Nursing Management, 40(9), 8–10.

Helgesen, S., & Johnson, J. (2010). The female vision: Women’s real power at work. San Francisco: Berrett-Koehler Publications.

Huber, L. M. (2009). Making community health care culturally correct. American Nurse Today, 4(5), 13–15.

Kaplan, A. M., & Haenlein, M. (2010). Users of the world, unite! The challenges and opportunities of social media. Business Horizons, 53(1), 59–68.

Kripalani, S., LeFevre, F., Phil- lips, C., Williams, M., Basaviah, P., & Baker, D. (2007). Deficits in com- munication and informa- tion transfer between

hospital-based and primary care physicians. Journal of American Medical Associa- tion, 297(8), 831–841.

Maxfield, D., Grenny, J., Lavandero, R., & Groah, L. (2005). The silent treat- ment: Why safety tools and checklists aren’t enough to save lives. Retrieved April 11, 2011 from http://www. silencekills.com/UPDL/Si- lenceKillsExecSummary.pdf

Propp, K. M., Apker, J., Zabava Ford, W. S., Wallace, N., Servenski, M., & Hofmeis- ter, N. (2010). Meeting the complex needs of the health care team: Identification of nurse-team communica- tion practices perceived to enhance patient outcomes. Qualitative Health Research, 20(1), 15–28.

Raingruber, B., Teleten, O., Curry, H., Vang-Yang, B., Kuzmenko, L., Marquez, V., & Hill, J. (2010). Improving nurse-patient communica- tion and quality of care: The transcultural, linguistic care team. Journal of Nurs- ing Administration, 40(6), 258–260.

Raso, R. (2010). Social media for nurse managers: What

does it all mean? Nursing Management, 41(8), 23–25.

Robertson-Malt, S., Herrin- Griffith, D. M., & Davies, J. (2010). Designing a patient care model with relevance to the cultural setting. Journal of Nursing Admin- istration, 40(6), 277–282.

Sullivan, E. J. (2013). Becom- ing influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall.

Suter, E., Arndt, J., Arthur, N., Parboosingh, J., Taylor, E., & Deutschlander, S. (2009). Role understanding and effective communication as core competencies for collaborative practice. Journal of Interprofessional Care, 23(1), 41–51.

Tannen, D. (2001). Talking from 9 to 5: How women’s and men’s conversational styles affect who gets heard, who gets credit, and what gets done at work. New York: Harper.

Trossman, S. (2010). Sharing too much? Nurses nationwide need more information on social networking pitfalls. American Nurse Today, 5(11), 38–39.

Web Resources LegacyMD: http://legacymd.com Silence Kills: The Seven Crucial Conversations in HealthCare:


Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!





Benefits of Delegation BENEFITS TO THE NURSE




The Five Rights of Delegation

The Delegation Process

Accepting Delegation








Delegating Successfully 10

Key Terms Accountability Assignment Authority

Delegation Overdelegation Responsibility

Reverse delegation Underdelegation

1. Describe how delegation involves responsi- bility, accountability, and authority.

2. Describe how effective delegation benefits the delegator, the delegate, the unit, and the organization.

3. Discuss how to be an effective delegator. 4. Identify obstacles that can impede effec-

tive delegation. 5. Explain how liability affects delegation.

Learning Outcomes After completing this chapter, you will be able to:


Delegation Delegation is the process by which responsibility and authority for performing a task (function, activity, or decision) is transferred to another individual who accepts that authority and responsi- bility. Although the delegator remains accountable for the task, the delegate is also accountable to the delegator for the responsibilities assumed. Delegation can help others to develop or en- hance their skills, promote teamwork, and improve productivity.

It is easy to say delegate, but delegation is a difficult leadership skill for nurses to learn and one that may not be taught in undergraduate education. Given the confusion over what tasks assistive personnel can perform and what are those that are the unique purview of RNs, nurses and nurse managers may be reluctant to delegate. Never before, however, has delegation been as critical a skill for nurses and nurse managers to perfect as it is today, with the emphasis on doing more with less.

The benefits of delegating appropriately are many. (See the next section.) In fact, a leader who models delegation promotes collaboration between nurses and support personnel (Orr, 2010) as well as a positive workplace environment (Standing & Anthony, 2008).

Responsibility, accountability, and authority are concepts related to delegation. Although responsibility and accountability are often used synonymously, the two words represent differ- ent concepts that go hand in hand. Responsibility denotes an obligation to accomplish a task, whereas accountability is accepting ownership for the results or lack thereof. Responsibility can be transferred, but accountability is shared.

You can delegate only those tasks for which you are responsible. If you have no direct respon- sibility for the task, then you can’t delegate that task. For instance, if a manager is responsible for filling holes in the staffing schedule, the manager can delegate this responsibility to another indi- vidual. However, if staffing is the responsibility of a central coordinator, the manager can make suggestions or otherwise assist the staffing coordinator, but cannot delegate the task.

Likewise, if an orderly who is responsible for setting up traction is detained and a nurse asks a physical therapist on the unit to assist with traction, this is not delegation, because setting up traction is not the responsibility of the nurse. However, if the orderly (the person responsible for the task) had asked the physical therapist to help, this could be an act of delegation if the other principles of delegation are met.

Along with responsibility, you must transfer authority. Authority is the right to act. There- fore, by transferring authority, the delegator is empowering the delegate to accomplish the task. Too often this principle of delegation is neglected. Nurses retain authority, crippling the del- egate’s abilities to accomplish the task, setting the individual up for failure, and minimizing efficiency and productivity.

Delegation is often confused with work assignment. Delegation involves transfer of respon- sibility and authority. In assignment no transfer of authority occurs. Instead, assignments are a bureaucratic function that reflect job descriptions and patient or organizational needs. Effective delegation benefits the delegator, the delegate, the manager, and the organization.

Benefits of Delegation

Benefits to the Nurse Nurses also benefit from delegation. If the nurse is able to delegate some tasks to UAPs, more time can be devoted to those tasks that cannot be delegated, especially complex patient care. Thus, patient care is enhanced, the nurse’s job satisfaction increases, and retention is improved.

Nancy, RN, has three central line dressing changes to complete as well as two patients to transfer to another unit before the end of shift in one hour. Nancy delegates the transfer duties to Shelley, LPN, and completes the central line dressing changes.


Benefits to the Delegate The delegate also benefits from delegation. The delegate gains new skills and abilities that can facilitate upward mobility. In addition, delegation can bring trust and support, and thereby build self-esteem and confidence. Subsequently, job satisfaction and motivation are enhanced as in- dividuals feel stimulated by new challenges. Morale improves; a sense of pride and belonging develops as well as greater awareness of responsibility. Individuals feel more appreciated and learn to appreciate the roles and responsibilities of others, increasing cooperation and enhancing teamwork.

Benefits to the Manager Delegation also yields benefits for the manager. First, if staff are using UAPs appropriately, the manager will have a better functioning unit. Also the manager may be able to delegate some tasks to staff members and devote more time to management tasks that cannot be delegated. With more time available, the manager can develop new skills and abilities, facilitating the op- portunity for career advancement.

Benefits to the Organization As teamwork improves, the organization benefits by achieving its goals more efficiently. Over- time and absences decrease. Subsequently, productivity increases, and the organization’s finan- cial position may improve. As delegation increases efficiency, the quality of care improves. As quality improves, patient satisfaction increases.

The Five Rights of Delegation Fear of liability often keeps nurses from delegating. State nurse practice acts determine the legal parameters for practice, professional associations set practice standards, and organizational pol- icy and job descriptions define delegation appropriate to the specific work setting. Also guide- lines from the National Council of State Boards of Nursing (NCSBN) can help.

The NCSBN identified the five rights of delegation shown in Table 10-1. In addition, each state board of nursing has its own rules regarding delegation.

● The right task specifies what can be safely delegated to a specific patient. These are com- monly assigned tasks. Tasks that require nursing assessment or judgment should not be delegated (Austin, 2008).

● The right circumstances include an appropriate setting and available resources. Evaluate the patient’s needs and the skills of personnel who could be assigned to meet those specific needs.

● The right person refers to both the delegator and the delegate. The delegator must have the authority and responsibility for the patient’s care and for the task to be assigned. The del- egate must be capable of performing the task and be available to assist. Give the right task to the right person for the right patient.

TABLE 10-1 The Five Rights of Delegation

● Right task ● Right circumstances ● Right person ● Right direction and communication ● Right supervision

National Council of State Boards of Nursing. (2007). The five rights of delegation. Retrieved June 28, 2011 at https://www.ncsbn.org/Joint_statement.pdf


Is the task consistent with the recommended criteria for delegation to nursing assistive personnel (NAP)?

Are there agency policies, procedures and/or protocols in place for this task/activity?

Is appropriate supervision available?

Proceed with delegation

Does the nursing assistive personnel have the appropriate knowledge, skills and abilities (KSA) to accept the delegation?

Does the ability of the NAP match the care needs of the client?

Is the delegating nurse competent to make delegation decisions?

Has there been assessment of the client needs?

Is the task within the scope of the delegating nurse?
















Are there laws and rules in place that support the delegation?

Do not delegate

Do not delegate

Do not delegate

Do not delegate

Do not delegate

Do not delegate

Assess client needs then delegate appropriately

Figure 10-1 • Decision tree for delegation to nursing assistive personnel. Source: Adapted from National Council of State Boards of Nursing. (2006). Joint statement on delegation. Retrieved December 2007 from www.ncsbn.org/Joint_ statement.pdf

● The right direction and communication requires the delegator to give clear, concise description of the task as well as describe the objectives, the limits, and the expectations as a result. The delegate should be able to recognize that the patient is responding as expected.

● The right supervision includes monitoring the delegate, evaluating the person’s perfor- mance, giving feedback as required, and intervening if necessary. The delegator remains responsible for the patient’s care regardless of who performs it.

Also the National Council of State Boards of Nursing decision tree can help guide nurses’ decisions about delegation. (See Figure 10-1.)

The Delegation Process The delegation process has five steps as shown in Table 10-2.

1. Define the task. Delegate only an aspect of your own work for which you have responsibil- ity and authority. These include:

• Routine tasks • Tasks for which you do not have time • Tasks that have moved down in priority


Define the aspects of the task. Ask yourself:

• Does the task involve technical skills or cognitive abilities? • Are specific qualifications necessary? • Is performance restricted by practice acts, standards, or job descriptions? • How complex is the task? • Is training or education required? • Are the steps well defined, or are creativity and problem solving required? • Would a change in circumstances affect who could perform the task?

While you are trying to define the complexity of the task and its components, it is important not to fall into the trap of thinking no one else is capable of performing this task. Often others can be prepared to perform a task through education and training. The time taken to prepare others can be recouped many times over. Also know well the task to be delegated.

An alternative would be to subdivide the task into component parts and delegate the components congruent with the available delegate’s capabilities. For example, developing a budget is a managerial responsibility that cannot be delegated, but someone else could explore the types of tympanic thermometers on the market, their costs, advantages, and so on. A committee of staff nurses could evaluate the options and make a recommendation that you could include in the budget justification.

But how do you know what should not be delegated? Before a task is delegated, determine what areas of authority and what resources you con-

trol to achieve the expected results. A unit manager who is responsible for maintaining ade- quate supplies needs budget authority. The authority to spend money on supplies, however, may be limited to a specific amount for specific supplies or may be allocated to supplies in general.

Certain tasks should never be delegated. Discipline should not be delegated, nor should a highly technical task. Also any situation that involves confidentiality or controversy should not be delegated to others.

2. Decide on delegate. Match the task to the individual. Analyze individuals’ skill levels and abilities to evaluate their capability to perform the various tasks; also determine charac- teristics that might prevent them from accepting responsibility for the task. Conversely experience and individual characteristics, such as initiative, intelligence, and enthusiasm, can expand the individual’s capabilities. A rule of thumb is to delegate to the lowest person in the hierarchy who has the requisite capabilities and who is allowed to do the task legally and by organizational policy.

Next determine availability. For example, Su Ling might be the best candidate, but she leaves for vacation tomorrow and won’t be back before the project is due. Then ask who would be willing to assume responsibility. Delegation is an agreement that is entered into voluntarily.

3. Determine the task. The next step in delegation is to clearly define your expectations for the delegate. Also plan when to meet. Attempting to delegate in the middle of a crisis is not del- egation; that is directing. Provide for enough time to describe the task and your expectations and to entertain questions. Also, meet in an environment as devoid of distractions as possible.

TABLE 10-2 Delegation Process

1. Define the task. 2. Decide on delegate. 3. Determine the task. 4. Reach agreement. 5. Monitor performance and provide feedback.


Key behaviors in delegating tasks are shown in Table 10-3

a. Describe the task using “I” statements, such as “I would like . . .” and appropriate non- verbal behaviors—open body language, face-to-face positioning, and eye contact. The delegate needs to know what is expected, when the task should be completed, and where and how, if that is appropriate. The more experienced delegates may be able to define for themselves the where and how. Decide whether written reports are necessary or if brief oral reports are sufficient. If written reports are required, indicate whether tables, charts, or other graphics are necessary. Be specific about reporting times. Identify criti- cal events or milestones that might be reached and brought to your attention. For patient care tasks, determine who has responsibility and authority to chart certain tasks. For ex- ample, UAPs can enter vital signs, but if they observe changes in patient status, the RN must investigate and chart the assessment.

b. Discuss the importance to the organization, you, the patient, and the delegate. Provide the delegate with an incentive for accepting both the responsibility and the authority to do the task.

c. Explain the expected outcome and the timeline for completion. Establish how closely the assignment will be supervised. Monitoring is important because you remain accountable for the task, but controls should never limit an individual’s opportunity to grow.

d. Identify any constraints for completing the task or any conditions that could change. For example, you may ask an assistant to feed a patient for you as long as the patient is coherent and awake, but you might decide to feed the patient if he were confused.

e. Validate understanding of the task and your expectations by eliciting questions and pro- viding feedback.

4. Reach agreement. Once you have outlined your expectations, you must be sure that the delegate agrees to accept responsibility and authority for the task. You need to be prepared to equip the delegate to complete the task successfully. This might mean providing ad- ditional information or resources or informing others about the arrangement as needed to empower the delegate. Before meeting with the individual, anticipate areas of negotiation, and identify what you are prepared and able to provide.

5. Monitor performance and provide feedback. Monitoring performance provides a mecha- nism for feedback and control that ensures that the delegated tasks are carried out as agreed. Give careful thought to monitoring efforts when objectives are established. When defining the task and expectations, clearly establish the where, when, and how. Remain accessible. Support builds confidence and reassures the delegate of your interest in the del- egate and negates any concerns about dumping undesirable tasks.

Monitoring the delegate too closely, however, conveys distrust. Analyze performance with respect to the established goal. If problem areas are identified, privately investigate and explain the problem, provide an opportunity for feedback, and inform the individual how to correct the mistake in the future. Provide additional support as needed. Also, be sure to give the praise and recognition due, and don’t be afraid to do so publicly.

TABLE 10-3 Key Behaviors in Delegating Tasks

● Describe the task using “I” statements. ● Discuss the importance to the organization. ● Explain the expected outcome and timeline for completion. ● Identify any constraints for completing the task. ● Validate understanding of the task and your expectations.


Accepting Delegation Accepting delegation means that you accept full responsibility for the outcome and its benefits or liabilities. Just as the delegator has the option to delegate parts of a task, you also have the option to negotiate for those aspects of a task you feel you can accomplish. Recognize, however, that this may be an opportunity for growth. You may decide to capitalize on it, obtaining new skills or resources in the process.

When you accept delegation, you must understand what is being asked of you. First, ac- knowledge the delegator’s confidence in you, but realistically examine whether you have the skills and abilities for the task and the time to do it. If you do not have the skills, you must in- form the delegator. However, it does not mean you cannot accept the responsibility. See whether the person is willing to train or otherwise equip you to accomplish the task. If not, then you need to refuse the offer.

Once you agree on the role and responsibilities you are to assume, make sure you are clear on the time frame, feedback mechanisms, and other expectations. Don’t assume any- thing. As a minimum, repeat to the delegator what you heard said; better yet, outline the task in writing.

Throughout the project, keep the delegator informed. Report any concerns you have as they come up. Foremost, complete the task as agreed. Successful completion can open more doors in the future.

If you are not qualified or do not have the time, do not be afraid to say no. Thank the delega- tor for the offer and clearly explain why you must decline at this time. Express your interest in working together in the future.

See how a school nurse handled delegation in Case Study 10-1.

DELEGATION Lisa Ford is a school nurse for a suburban school district. She has responsibility for three school buildings, includ- ing a middle school, a high school, and a vocational rehabilitation workshop for mentally and physically handicapped secondary students. Her management re- sponsibilities include providing health services for 1,000 students, 60 faculty members, and 25 staff members, as well as supervising two unlicensed school health aides and three special education health aides. The logistics of managing multiple school sites results in the delegation of many daily health room tasks, including medication administration, to the school-based health aides.

Nancy Andrews is an unlicensed health aide at the middle school. This is her first year as a health aide and she has a limited background in health care. The nurse practice act in the state allows for the delega- tion of medication administration in the school setting. Lisa is responsible for training Nancy to safely adminis- ter medication to students, documenting the training, evaluating Nancy’s performance, and providing ongo- ing supervision. Part of Nancy’s training will also include a discussion of those medication-related decisions that must be made by a registered nurse.

Manager’s Checklist The nurse manger is responsible for:

● Understanding the state nurse practice act and its applicability to the school setting

● Implementing school district policies related to health services and medication administration

● Developing and implementing an appropriate train- ing program

● Limiting opportunities for error and decreasing liability by ensuring that unlicensed health aides are appropriately trained to handle delegated tasks

● Maintaining documentation related to training and observing medication administration by unlicensed staff

● Auditing medication administration records to en- sure accuracy and completeness

● Conducting several “drop in” visits during the school year to track competency of health aides

● If necessary, reporting any medication errors to ad- ministration and following up with focused training and closer supervision



Ineffective Delegation Ineffective delegation results in missed or omitted routine care, such as feeding, turning, am- bulating, and toileting (Bittner & Gravlin, 2009; Gravlin & Bittner, 2010). Poor communica- tion and interpersonal relationship between nurses and unlicensed assistive personnel (UAP) has been found to result in ineffective delegation (Standing & Anthony, 2008).

The RN/UAP unit is a microsystem in health care and when that unit is dysfunctional or functioning at less than optimal performance, the quality of care suffers. One reason for prob- lems with delegation is the assignment of a single UAP to more than one RN. The UAP’s work- load may be more than one person can handle but each nurse may be unaware of the assistant’s overload.

Another reason for ineffective delegation is that nurses define delegation differently (Stand- ing & Anthony, 2008). Some nurses define delegation as explicit instructions to carry out a spe- cific task. Others think that delegation is both specific and implicit in expected tasks, such as ambulating or toileting.

Potential barriers to effective delegation include organizational factors or the delegator’s or delegate’s beliefs or inexperience.

Organizational Culture The culture within the organization may restrict delegation. Hierarchies, management styles, and norms may all preclude delegation. Rigid chains of command and autocratic leadership styles do not facilitate delegation and rarely provide good role models. The norm is to do the work oneself because others are not capable or skilled. An atmosphere of distrust prevails as well as a poor tolerance for mistakes. A norm of crisis management or poorly defined job descriptions or chains of command also impede successful delegation.

Lack of Resources Another difficulty frequently encountered is a lack of resources. For example, there may be no one to whom you can delegate. Consider the sole registered nurse in a skilled nursing facility. If practice acts define a task as one that only a registered nurse can perform, there is no one else to whom that nurse can delegate that task.

Financial constraints also can interfere with delegation. For instance, someone from your department must attend the annual conference in your nursing specialty area. However, the or- ganization will only pay the manager’s travel and conference expenses, which precludes anyone else from attending.

Educational resources may be another limiting factor. Perhaps others could learn how to do a task if they could practice with the equipment, but the equipment or a trainer is not available.

Time can also be a limiting factor. For example, it is Friday, and the schedule needs to be posted on Monday. No one on your staff has experience developing schedules and you need to go out of town for a family emergency, so there is no one else to do the schedule.

An Insecure Delegation The majority of the barriers to delegation arise from the delegator. Reasons people give to fail to delegate include:

“I can do it better.”

“I can do it faster.”

“I’d rather do it myself.”

“I don’t have time to delegate.”

Often underlying these statements are erroneous beliefs, fears, and inexperience in delega- tion. Certainly, the experienced person can do the task better and faster. Indeed, delegation takes


time, but failing to delegate is a time waster. Time invested in developing staff today is later repaid many times over.

Common fears are:

● Fear of competition or criticism. What if someone else can do the job better or faster than I? Will I lose my job? Be demoted? What will others think? Will I lose respect and control? This fear is unfounded if the delegator has selected the right task and matched it with the right individual. In fact, the delegate’s success in the task provides evidence of the delegator’s leadership and decision-making abilities.

● Fear of liability. Some individuals are not risk takers and shy away from delegation for this reason. There are risks associated with delegation, but the delegator can minimize these risks by following the steps of delegation. A related concern is a fear of being blamed for the delegate’s mistakes. If the delegator selected the task and delegate appro- priately, then the responsibility for any mistakes made are solely those of the delegate; it is not necessary to take on guilt for another’s mistakes.

Review the five rights of delegation and the decision tree for the National Council of State Boards of Nursing as well as the state’s nurse practice act and the organization’s policies. RNs often fear blame from management if something goes wrong when a task has been delegated to an LPN or UAP, but those fears can be relieved if state law, organi- zational policies, and job descriptions are followed.

● Fear of loss of control. Will I be kept informed? Will the job be done right? How can I be sure? The more one is insecure and inexperienced in delegation, the more this fear is an issue. This is also a predominant concern in individuals who tend toward autocratic styles of leadership and perfectionism. The key to retaining control is to clearly identify the task and expectations and then to monitor progress and provide feedback.

● Fear of overburdening others. They already have so much to do; how can I suggest more? Everyone has work to do. Such a statement belittles the decisional capabilities of others. Recall that delegation is a voluntary, contractual agreement; acceptance of a delegated task indicates the availability and willingness of the delegate to perform the task. Often, the delegate welcomes the diversion and stimulation, and what the delegator perceives as a burden is actually a blessing. The onus is on the delegator to select the right person for the right reason.

● Fear of decreased personal job satisfaction. Because the type of tasks recommended to delegate are those that are familiar and routine, the delegator’s job satisfaction should ac- tually increase with the opportunity to explore new challenges and obtain other skills and abilities.

An Unwilling Delegate Inexperience and fear of failure can motivate a potential delegate to refuse to accept a delegated task. Much reassurance and support are needed. In addition, the delegate should be equipped to handle the task. If proper selection criteria are used and the steps of delegation followed, then the delegate should not fail. The delegator can boost the delegate’s lack of confidence by build- ing on simple tasks. The delegate needs to be reminded that everyone was inexperienced at one time. Another common concern is how mistakes will be handled. When describing the task, the delegator should provide clear guidelines for handling problems, guidelines that adhere to orga- nizational policies.

Another barrier is the individual who avoids responsibility or is overdependent on others. Success breeds success; therefore, it is important to use an enticing incentive to engage the indi- vidual in a simple task that guarantees success.

When the steps of delegation are not followed or barriers remain unresolved, delegation is often ineffective. Inefficient delegation can result from unnecessary duplication, underdelega- tion, reverse delegation, and overdelegation.


Underdelegation Underdelegation occurs when

● The delegator fails to transfer full authority to the delegate; ● The delegator takes back responsibility for aspects of the task; or ● The delegator fails to equip and direct the delegate.

As a result, the delegate is unable to complete the task, and the delegator must resume re- sponsibility for its completion.

Sharon, RN, is a school nurse with three separate buildings under her direction. UAPs, called health clerks, operate in the school health office when Sharon is at another build- ing. Joye, a first-year health clerk, has had minimal medication administration instruction and experience. During the first week of school, Joye tries to “speed up” the medication administration process and sets out all of the noon medications in individual, unlabeled cups for the students. The cups are rearranged by students trying to find their meds and Joye cannot identify what meds belong to which students. Sharon is called back to the school to administer the correct medications, students are late to class, and Joye is frus- trated that she couldn’t handle the task.

It may be that the RN fears liability or lacks confidence or experience in delegating and decides to do all the tasks rather than delegate to an assistant (Mitty et al., 2010). Conversely, the assistant may not be prepared for the tasks or may not believe the task is within the assistant’s scope of practice. In addition, the assistant may not be able to complete all the tasks, especially if the person is assigned to several nurses.

Reverse Delegation In reverse delegation, someone with a lower rank delegates to someone with more authority.

Thomas is a nurse practitioner for the burn unit. He recently arrived on the unit to find several patients whose dressing changes have not been completed due to a code situa- tion earlier in the morning. Dawn, LPN, asks Thomas to help the staff complete dressing changes before physician rounds begin.

Overdelegation Overdelegation occurs when the delegator loses control over a situation by providing the del- egate with too much authority or too much responsibility. This places the delegator in a risky position, increasing the potential for liability. In this instance, the nurse assumes that any task that doesn’t involve nursing assessment or judgment should be assigned to assistive personnel.

Ellen, GN, is in her sixth week of orientation in the trauma ICU. Her mentor, Dolores, RN, notes that Mr. Anderson is scheduled for an MRI off the unit. Dolores delegates the task of escorting Mr. Anderson to the MRI unit to Ellen who is not ACLS certified. During the MRI, Mr. Anderson is accidentally extubated and suffers respiratory and cardiac ar- rest. A code is called in the MRI suite and ER nurses must respond since an ACLS certified nurse is not with the patient.

Not delegating appropriately negatively affects other staff on the unit as well. Here are two examples:

Sally, RN, always says she “likes to do everything herself” for her patients. She doesn’t like to ask aides for assistance. Her patients are usually happy, but Sally is ex- tremely busy all day and doesn’t ever have time to help a peer RN when asked or answer call lights to help the team. Sally’s peers get frustrated because her lack of delegating


appropriate tasks to her nurse’s aide partner makes the aide feel not valued, Sally feels too busy in her job, and her peers feel like they get no help from Sally when needed.

Bridgett, RN, feels that she has spent her time doing aide work while she was in nurs- ing school. Now that she has taken NCLEX boards and is working as a nurse, she won’t help patients to the bathroom or empty a bedpan, or change bed linens. She will call an aide to do these tasks even if she is in the room and has time to do the tasks herself. Bridgett’s inappropriate delegation causes aides to be angry, peer RNs to be frustrated because the aides don’t have time to help them because they are always doing Bridgett’s work, and results in inconsistency in the practice between Bridgett and other nurses, which Bridget’ patients’ notice.

Delegation is a skill that can be learned. Like other skills, successfully delegating requires practice. Sometimes it seems it might be easier to do it yourself. But it is not. Once you learn how to delegate, you will extend your ability to accomplish more by using others’ help.

By delegating appropriately, managers can role model this behavior and teach their staff to do likewise. In addition, it is the best use of their time.

No one in health care today can afford not to delegate.

What You Know Now • Delegation is a contractual agreement in which authority and responsibility for a task is transferred by

the person accountable for the task to another individual. • Delegation benefits the delegator, delegate, the manager, the unit, and the organization.

• The five rights of delegation are the right task, the right circumstances, the right person, the right direction, and the right supervision.

• Delegation involves skill in identifying and determining the task and level of responsibility, deciding who has the requisite skills and abilities, describing expectations clearly, reaching mutual agreement, and monitoring performance and providing feedback.

• Delegatable tasks are personal, routine tasks that the delegator can perform well; that do not involve discipline, highly technical tasks, or confidential information; and that are not controversial.

• To accept delegation, agree on roles and responsibilities, the time frame for completion, feedback mechanisms, and expectations.

• Ineffective delegation can occur with organizational constraints or the delegate’s or delegator’s lack of experience or beliefs.

• Managers can role model appropriate delegation. • Delegation is essential in health care today.

Tools for Delegating Successfully 1. Delegate only tasks for which you have responsibility. 2. Transfer authority when you delegate responsibility. 3. Be sure you follow state regulations, job descriptions, and organizational policies when delegating. 4. Follow the delegation process and key behaviors for delegating described in the chapter. 5. Accept delegation when you are clear about the task, time frame, reporting, and other expectations. 6. Review the five rights of delegation and the NCSBN’s decision tree to delegate appropriately.

Questions to Challenge You 1. Review your state’s nurse practice act. How is delegation defined? What tasks can and cannot be

delegated? How is supervision defined? Are there any other guidelines for supervision? Are respon- sibilities regarding advanced practice delineated? How does the scope of practice differ between registered and licensed practical/vocational nurses? What is the scope of practice of other health care providers?

2. What are your organization’s policies on delegation?


Austin, S. (2008). 7 legal tips for safe nursing practice. Nursing 2008, 38(3), 34–39.

Bittner, N. P., & Gravlin, G. (2009). Critical thinking, delegation, and missed care in nursing practice. Journal of Nursing Administration, 39(3), 142–146.

Gravlin, G., & Bittner, N. P. (2010). Nurses’ and nursing assistants’ reports of missed care and delegation. Journal

of Nursing Administration, 40(7/8), 329–335.

Mitty, E., Resnick, B., Bakerjian, D., Gardner, W., Rainbard, S., Mezey, M. (2010). Nursing delegation and medication administration in assisted living. Nursing Administration Quarterly, 34(2), 162–171.

National Council of State Boards of Nursing. (2007). The five rights of delegation. Retrieved June 28, 2011 at

https://www.ncsbn.org/ Joint_statement.pdf

Orr, S. E. (2010). Characteristics of positive working rela- tionships between nursing and support service em- ployees. Journal of Nurs- ing Administration, 40(3), 129–134.

Standing, T. S., & Anthony, M. K. (2008). Delegation: What it means to acute care nurses. Applied Nursing Research, 21(1), 8–14.

3. Describe a situation when you delegated a task to someone else. Did you follow the steps of delega- tion explained in the chapter? Was the outcome positive? If not, what went wrong?

4. Describe a situation when someone else delegated a task to you. Did your delegator explain what to do? Did you receive too much information? Not enough? Was supervision appropriate to the task and to your abilities? What was the outcome?


Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!


Groups and Teams

Group and Team Processes NORMS


Building Teams ASSESSMENT


Managing Teams TASK





The Nurse Manager as Team Leader



Leading Committees and Task Forces



Patient Care Conferences

Building and Managing Teams 11

1. Describe how groups and teams function. 2. Differentiate between team building and man-

aging teams. 3. Describe various methods of team


Learning Outcomes After completing this chapter, you will be able to:

4. Discuss factors that influence team management. 5. Explain why the nurse manager’s leadership

skills are essential to team performance. 6. Discuss how to lead groups, task forces, and

patient care conferences.

Key Terms Additive task Adjourning Clinical ladder Cohesiveness Committees or task

forces Competing groups Conjunctive task Disjunctive task Divisible task Formal committees Formal groups

Forming Group Hidden agendas Informal committees Informal groups Norming Norms Ordinary interacting

groups Performing Pooled interdependence Productivity

Real (command) groups Reciprocal interdependence Re-forming Role Sequential interdependence Status Status incongruence Storming Task forces Task group Team building Teams


M ost often, nursing occurs in a team environment. Work groups that share common objectives function in a harmonious, coordinated, purposeful manner as teams. The staff nurse is constantly involved in teamwork. The nurse/aide/unit secretary team works together every day on a nursing unit. With shared governance more often the norm and interprofessional team work common, the nurse may participate or lead a team broader in scale than one unit. For example, a nurse might lead the acute care practice council or be on a team to implement supplies at the bedside.

High-performance teams require expert leadership skills. In a health care delivery system integrated across settings, a team environment becomes increasingly essential. Nurse managers must skillfully orchestrate the activity and interactions of interprofessional teams as well as con- ventional nursing work groups. Understanding the nature of groups and how groups are trans- formed into teams is essential for the nurse to be effective.

Groups and Teams A group is an aggregate of individuals who interact and mutually influence each other. Both formal and informal groups exist in organizations. Formal groups are clusters of individuals designated temporarily or permanently by an organization to perform specified organizational tasks. Formal groups may be structured laterally, vertically, or diagonally. Task groups, teams, task forces, and committees may be structured in all of these ways, whereas command groups generally are structured vertically.

Group members include:

● Individuals from a single work group (e.g., nurses on one unit) or individuals at similar job levels from more than one work group (e.g., all professional staff)

● Individuals from different job levels (e.g., nurses and UAPs) ● Individuals from different work groups and different job levels in the organization

(e.g., committee to review staff orientation classes)

Groups may be permanent or temporary. Command groups, teams, and committees usually are permanent, whereas task groups and task forces are often temporary.

Informal groups evolve naturally from social interactions. Groups are informal in the sense that they are not defined by an organizational structure. Examples of informal groups include individuals who regularly eat lunch together or who convene spontaneously to discuss a clinical dilemma.

Real (command) groups accomplish tasks in organizations and are recognized as a legitimate organizational entity. Its members are interdependent, share a set of norms, generally differentiate roles and duties among themselves, are organized to achieve ongoing organizational goals, and are collectively held responsible for measurable outcomes.

The group’s manager has line authority in relation to group members individually and col- lectively. The group’s assignments are usually routine and designed to fulfill the specific mission of the agency or organization. The regularly assigned staff who work together under the direction of a single manager constitute a command group.

A task group is composed of several persons who work together, with or without a desig- nated leader, and are charged with accomplishing specific time-limited assignments. A group of nurses selected by their colleagues to plan an orientation program for new staff constitute a task group. Usually, several task groups exist within a service area and may include representatives from several disciplines (e.g., nurse, physician, dietitian, social worker).

Other special groups include committees or task forces formed to deal with specific issues involving several service areas. A committee responsible for monitoring and improving patient safety or a task force assigned to develop procedures to adhere to patient privacy regulations are examples of special work groups.

Health care organizations depend on numerous committees, which nurses participate in and often lead. Some of these committees are mandated by accrediting and regulatory


bodies, such as committees for education, standards, disaster, and patient care evaluation. Others are established to meet a specific need (e.g., to formulate a new policy on substance abuse).

Teams are real groups in which individuals must work cooperatively with each other in order to achieve some overarching goal. Teams have command or line authority to perform tasks, and membership is based on the specific skills required to accomplish the tasks. Similar to groups described above, teams may include individuals from a single work group or individuals at similar job levels from more than one work group, individuals from different job levels, or in- dividuals from different work groups and different job levels in the organization. They may have a short life span or exist indefinitely.

Metropolitan Hospital has established a clinical ladder system for nursing staff. Each quarter, members of the clinical excellence committee meet to review applications from staff nurses who are seeking promotion to the next clinical ladder level. The committee is made up of staff nurses and nurse managers from each service line. Each applicant is responsible for completing a comprehensive application. The committee members evalu- ate each application and make recommendations to the vice president for patient care on those nurses who should be considered for promotion.

Not all work groups, however, are teams. For example, groups of individuals who perform their tasks independently of each other are not teams. Competing groups, in which members compete with each other for resources to perform their tasks or compete for recognition, are also not teams.

A work group becomes a team when the individuals must apply group process skills to achieve specific results. They must exchange ideas, coordinate work activities, and develop an understanding of other team members’ roles in order to perform effectively. Members appreciate the talents and contributions of each individual on the team and find ways to capital- ize on them. Most work teams have a leader who maintains the integrity of the team’s function and guides the team’s activities, performance, and development. Teams may be self-directed, that is, led jointly by group members who decide together about work objectives and activities on an ongoing basis.

In a given service area, the entire staff might not function as a team, but a subgroup may. For example, case managers for the inpatient and ambulatory cystic fibrosis population in a chil- dren’s medical center might be called a team. Individual members of an interdisciplinary team, such as this one, may report formally to different managers, but in delivering care to the cystic fibrosis population there is no designated individual in charge. In meetings, the team members discuss clients’ problems and jointly decide on plans of action.

Many different types of groups and teams are used throughout organizations. Examples are ad hoc task groups, quality improvement teams, quality circles, self-directed work teams, shared governance councils, and focus groups.

Nurse managers at a large university hospital are responsible for educating their staff about patient satisfaction. Patient satisfaction surveys are sent to randomly selected pa- tients. Results are compiled, and each department receives a detailed report of the results. Staff members review the data at monthly staff meetings, using both positive and negative comments to guide their patient care activities. As needed, department standards and pro- tocols are updated to reflect improved processes.

Most groups are considered ordinary interacting groups. These groups usually have a des- ignated formal leader, but they may be leaderless. Most work teams, task groups, and commit- tees are ordinary interacting groups. Discussions usually begin with a statement of the problem by the group leader followed by an open, unstructured conversation. Normally, the final deci- sion is made by consensus (without formal voting; members indicate concurrence with a group agreement that everyone can live with and support publicly). The decision may also be made by the leader or someone in authority, majority vote, an average of members’ opinions, minority


control, or an expert member. Interacting groups enhance the cohesiveness and esprit de corps among group members. Participants are able to build strong social ties and will be committed to the solution decided on by the group.

Infection control nurses have been tracking occurrences of MRSA infections among patients in their hospital system. In addition to implementing patient care protocols as recommended by federal and state infectious disease agencies, the nurses track compliance in high-risk units and tailor education programs to meet the needs of nursing and assistive staffs.

Ordinary interacting groups, however, may be dominated by one or a few members. If the group is highly cohesive, its decision-making ability may be affected by groupthink (dis- cussed in Chapter 8). Groupthink results in pressure for every member to conform, usually to the leader’s beliefs, even to violating personal norms.

Sometimes groups spend excessive time dealing with socioemotional relationships, reducing the time spent on the problem and slowing consensus. Ordinary groups may reach compromise decisions that may not really satisfy any of the participants. Because of these problems, the func- tioning of ordinary groups is dependent on the leader’s skills.

Each type of group presents unique opportunities and challenges. An important role of the nurse manager is to link service areas with groups at higher levels in the organization. This link facilitates problem solving, coordination, and communication throughout the organization. Leadership roles in work groups are important and may also be either formal or informal. For example, the nurse manager formally leads the unit or service area staff but may also informally lead a support group of nurse managers.

The leader’s influence on group processes, formal or informal, and the ability of the group to work together as a team often determine whether the group accomplishes its goals. Nurse manag- ers may effectively manage work groups and turn them into teams by understanding principles of group processes and applying them to group decision making, team building, and leading com- mittees and task forces.

Group and Team Processes The modified version of Homans’s (1950, 1961) social system conceptual scheme presented in Figure 11-1 provides a framework for understanding group inputs, processes, and outcomes. The schematic depicts the effects of organizational and individual background factors on group leadership, including dynamics (tasks, activities, interactions, attitudes) and processes (forming, storming, norming, performing, adjourning). Elements of the required group system and pro- cesses influence each other and the emergent group system and social structure.

This system determines the productivity of the group as well as members’ quality of work life, such as job satisfaction, development, growth, and similarity in thinking. The framework distinguishes required factors that are imposed by the external system from factors that emerge from the internal dynamics of the group.

According to Homans’s framework, the three essential elements of a group system are activities, interactions, and attitudes. Activities are the observable behaviors of group members. Interactions are the verbal or nonverbal exchanges of words or objects among two or more group members. Attitudes are the perceptions, feelings, and values held by individual group members, which may be both positive and negative. To understand and guide group functioning, a manager should analyze the activities, interactions, and attitudes of work group members.

Homans’s framework indicates that background factors, the manager’s leadership style, and the organizational system influence the normal development of the group. Groups, whether formal or informal, typically develop in these phases: form, storm, norm, perform, and adjourn or re-form. In the initial stage, forming, individuals assemble into a well-defined cluster. Group members are cautious in approaching each other as they come together as a group and begin to understand requirements of group membership. At this stage, the members often depend on a leader to define purpose, tasks, and roles.


As the group begins to develop, storming occurs. Members wrestle with roles and relation- ships. Conflict, dissatisfaction, and competition arise on important issues related to procedures and behavior. During this stage, members often compete for power and status, and informal leadership emerges. During the storming stage, the leader helps the group to acknowledge the conflict and to resolve it in a win–win manner.

In the third stage, norming, the group defines its goals and rules of behavior. The group determines what are or are not acceptable behaviors and attitudes. The group structure, roles, and relationships become clearer. Cohesiveness develops. The leader explains standards of per- formance and behavior, defines the group’s structure, and facilitates relationship building.

In the fourth stage, performing, members agree on basic purposes and activities and carry out the work. The group’s energy becomes task-oriented. Cooperation improves, and emotional issues subside. Members communicate effectively and interact in a relaxed atmosphere of sharing. The leader provides feedback on the quality and quantity of work, praises achievement, critiques poor work and takes steps to improve it, and reinforces interpersonal relationships within the group.

The fifth stage is either adjourning (the group dissolves after achieving its objectives) or re-forming, when some major change takes place in the environment or in the composition or goals of the group that requires the group to refocus its activities and recycle through the four stages. When a group adjourns, the leader must prepare group members for dissolution and facil- itate closure through celebration of success and leave-taking. If the group is to refocus its activi- ties, the leader will explain the new direction and provide guidance in the process of re-forming.

Norms Norms are the informal rules of behavior shared and enforced by group members. Norms emerge whenever humans interact. Groups develop norms that members believe must be adhered to for fruitful, stable group functioning. Nursing groups often establish norms related to how members



Required system

Tasks Activities Interactions Attitudes

Group processes

Form Storm Norm Perform Adjourn/Re-form


Productivity Satisfaction Development Conflict Groupthink

Background factors

Organizational requirements External status Personal characteristics

Leadership style



Results in



Emergent group system

Activities Interactions Sentiments Roles Status Communication


Figure 11-1 • Conceptual scheme of a basic social system. Source: Adapted from Homans, G. (1950). The human group. New York: Harcourt Brace Jovanovich; and Homans, G. (1961). Social behavior: Its elementary forms. New York: Harcourt Brace. By permission of Transaction Publishers.


deal with absences that affect the workload of colleagues. Norms may include not calling in sick on weekends, readily accommodating requests for trading shifts, and returning from breaks in a timely manner. In a team environment, norms are more likely to be linked to each team member’s expected contribution to the performance and products of the team’s efforts. If an individual agrees to take on a specific assignment on the team’s behalf and fails to complete the assignment on time, a group norm has been violated.

Group norms are likely to be enforced if they serve to facilitate group survival, ensure predict- ability of behavior, help avoid embarrassing interpersonal problems, express the central values of the group, and clarify the group’s distinctive identity.

Groups go through several stages in enforcing norms with deviant members. First, members use rational argument or present reasons for adhering to the norms to the deviant individual. Second, if rational argument is not effective, members may use persuasive or manipulative tech- niques, reminding the deviant of the value of the group. The third stage is attack. Attacks may be verbal or even physical and sometimes include sabotaging the deviant’s work. The final stage is ignoring the deviant.

It becomes increasingly difficult for a deviant to acquiesce to the group as these strategies escalate. Agreeing to rational argument is easy, but agreeing after an attack is difficult. When the final stage (ignoring) is reached, acquiescence may be impossible because group members refuse to acknowledge the deviant’s surrender. A nurse manager has a responsibility to help groups deal with members who violate group norms related to performance, including counsel- ing the employee and preventing destructive conflict.

Roles Norms apply to all group members, whereas roles are specific to positions in the group. A role is a set of expected behaviors that fit together into a unified whole and are characteristic of persons in a given context. Roles commonly seen in groups can be classified as either task roles or socioemotional (nurturing) roles. Often, individuals fill several roles. Individuals performing task roles attempt to keep the group focused on its goals.

Task roles include:

● Initiator–contributor. Redefines problems and offers solutions, clarifies objectives, suggests agenda items, and maintains time limits

● Information seeker. Pursues descriptive bases for the group’s work ● Information giver. Expands information given by sharing experiences and making

inferences ● Opinion seeker. Explores viewpoints that clarify or reflect the values of other members’

suggestions ● Opinion giver. Conveys to group members what their pertinent values should be ● Elaborator. Predicts outcomes and provides illustrations or expands suggestions,

clarifying how they could work ● Coordinator. Links ideas or suggestions offered by others ● Orienter. Summarizes the group’s discussions and actions ● Evaluator-critic. Appraises the quantity and quality of the group’s accomplishments

against set standards ● Energizer. Motivates group to accomplish, qualitatively and quantitatively, the group’s

goals ● Procedural technician. Supports group activity by arranging the environment

(e.g., scheduling meeting room) and providing necessary tools (e.g., ordering visual equipment)

● Recorder. Documents the group’s actions and achievements

Nurturing roles facilitate the growth and maintenance of the group. Individuals assuming these roles are concerned with group functioning and interpersonal needs.


Nurturing roles include:

● Encourager. Compliments members for their opinions and contributions to the group ● Harmonizer. Relieves tension and conflict ● Compromiser. Suppresses own position to maintain group harmony ● Gatekeeper. Encourages all group members to communicate and participate ● Group observer. Takes note of group processes and dynamics and informs group

of them ● Follower. Passively attends meetings, listens to discussions, and accepts group’s


Status is the social ranking of individuals relative to others in a group based on the position they occupy. Status comes from factors the group values, such as achievement, personal char- acteristics, the ability to control rewards, or the ability to control information. Status is usually enjoyed by members who most conform to group norms. Higher-status members often exercise more influence in group decisions than others.

Status incongruence occurs when factors associated with group status are not congruent, such as when a younger, less experienced person becomes the group leader. Status incongru- ence can have a disruptive impact on a group. For example, isolates are members who have high external status and different backgrounds from regular group members. They usually work at acceptable levels but are isolated from the group because they do not fit the group member profile. Sometimes status incongruence occurs because the individual does not need the group’s approval and makes no effort to obtain it.

The most important role in a group is the leadership role. Leaders are appointed for most formal groups, such as command groups, teams, committees, or task forces. Leaders in informal groups tend to emerge over time and in relation to the task to be performed. Some of the factors contributing to the emergence of leadership in small groups include the ability to accomplish the group’s goals, sociability, good communication skills, self-confidence, and a desire for recognition. Guidelines for performing this leadership role are discussed later in this chapter.

Building Teams Team building focuses on both task and relationship aspects of a group’s functioning and is intended to increase efficiency and productivity. The group’s work and problem-solving proce- dures, member–member relations, and leadership are analyzed, and exercises are prescribed to help members modify their patterns of interaction or processes of decision making.

Assessment The most important initial activities in team building are data gathering and diagnosis. Questions must be asked about the group’s context (organizational structure, climate, culture, mission, and goals); characteristics of the group’s work, including group members’ roles, styles, procedures, job complexity; and the team, its problem-solving style, interpersonal relationships, and relations with other groups.

The following questions may be asked:

1. To what extent do the team’s members understand and accept the goals of the organization?

2. What, if any, hidden agendas interfere with the group’s performance? Hidden agendas are members’ individual unspoken objectives that interfere with commitment or enthusiasm.

3. How effective is the group’s leadership?

4. To what extent do group members understand and accept their roles?

5. How does the group make decisions?


6. How does the group handle conflict? Are conflicts dealt with through avoidance, forcing, accommodating, compromising, competing, or collaborating?

7. What personal feelings do members have about each other?

8. To what extent do members trust and respect each other?

9. What is the relationship between the team and other units in the organization?

Only after assessing and diagnosing problems can the leader take actions to improve team functioning (Hill, 2010).

Team-Building Activities Team-building activities, originally designed to improve interpersonal workplace relation- ships, have expanded to include meeting goals and accomplishing tasks (Salas et al., 2008). A recent study found that female students in medicine and nursing were more open-minded about cooperating with other health professions than were male medical or nursing students (Wilhelmsson et al., 2011). This is positive news for those involved in team building with women, less so with male participants.

Training sessions for team-building can be effective in helping participants acquire skills, but the results are short-lived if the skills are not reinforced on the job. To effectively maintain the team performance, learned behaviors should be measured and rewarded (Salas et al., 2008).

Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is a program developed by the Department of Defense and the Agency for Healthcare Research and Quality (AHRQ) to integrate teamwork into practice (Henriksen et al., 2008; King et al., 2008). TeamSTEPPS involves three phases:

● Assessing the need ● Training onsite ● Implementing and sustaining training

McKeon, Cunningham, and Detty Oswaks (2009) tested TeamSTEPPS in a health care set- ting and found that these safety-oriented skills can be taught and that nurses can learn to practice and evaluate high-reliability behaviors in practice.

Simulation-based training can also be used for team building (Rosen et al., 2008). Partic- ipants act out a simulated incident, receive feedback on their performance, and repeat the performance incorporating the learned behaviors. The program, LegacyMD (mentioned in Chapter 9) is an example (see Web resources for the URL). Rosen and colleagues (2008) found quality measures improved after simulation training.

Thoughtful team-building strategies allow group members to acknowledge the developmen- tal process and respond to it in constructive ways. Team-building activities may also be used to facilitate the normal stages of group development (forming, storming, norming, performing, and adjourning or re-forming), an important process in managing teams.

In traditional work groups experiencing problems, team-building strategies may help improve performance. Numerous techniques and commercial resources are available.

A nurse manager may decide to assume personal responsibility for team building when the team is basically functional and simply needs some fine-tuning to deal more effectively with minor interpersonal issues or changing circumstances.

Managing Teams Managing teams differs from team building and depends on the task, group size and composition, productivity and cohesiveness, the group’s development and growth, and the extent of shared governance in the organization.


Task The size of the group can influence its effectiveness, depending on the type of task: additive, disjunctive, divisible, or conjunctive (Steiner, 1972, 1976). The more people who work on an additive task (group performance depends on the sum of individual performance), the more inputs are available to produce a favorable result. For example, the game tug-of-war involves the combined effort of the team.

For a disjunctive task (the group succeeds if one member succeeds), the greater the number of people, the higher the probability that one group member will solve the problem. Consider the Olympics. The more athletes on one team, the greater the opportunity for a gold medal. Regard- less of the event, a medalist from the United States team brings recognition to the country, and every citizen is able to share the honor.

With a divisible task (tasks that can break down into subtasks with division of labor), more people provide a greater opportunity for specialization and interdependence in performing the tasks. For instance, the construction of a car is a complex task. From design of the car to inser- tion of the last bolt, each individual involved has a specialized task. With a conjunctive task (the group succeeds only if all members succeed), more people increase the likelihood that one person can slow up the group’s performance (e.g., a jury trial).

On many tasks, interdependence is important. There are three kinds:

● Pooled interdependence, in which each individual contributes but no one contribution is dependent on any other (e.g., a committee discussion)

● Sequential interdependence, in which group members must coordinate their activities with others in some designated order (e.g., an assembly line)

● Reciprocal interdependence, in which members must coordinate their activities with every other individual in the group (e.g., team nursing)

Group Size and Composition Groups with 5 to 10 members tend to be optimal for most complex organizational tasks, which require diversity in knowledge, skills, and attitudes and allow full participation. In larger groups, members tend to contribute less of their individual potential while the leader is called on to take more corrective action, do more role clarification, manage more disruption, and make recogni- tion more explicit. Groups tend to perform better with competent individuals as members. How- ever, coordination of effort and proper utilization of abilities and task strategies must occur as well. Homogeneous groups tend to function more harmoniously, whereas heterogeneous groups may experience considerable conflict.

Productivity and Cohesiveness Productivity represents how well the work group or team uses the resources available to achieve its goals and produce its services. If patient care is satisfactorily completed at the end of each shift in relation to the levels of staffing, supplies, equipment, and support services used, the group has been productive. Productivity is influenced by work-group dynamics, especially a group’s cohesiveness and collaboration.

Cohesiveness is the degree to which the members are attracted to the group and how much they are willing to contribute. Cohesiveness is also related to homogeneity of interests, values, attitudes, and background factors. Strong group cohesiveness leads to a feeling of “we” as more important than “I” and ensures a higher degree of cooperation and interpersonal support among group members.

Group norms may support or subvert organizational objectives, depending on the level of group cohesiveness. High group cohesiveness may foster high or low individual performance, depending on the prevailing group norms for performance. When cohesiveness is low, productiv- ity may vary significantly. Although groups, in general, tend toward lower productivity, nursing


education and practice have especially high standards of performance that help to counter this tendency.

Groups are more likely to become cohesive when members:

● Share similar values and beliefs ● Are motivated by the same goals and tasks ● Must interact to achieve their goals and tasks ● Work in proximity to each other (on the same unit and on the same shift, for example) ● Have specific needs that can be satisfied by involvement in the group

Group cohesiveness is also influenced by the formal reward system. Groups tend to be more cohesive when group members receive comparable treatment and pay and perform similar tasks that require interaction among the members. Similarities in values, education, social class, gen- der, age, and ethnicity that lead to similar attitudes strengthen group cohesiveness.

Cohesiveness can produce intense social pressure. Highly cohesive groups can demand and enforce adherence to norms regardless of their practicality or effectiveness. In this circumstance, the nurse manager may have a difficult time influencing individual nurses, especially if the group norms deviate from the manager’s values or expectations. For example, operating room nurses may be used to arriving at the time their shift starts and then changing into scrubs. The nurse manager, in contrast, may expect the staff to be changed and ready for work by the time the shift starts. In addition, group dynamics can affect absenteeism and turnover. Groups with high levels of cohesiveness exhibit lower turnover and absenteeism than groups with low levels of cohesiveness.

For most individuals, the work group provides one of the most important social contacts in life; the experience of working on an effective work team contributes significantly to one’s pro- fessional confidence and to the quality of work life and job satisfaction. The work group often provides the primary motivation for returning to the job day after day even when employees are dissatisfied with the employing organization or other working conditions.

Work groups not only perform tasks but also provide the context in which novices learn basic skills and become socialized and experts engage in clinical mentorship, standard setting, quality improvement, and innovation. Work-group relations influence the satisfaction of staff with their jobs, the overall quality of work life, and the quality of the environment for patient care. Managers play key roles in guiding the tasks of work groups and ensuring efficient and effective performance; managers also encourage relationships among members of work teams that will promote coordination and cooperation.

Development and Growth Groups can also provide learning opportunities by increasing individual skills or abilities. The group may facilitate socialization of new employees into the organization by “showing them the ropes.” The nurse manager must establish an atmosphere that encourages learning new skills and knowledge, creating a group-oriented learning environment by continuously encouraging group members to improve their technical and interpersonal skills and knowledge through training and development. Group cohesiveness and effectiveness improve as staff members take responsibil- ity for teaching each other and jointly seeking new information or techniques.

Shared Governance Shared decision making is a hallmark of shared governance. That is, both managers and staff members participate in making decisions. Such participation can improve collaboration, staff retention, job satisfaction, productivity, and patient outcomes. Measuring the distribution of con- trol, influence, power, and authority, Hess (2011) found that managers perceived staff to have more power in making decisions than staff perceived that they did. Workload issues offered op- portunities for shared decision making in another study (MacPhee, Wardrop, & Campbell, 2010).


As a requirement for Magnet certification, shared governance increases staff involvement in the organization’s functioning and future planning and, at the same time, increases staff allegiance to the organization.

The Nurse Manager as Team Leader Because staff nurses work in close proximity and frequently depend on each other to perform their work, the nurse manager’s leadership is vital. A positive climate is one in which there is mutual high regard and in which group members safely may discuss work-related concerns, critique and offer suggestions about clinical practice, and comfortably experiment with new behaviors. Maintaining a positive work group climate and building a team is a complex and demanding leadership task.

Communication Communication is a central component of the nurse manager’s leadership. The Joint Commis- sion, the organization that accredits hospitals, found that poor interprofessional communication was the cause of nearly 70 percent of unexpected events causing death or serious injury (Joint Commission, 2011).

Effective nurse managers can facilitate communication in groups by maintaining an atmo- sphere in which group members feel free to discuss concerns, make suggestions, critique ideas, and show respect and trust. An important leadership function related to communication is gatekeeping, that is, keeping communication channels open, refocusing attention on critical issues, identifying and processing conflict, fostering self-esteem, checking for understanding, actively seeking the participation of all group members, and suggesting procedures for discussing group problems.

The manager’s communication style also affects group cohesiveness. If the manager main- tains a high degree of information power and controls not only what information is received but also who receives it, group performance may suffer. By interrupting, changing the subject, monopolizing the conversation, or ignoring the feedback, problems escalate and the leader re- mains uninformed and both individuals in the group and the group’s ability to function suffer.

If, on the other hand, the manager shares information freely, encourages a high degree of mutual communication and participative problem solving, performance and job satisfaction improves. In participative groups, each individual has the opportunity, and is encouraged, to seek and share information and to communicate frequently with anyone and everyone in the group. Managers and staff alike check with each other to ensure that information is clear, to offer suggestions, and to provide feedback.

Handling conflict (Chapter 12) and change management (Chapter 5) are essential manage- ment skills as well (MacPhee & Bouthillette, 2008).

Evaluating Team Performance The manager may be accustomed to evaluating individual performance, but evaluating how well a team performs requires different assessments. Patient outcomes and team functioning are the criteria by which teams can be evaluated (Rosen et al., 2008). Outcome data, such as clinical pathway information, variances in critical paths, complication rates, falls, and medication errors, can help evaluate team performance.

Group functioning can be assessed by the level of work-group cohesion, involvement in the job, and willingness to help each other. Conversely aggression, competition, hostility, aloofness, shaming, or blaming are characteristics of poorly functioning groups. Stability of members is an additional measure of group functioning.

Influencing team processes toward the attainment of organizational objectives is the direct responsibility of the nurse manager. By publicizing team accomplishments, creating opportuni- ties for team members to demonstrate new skills, and supporting social activities, the manager


can increase the perceived value of group membership. Members of groups who have a history of success are attracted to each other more than those who have not been successful.

See how one nurse handled his new assignment as manager for an interprofessional team in Case Study 11-1.

Leading Committees and Task Forces Committees are generally permanent and deal with recurring problems. Membership on com- mittees is usually determined by organizational position and role. Formal committees are part of the organization and have authority as well as a specific role. Informal committees are pri- marily for discussion and have no delegated authority. Task forces are ad hoc committees ap- pointed for a specific purpose and a limited time. Task forces work on problems or projects that cannot be readily handled by the organization through its normal activities and structures. Task forces often deal with problems crossing departmental boundaries. They tend to generate recom- mendations and then disband.

Nurses are often selected for leadership roles on committees and task forces. In these leader- ship roles and as unit managers and team leaders, they conduct numerous meetings. The follow- ing section provides guidance for leading and conducting meetings.

INTRODUCING MULTIDISCIPLINARY TEAMS Bruce Shapiro was promoted six months ago to nurse manager for the stroke rehabilitation unit of a nationally owned rehabilitation hospital. Patient care delivery sys- tems have been under intensive review at the corporate level, and major changes in staffing are underway. Previ- ously, physical and occupational therapists were staffed out of a separate department and reported to the direc- tor of physical therapy. Now all therapists will be unit based and report to the nurse manager. Documentation will now be team centered instead of being split among nursing, therapists, and other care providers.

Janice Simpson has been a physical therapist for 25 years and has been at the rehab hospital for the past 6 years. She worked as a shift leader for physical therapy until the new unit-based staffing was implemented. Janice has been assigned to the stroke rehab unit and will report to Bruce. She feels uncomfortable in her new role and is concerned about how she will fit in with the established nursing staff. Janice is also concerned that with the new documentation system, the physical therapy patient evaluations will not be included in determining patient goals.

Bruce is eager for Janice to join the staff of the stroke rehabilitation unit. He schedules individual meetings with Janice and the three other therapists who will be assigned to his unit. Bruce outlines the roles and expec- tations of staff on the unit and listens attentively to their questions and concerns. He also reviews the physical and occupational therapy job descriptions and reviews their respective documentation standards. At the monthly

staff meeting, Bruce discusses the roles and responsibili- ties of the therapists with the nursing staff. A mentor is assigned to meet daily with each therapist for their first two weeks on the unit.

Manager’s Checklist The nurse manager is responsible for:

● Understanding the new staffing policies and the impact on the unit

● Gaining knowledge related to physical and occupational therapy practice

● Easing the transition of new staff into the existing staff group and helping build trust and respect

● Educating all staff on the new staffing policies ● Ensuring that all therapists and nurses attend

mandatory documentation training and audit patient records for compliance with new documentation standards

● Communicating with human resources if there are any questions regarding performance evaluation, scheduling, or compensation

● Reviewing the personnel files of new staff ● Establishing roles for the therapists in the unit

governance structure ● Facilitating open communication with therapists

and nurses to discuss concerns or suggestions ● Providing appropriate feedback to nursing

management related to the new staffing changes



Guidelines for Conducting Meetings Although meetings are vital to the conduct of organizational work, they should be held princi- pally for problem solving, decision making, and enhancing working relationships. Other uses of meetings, such as socializing, giving or clarifying information, or soliciting suggestions must be thoroughly justified. Meetings should be conducted efficiently and should result in relevant and meaningful outcomes. Meetings should not result in damaged interpersonal relations, frustration, or inconclusiveness.

Preparation The first key to a successful meeting is thorough preparation. Preparation includes clearly defining the purpose of the meeting. The leader should prepare an agenda, determine who should attend, make assignments, distribute relevant material, arrange for recording of minutes, and select an appropriate time and place for the meeting. The agenda should be distributed well ahead of time, 7 to 10 days prior to the meeting, and it should include what topics will be cov- ered, who will be responsible for each topic, what prework should be done, what outcomes are expected in relation to each topic, and how much time will be allotted for each topic.

Sometimes a “meeting before the meeting” is advisable (Sullivan, 2013). This is especially important if you are going into a meeting where you expect dissension. It may involve simply chatting with a few key people to identify any problems or issues they expect, or you may need to actually sit down with a key decision maker who has veto power. Also asking people you expect might have opposing points of view their opinion might be helpful as well.

Participation In general, the meeting should include the fewest number of stakeholders who can actively and effectively participate in decision making, who have the skills and knowledge necessary to deal with the agenda, and who adequately can represent the interests of those who will be affected by decisions made. Too few or too many participants may limit the effectiveness of a committee or task force.

Place and Time Meetings should be held in places where interruptions can be controlled and at a time when there is a natural time limit to the meeting, such as late in the morning or afternoon, when lunch or dinner make natural time barriers. Meetings should be limited to 50 to 90 minutes, except when members are dealing with complex, detailed issues in a one-time session. Meetings that exceed 90 minutes should be planned to include breaks at least every hour. Meetings should start and finish on time. Starting late positively reinforces latecomers, while penalizing those who arrive on time or early. If sanctions for late arrival are indicated, they should be applied respect- fully and objectively. If it is the leader who is late, the cost of starting meetings late should be reiterated and an appropriate designee should begin the meeting on time.

Member Behaviors The behavior of each member may be positive, negative, or neutral in relation to the group’s goals. Members may contribute very little, or they may use the group to meet personal needs. Some members may assume most of the responsibility for the group action, thereby enabling less participative members to avoid contributing.

Group members should:

● Be prepared for the meeting, having read pertinent materials ahead of time ● Ask for clarification as needed ● Offer suggestions and ideas as appropriate ● Encourage others to contribute their ideas and opinions ● Offer constructive criticism as appropriate


● Help the discussion stay on track ● Assist with implementation as agreed

These behaviors facilitate group performance. All attendees should be familiar with behaviors that they may employ to facilitate well-managed meetings. All meeting participants must be helped to understand that they share responsibility for successful meetings.

A leader can increase meeting effectiveness greatly by not permitting one individual to dominate the discussion; separating idea generation from evaluation; encouraging members to refine and develop the ideas of others (a key to the success of brainstorming); recording problems, ideas, and solutions on a white board or flip chart; checking for understanding; peri- odically summarizing information and the group’s progress; encouraging further discussion; and bringing disagreements out into the open and facilitating their reconciliation. The leader is also responsible for drawing out the members’ hidden agendas (personal goals or needs). Revealing hidden agendas ensures that these agendas either contribute positively to group performance or are neutralized. Guidelines for leading group meetings are provided in Box 11-1.

Managing Task Forces There are a few critical differences between task forces and formal committees. For example, members of a task force have less time to build relationships with each other, and, because task forces are temporary, there may be no desire for long-term positive relationships. Formation of a task force may suggest that the organization’s usual problem-solving mechanisms have failed. This perception may lead to tensions among task force members and between the task force and other units in the organization. The various members of a task force usually come from different parts of the organization and, therefore, have different values, goals, and viewpoints. The leader will need to take specific action to efficiently familiarize task force members with each other and create bonds in relation to the task.

Preparing for the First Meeting Prior to the task force’s first meeting, the leader must clarify the objectives in specific measur- able outcomes, determine its membership, set a task completion date, plan how often and to whom the task force should report while working on the project, and ascertain the group’s scope of authority, including its budget, availability of relevant information, and decision-making power. The task force leader should communicate directly and regularly with the administrator

BOX 11-1 Guidelines for Leading Group Meetings

● Begin and end on time. ● Create a warm, accepting, and nonthreatening

climate. ● Arrange seating to minimize differences in power,

maximize involvement, and allow visualization of all meeting activities. (A U-shape is optimal.)

● Use interesting and varied visuals and other aids. ● Clarify all terms and concepts. Avoid jargon. ● Foster cooperation in the group. ● Establish goals and key objectives. ● Keep the group focused. ● Focus the discussion on one topic at a time.

● Facilitate thoughtful problem solving. ● Allocate time for all problem-solving steps. ● Promote involvement. ● Facilitate integration of material and ideas. ● Encourage exploration of implications of ideas. ● Facilitate evaluation of the quality of the

discussion. ● Elicit the expression of dissenting opinions. ● Summarize discussion. ● Finalize the plan of action for implementing

decisions. ● Arrange for follow-up.


or governing body that commissioned the task force’s work so that ongoing clarification of its charge and progress can be tracked and adjusted.

Task force members should be selected on the basis of their knowledge, skills, personal con- cern for the task, time availability, and organizational credibility. They should also be selected on the basis of their interpersonal skills. Those who relish group activities and can facilitate the group’s efforts are especially good members. The group leader should also plan to include one or two individuals who potentially may oppose task force recommendations in order to solicit their input, involve them in the decision-making process, and win their support. By holding personal conversations with task force members before the first meeting, the group leader can explore individual expectations, concerns, and potential contributions. It also provides the leader with an opportunity to identify potential needs and conflicts and to build confidence and trust.

Conducting the First Meeting The goal of the first meeting is to come to a common understanding of the group’s task and to define the group’s working procedures and relationships. Task forces must rely on the general norms of the organization to function. The task force leader should legitimize the representative nature of participation on the task force and encourage members to discuss the task force’s process with the other members of the organization.

During the first meeting, a standard of total participation should be well established. The leader should remain as neutral as possible and should prevent premature decision making. Working procedures and relationships among the various members, subgroups, and the rest of the organization need to be established. The frequency and nature of full task force meetings and the number of subgroups must be determined. Ground rules for communicating must be estab- lished, along with norms for decision making and conflict resolution.

Managing Subsequent Meetings and Subgroups In running a task force, especially when several subgroups are formed, the leader should hold full task force meetings often enough to keep all members informed of the group’s progress. Unless a task force is small, subgroups are essential. The leader must not be aligned too closely with one position or subgroup. A work plan should be developed that includes realistic interim project deadlines. The task force and subgroups should be held to these deadlines. The leader plays a key role in coaching subgroups and the task force to meet its deadlines.

The leader must also be sensitive to the conflicting loyalties sometimes created by belong- ing to a task force. One of the leader’s most important roles is to communicate information to both task force members and the rest of the organization in a timely and regular fashion. The leader should solicit feedback from other key organizational representatives during the course of the task force’s work.

Completing the Task Force’s Report In bringing a project to completion, the task force should prepare a written report for the com- missioning administrators that summarizes the findings and recommendations. Drafts of this report should be shared with the full task force prior to presentation. To identify any overlooked or sensitive information and reduce defensive reactions, it is especially important that the task force leader personally brief key administrators prior to presenting the report. This gives admin- istrators a chance to read and respond to the report before making recommendations. The leader should consider involving a few task force members in the administrative presentation.

Patient Care Conferences Patient-related conferences are held to address the needs of individual patients or patient popula- tions. The purpose of the conference determines the composition of the group. Patient-focused meetings are usually interprofessional and used for case management to discuss specific patient


care problems. For example, an interprofessional team may form to discuss the failure of a reha- bilitation regimen to help a home care patient and to develop new plans for intervention.

Often nurses are also involved in activities associated with improving the quality of care for various patient groups and their families. For example, a nurse manager might organize meetings with primary care physicians and other managers to discuss how to improve discharge planning, to explore strategies to reduce the length of inpatient stays, or to improve coordination with out- patient clinics.

The team leader of a patient care conference often may not be a manager with line respon- sibility to supervise, evaluate, or hire employees. Frequently in patient rounds, the nurse is the person who can lead the conversation because the nurse has spent the most amount of time with the patient. The team leader is, however, a coach, teacher, and facilitator. Thus, the team leader needs to have excellent leadership skills. The task of a team leader varies according to the task and the skill level of the team members.

Nurses may be members of teams as well as leaders. Understanding how groups and teams function (or do not) is essential to contribute to the organization, be successful in your position, and to garner satisfaction from your work.

What You Know Now • A group is an aggregate of individuals who interact and mutually influence each other. • Groups may be classified as real or task, formal or informal, permanent or temporary. • A team is a group of individuals with complementary skills, a common purpose and performance goals,

and a set of methods for which they hold themselves accountable. • Assessment of problems should precede team-building activities. • Team-building now includes a focus on meeting goals and accomplishing tasks as well as improving

interpersonal relationships. • Team-building activities are more likely to be successful if skills are reinforced on the job. • Managing teams depends on the task, group size and composition, productivity and cohesiveness,

development and growth, and the extent of shared governance in the organization. • The nurse manager’s communication skills affect the team’s productivity and performance. • Managing meetings involves preparing thoroughly, facilitating participation, and completing the

group’s work.

Tools for Building and Managing Teams 1. Notice how groups around you function. Use the best ideas with your own groups. 2. Watch effective leaders. Identify skills you could incorporate into your own leadership repertoire. 3. Recognize that you can develop good team leadership skills. Practice those discussed in the chapter. 4. At the next opportunity be prepared to follow the directions for leading meetings. 5. Make a development plan to enhance your leadership skills.

Questions to Challenge You 1. Identify the groups that include you in your work or school. How are they different? Similar?

Explain. 2. Describe an example of effective group leadership and an example of poor leadership. 3. Evaluate your own leadership performance. How could you improve? 4. Have you been involved in team building at work or school? Was it effective? Explain. 5. What roles do you usually play in a group meeting (or class)? What role would you like to play?

Describe it.



Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

Henriksen, K., Battles, J. B., Keyes, M. A., & Grady, M. L. (Eds.), (2008). Advances in patient safety: New directions and alternative approaches (Vol. 3: Performance and tools). Rockville, MD: Agency for Healthcare Research and Quality.

Hess, R. G. (2011). Slicing and dicing shared governance. Nursing Administration Quarterly, 35(3), 235–241.

Hill, K. S. (2010). Building leadership teams. Journal of Nursing Administration, 40(3), 1031–1035.

Homans, G. (1950). The human group. New York: Harcourt.

Homans, G. (1961). Social behavior: Its elementary forms. New York: Harcourt.

Joint Commission on Ac- creditation of Healthcare Organizations. (2011). Root causes for sentinel events. Retrieved July 8, 2011 from http://www. jointcommission.org/ Sentinel_Event_Statistics/

King, H. B., Battles, J., Baker, D. P., Alonso, A., Salas, E., Webster, J., Toomey, L., & Salisbury, M. (2008). TeamSTEPPS: Team strate- gies and tools to enhance performance and patient

safety. Retrieved December 12, 2011 from http://www. ahrq.gov/downloads/pub/ advances2/vol3/Advances- King_1.pdf

MacPhee, M., & Bouthillette, F. (2008). Developing leader- ship in nurse managers: The British Columbia Nursing Leadership Insti- tute. The Canadian Journal of Nursing Leadership, 21(3), 64–75.

MacPhee, M., Wardrop, A., & Campbell, C. (2010). Transforming work place relationships through shared decision making. Journal of Nursing Management, 18(8), 1016–1126.

McKeon, L. M., Cunningham, P. D., & Detty Oswaks, J. S. (2009). Improving pat- ent safety: Patient-focused, high-reliability team train- ing. Journal of Nursing Care Quality, 24(1), 76–82.

Rosen, M. A., Salas, E., Wilson, K. A., King, H. B., Salisbury, M., Augenstein, J. S., Robinson, D. W., & Birnbach, D. J. (2008). Measuring team perfor- mance in simulation-based training: Adopting best practices for healthcare. Simulation in Healthcare, 3(1), 33–41.

Salas, E., DiazGranados, D., Weaver, S. J., & King, H. (2008). Does team training work? Principles for health care. Academic Emergency Medicine, 15(11), 1002–1009.

Steiner, I. D. (1972). Group process and productivity. New York: Academic Press.

Steiner, I. D. (1976). Task- performing groups. In J. W. Thibaut, J. T. Spence, & R. C. Carson (Eds.), Con- temporary topics in social psychology (pp. 94–108). Morristown, NJ: General Learning Press.

Sullivan, E. J. (2013). Becom- ing influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall.

Thompson, J. D. (1967). Organizations in action. New York: McGraw-Hill.

Wilhelmsson, M., Ponzer, S., Dahlgren, L. O., Timpka, T., & Faresjö, T. (2011). Are female students in gen- eral and nursing students more ready for teamwork and interprofessional col- laboration in healthcare? BMC Medical Education. Retrieved July 8, 2011 from http://www.biomedcentral. com/1472-6920/11/15

Web Resources TeamSTEPPS: http://teamstepps.ahrq.gov/ Legacy MD: http://legacymd.com



Handling Conflict

Key Terms Accommodating Avoiding Collaboration Competing Competitive conflict Compromise Conflict Confrontation


Interprofessional Conflict










1. Describe why conflict can be positive or negative.

2. Discuss how conflict can help generate change.

3. Describe the components of conflict.

4. Identify different approaches that can be used to manage conflict.

5. Explain how to manage conflict.

Learning Outcomes After completing this chapter, you will be able to:


Consensus Disruptive conflict Felt conflict Forcing Integrative decision making Lose–lose strategy Mediation Negotiation

Perceived conflict Resistance Resolution Smoothing Suppression Win–lose strategy Win–win strategy Withdrawal


Conflict Conflict is a natural, inevitable condition in organizations, and a manager’s communication frequently centers on conflict. It is often a prerequisite to change in people and organizations.

Conflict is defined as the consequence of real or perceived differences in mutually exclu- sive goals, values, ideas, attitudes, beliefs, feelings, or actions (a) within one individual (intra- personal conflict), (b) between two or more individuals (interpersonal conflict), (c) within one group (intragroup conflict), or (d) between two or more groups (intergroup conflict). Conflict is dynamic. It can be positive or negative, healthy or dysfunctional.

A certain amount of conflict is beneficial to an organization. It can provide heightened sen- sitivity to an issue, further piquing the interest and curiosity of others. Conflict can also increase creativity by acting as a stimulus for developing new ideas or identifying methods for solving problems. Disagreements can help all parties become more aware of the trade-offs, especially costs versus benefits, of a particular service or technique.

Conflict also helps people recognize legitimate differences within the organization or pro- fession and serves as a powerful motivator to improve performance and effectiveness as well as satisfaction. For example, during intergroup conflict, individual groups become more cohesive and task oriented, whereas communication between groups diminishes.

Competition occurs when two or more groups attempt the same goals and only one group can attain those goals. Filley (1975) defines competitive conflict as a victory for one side and a loss for the other side. The process by which the conflict is resolved is determined by a set of rules. The goals of each side are mutually incompatible, but the emphasis is on winning, not the defeat or reduction of the opponent. When one side has clearly won, competition is terminated.

Disruptive conflict, in contrast, does not follow any mutually acceptable set of rules and does not emphasize winning. The parties involved are engaged in activities to reduce, defeat, or eliminate the opponent. This type of conflict takes place in an environment charged with fear, anger, and stress.

Interprofessional Conflict Working in high-stress jobs, nurses often have conflicts with other health care professionals, ad- ministrators, or coworkers. A common example is conflict in the interprofessional team is feel- ing like each other’s time isn’t respected. To do multidisciplinary rounds, the doctor might want to meet at 1 p.m., the nurse at 1:30 p.m., the social worker at 10 a.m., etc. A time that works with the work flow of each job is important so that conflict doesn’t arise over a person feeling that he or she isn’t valued or respected.

Conflicts between physicians and nurses, however, dominate problems reported by both professions (Leever et al., 2010). For example, the physician may want to send the patient home today, while the nurse knows the patient is struggling to understand ordered medications. In addition, the physical therapist tells the nurse that the patient needs another day of practicing exercises before she can be safely discharged.

The nurse manager can teach staff how to handle interprofessional conversations to advo- cate for the patient, explaining the following:

● Use facts to support your point ● Speak from the vantage point of the patient ● Explain what will best help the patient ● Do not inject what you personally want

Interprofessional conflict is expected to escalate as the most effective and least expen- sive care is promoted (Webb, 2010). For example, nurse practitioners (NPs) already handle a considerable amount of routine care (e.g., minor injuries, sinusitis, sports exams) because of accessibility (often in retail clinics) and because of cost. Physicians and NPs may have


conflicts over which profession should provide and—more importantly, be reimbursed— for this care.

How nurses handle conflict has been studied. The relationship between the nurse’s person- ality type and how the person handles conflict was reported by Whitworth (2008). Using the Thomas Kilmann Mode Instrument (Thomas & Kilmann, 1974) the researcher found no statisti- cal correlation between the two constructs. Whitworth suggested, however, that the environment may have more influence than personality factors.

Using the same instrument, Morrison (2008) examined nurses’ emotional intelligence com- petencies and how nurses handle conflict. Emotional intelligence (Goleman, 2006) measures self-awareness, self-management, social awareness, and relationship management. In the nurses studied, higher emotional intelligence scores in all four measures correlated with collaborating, but negatively with accommodating.

Outcomes and conflict have also been studied. One study compared how groups managed conflict with their performance and satisfaction (Behfar et al., 2008). Researchers found that three conflict resolution styles more often led to positive performance and job satisfaction out- comes: focusing on content of the conflict rather than the delivery; explicitly discussing rea- sons for work assignments; and making assignments based on expertise rather than volunteering, default, or convenience. Cole, Bedeian, and Bruch (2011) found that transformational leader behavior and team performance was indirect, leading them to conclude that team empowerment improved performance.

Conflict Process Model Several authors have proposed models for examining conflict (Pondy, 1967; Filley, 1975; Thomas, 1976). All follow a generalized format for examining conflict. These models provide a framework that helps explain how and why conflict occurs and, ultimately, how one can mini- mize conflict or resolve it with the least amount of negative aftermath.

Conflict and its resolution develop according to a specific process (see Figure 12-1). This process begins with certain preexisting conditions (antecedent conditions). The parties are in- fluenced by their feelings or perceptions about the situation (perceived or felt conflict), which initiates behavior, and conflict is exhibited. The conflict is either resolved or suppressed, and the outcome results in new attitudes and feelings between the parties.

Antecedent conditions

Conflict behavior

Conflict resolved or suppressed


Felt conflictPerceived conflict

Figure 12-1 • The conflict process.


Antecedent Conditions Antecedent conditions are associated with increases in conflict. Antecedent conditions propel a situation toward conflict; they may or may not be the cause. In nursing, antecedent conditions include incompatible goals, differences in values and beliefs, task interdependencies (especially asymmetric dependencies, in which one party is dependent on the other but not vice versa), unclear or ambiguous roles, competition for scarce resources, differentiation or distancing mechanisms, and unifying mechanisms.

Incompatible Goals The most important antecedent condition to conflict is incompatible goals. As discussed in Chapter 2, goals are desired results toward which behavior is directed. Even though the com- mon goal in health care organizations is to give quality patient care in a cost-effective manner, conflict in achieving these goals is inevitable because individuals often view this from different perspectives.

The dichotomy between health care providers and third-party payers is an example. Health care providers want to maximize the quality of care, whereas payers are concerned with mini- mizing costs.

A health care organization may have specific goals to achieve the best possible care for patients and control costs to stay within budget and, at the same time, to provide intrinsically satisfying jobs for its employees. These multiple goals will frequently conflict with each other, so they will have to be prioritized. Priority setting can be one of the most difficult but important activities a health care manager must face. Goals are important because they become the basis for allocating resources and thus become an important source (antecedent) of conflict in the organization.

Similarly, individuals themselves have multiple goals, and those goals may also conflict. Individuals allocate scarce resources, such as their time, on the basis of priority and, therefore, might achieve one goal at the expense of others. The inability to attain multiple (and mutually incompatible) goals—whether those goals are personal or organizational—can cause conflict.

Role Conflicts Roles are defined as other people’s expectations regarding behavior and attitudes. Roles become unclear when one or more parties have related responsibilities that are ambiguous or overlapping. A manager might experience conflict between his or her responsibilities as an administrator and responsibilities as a staff member. Similarly, unclear or overlapping job descriptions or assign- ments may lead to conflict. For example, there could be conflict over such mundane issues as who has responsibility to deliver a patient to the radiology department—the nurse or the transport staff?

Task interdependence is another potential source of conflict. Nursing and housekeeping, for example, are interdependent. Housekeeping cannot completely clean a room until nursing has discharged the patient. Other examples of interdependence are the relationships among shifts and those between physicians and nurses. Interdependent relationships have the potential to ini- tiate conflict.

Structural Conflict One conflict commonly seen in the health care environment is structural conflict. Structured relationships (manager to staff, peer to peer) provoke conflict because of poor communication, competition for resources, opposing interests, or a lack of shared perceptions or attitudes. The nurse manager following up on a patient complaint with corrective counseling or coaching with a staff nurse is an example of structural conflict. The staff member may dispute the complaint and become defensive. In this situation, the manager may impose positional power. Positional power is the authority inherent in a certain position—for example, the nurse administrator has greater positional power than a nurse manager.


Competition for Resources Competition for scarce resources can be internal (among different units in the organization) or external (among different organizations). Internally, competition for resources may involve assigning staff from one unit to another or purchasing high-technology equipment when another unit is desperate for staff.

Externally, health care organizations compete for finite external resources (e.g., desig- nation as an accountable care organization for Medicare). Organizations are using a variety of means, such as developing new services and advertising, to try to capture the market in health care.

Values and Beliefs Differences in values and beliefs frequently contribute to conflict in health care organizations. Values and beliefs result from the individual’s socialization experience. Conflicts between phy- sicians and nurses, between nurses and administrators, or even between nurses with associate degrees versus those with baccalaureate degrees, often occur because of differences in values, beliefs, and experiences.

Distancing mechanisms or differentiation serve to divide a group’s members into small, distinct groups, thus increasing the chance for conflict. This tends to lead to a “we–they” distinction. One of the more frequently seen examples is distancing between physicians and nurses. Opposition between intensive care nurses and nurses on medical floors, night versus day shifts, and unlicensed versus licensed personnel are also examples. Differentiation among subunits also occurs and is due to differences in structure. The administrative unit may be bu- reaucratic, the nursing unit structured on a more professional basis, and staff physicians on an even different structure. Nonstaff physicians may be relatively independent of the health care organization.

Unifying mechanisms occur when greater intimacy develops or when unity is sought. All nurses might be expected to reach consensus over an issue, but they might experience internal conflict if they are forced to accept a group position even though individually they may not be wholly committed to the decision. A nurse manager’s friendship with a staff member may also lead to this type of conflict.

Perceived and Felt Conflict Perceived and felt conflict account for the conflict that may occur when the parties involved view situations or issues from differing perspectives, when they misunderstand each other’s position, or when positions are based on limited knowledge. Perceived conflict refers to each party’s per- ception of the other’s position. Felt conflict refers to the negative feelings between two or more parties. It is characterized by mistrust, hostility, and fear.

To demonstrate how this process works, consider this situation. A nurse manager and a surgeon have worked together for years. They have mutual respect for each other’s ability and skills, and they communicate frequently. When their subordinates clash, they are left with con- flicting accounts of a situation, in which the only agreed-upon fact is that a patient received less- than-appropriate care. Now consider the same scenario if the nurse and doctor have never dealt with each other or if one feels that the other will not approach the problem constructively.

In the first situation (perceived conflict), their positive regard for each other’s abilities makes the nurse and physician believe they can constructively solve the conflict. The nurse does not feel the physician will try to dominate, and the physician respects the nurse manager’s lead- ership ability. With these preexisting attitudes, the physician and nurse can remain neutral while helping their subordinates solve the conflict.

If the nurse and physician were experiencing felt conflict, on the other hand, they might ap- proach the situation differently. Each might assume the other will defend her or his subordinates at all costs and communication will be inhibited. The conflict is resolved by domination of the stronger person, either in personality or position. One wins; the other loses.


Conflict Behaviors Conflict behavior results from the parties’ perceived or felt conflict. Behaviors may be overt or covert. Overt behavior may take the form of aggression, competition, debate, or problem solv- ing. Covert behavior may be expressed by a variety of indirect tactics, such as scapegoating, avoidance, or apathy.

Conflict Resolved or Suppressed In the next stage of the process conflict is resolved or suppressed. Resolution occurs when a mu- tually agreed-upon solution is arrived at and both parties commit themselves to carrying out the agreement. Suppression occurs when one person or group defeats the other. Only the dominant side is committed to the agreement, and the loser may or may not carry out the agreement.

Outcomes The outcome affects how conflict will be addressed by the parties in the future. The optimal solution is to manage the issues in a way that will lead to a solution wherein both parties see themselves as winners and the problem is solved. This leaves a positive aftermath that will affect future relations and influence feelings and attitudes. In the example of conflict between the nurse manager and the physician, consider the difference in the aftermath and how future issues would be approached if both parties felt positive about the outcome, as compared to future interactions if one or both parties felt they had lost.

Managing Conflict Managing conflict is an important part of the nurse manager’s job. Managers are often involved in conflict management on several different levels. They may be participants in the conflict as individuals, administrators, or representatives of a unit. In fact, they must often initiate conflict by confronting staff, individually or collectively, when a problem develops. They may also serve as mediators or judges to conflicting parties. There could be a conflict within the unit, between parties from different units, or between internal and external parties (for example, a university nursing instructor may have a conflict with staff on a particular unit).

Everyone must be realistic regarding the outcome. Often those inexperienced in conflict ne- gotiation expect unrealistic outcomes. When two or more parties hold mutually exclusive ideas, attitudes, feelings, or goals, it is extremely difficult, without the commitment and willingness of all concerned, to arrive at an agreeable solution that meets the needs of both. Battles between Democrats and Republicans in Congress are an example.

Conflict management begins with a decision regarding if and when to intervene. Failure to intervene can allow the conflict to get out of hand, whereas early intervention may be detri- mental to those involved, causing them to lose confidence in themselves and reduce risk-taking behavior in the future.

Some conflicts are so minor, particularly if they are between only two people, that they do not require intervention and would be better handled by the two people involved. Allowing them to resolve their conflict might provide a developmental experience and improve their abilities to resolve conflict in the future.

Sometimes it is best to postpone intervention purposely to allow the conflict to escalate, because increased intensity can motivate participants to seek resolution. You could escalate the conflict even further by exposing participants to each other more frequently without the presence of others and without an easy means of escape. Participants are then forced to face the conflict between them.

Giving participants a shared task or shared goals not directly related to the conflict may help them understand each other better and increase their chances to resolve their conflicts by themselves. Using such a method is useful only if the conflict is not of high intensity, if the


participants are not highly anxious about it, and if the manager believes that the conflict will not decrease the efficiency of the unit in the meantime. When the conflict might result in consider- able harm, however, the nurse manager must intervene.

If you decide to intervene in a conflict between two or more parties, you can apply me- diation techniques, deciding when, where, and how the intervention should take place. Routine problems can be handled in either party’s office, but serious confrontations should take place in a neutral location unless the parties involved are of unequal power. In this case, the setting should favor the disadvantaged participant, thereby equalizing their power.

The place should be one where distractions will not interfere and adequate time is available. Because conflict management takes time, the manager must be prepared to allow sufficient time for all parties to explain their points of view and arrive at a mutually agreeable solution. A quick solution that inexperienced managers often resort to is to impose positional power and make a premature decision. This results in a win–lose outcome, which leads to feelings of elation and eventual complacency for the winners, and loss of morale for the losers.

The following are basic rules on how to mediate a conflict between two or more parties:

1. Protect each party’s self-respect. Deal with a conflict of issues, not personalities.

2. Do not put blame or responsibility for the problem on the participants. The participants are responsible for developing a solution to the problem.

3. Allow open and complete discussion of the problem from each participant.

4. Maintain equity in the frequency and duration of each party’s presentation. A person of higher status tends to speak more frequently and longer than a person of lower status. If this occurs, the mediator should intervene and ask the person of lower status for response and opinion.

5. Encourage full expression of positive and negative feelings in an accepting atmosphere. The novice mediator tends to discourage expressions of disagreement.

6. Make sure both parties listen actively to each other’s words. One way to do this is to ask one person to summarize the other person’s comments before stating her or his own.

7. Identify key themes in the discussion and restate them at frequent intervals.

8. Encourage the parties to provide frequent feedback to each other’s comments; each must truly understand the other’s position.

9. Help the participants develop alternative solutions, select a mutually agreeable one, and develop a plan to carry it out. All parties must agree to the solution for successful resolu- tion to occur.

10. At an agreed-upon interval, follow up on the progress of the plan.

11. Give positive feedback to participants regarding their cooperation in solving the conflict.

Conflict management is a difficult process, consuming both time and energy. Management and staff must be concerned and committed to resolving conflict by being willing to listen to others’ positions and to find agreeable solutions.

Conflict Responses Confrontation is considered the most effective means for resolving conflicts. This is a problem- oriented technique in which the conflict is brought out into the open and attempts are made to resolve it through knowledge and reason. The goal of this technique is to achieve win–win solutions. Facts should be used to identify the problem. The desired outcome should be ex- plicit. “This is the third time this week that you have not been here for report. According to


hospital policy, you are expected to be changed, scrubbed, and ready for report in the lounge at 7:00 a.m.” is an example.

Confrontation is most effective when delivered in private as soon as possible after the inci- dent occurs. Employee respect and manager credibility are two important considerations when a situation warrants confrontation. A more immediate confrontation also helps both the employee and manager sort out pertinent facts. In an emotionally charged situation, however, it may be best for the parties to wait. Regardless of timing, the message is usually more effective if the manager listens and is empathetic.

Negotiation involves give-and-take on various issues among the parties. Its purpose is to achieve agreement even though consensus will never be reached. Therefore, the best solution is not often achieved. Negotiation often becomes a structured, formal procedure, as in collec- tive bargaining (see Chapter 24). However, negotiation skills are important in arriving at an agreeable solution between any two parties. Staff learn to negotiate schedules, advanced prac- tice nurses negotiate with third-party payers for reimbursement, insurance companies negotiate with vendors and hospitals for discounts, and clinic managers negotiate employment contracts with physicians. Although negotiation involves adept communication skills, its usefulness re- volves around issues of conflict. Without differences in opinion, there would be no need for negotiation.

Collaboration implies mutual attention to the problem, in which the talents of all parties are used. In collaboration, the focus is on solving the problem, not defeating the opponent. The goal is to satisfy both parties’ concerns. Collaboration is useful in situations in which the goals of both parties are too important to be compromised.

Compromise is used to divide the rewards between both parties. Neither gets what she or he wants. Compromise can serve as a backup to resolve conflict when collaboration is ineffective. It is sometimes the only choice when opponents of equal power are in conflict over two or more mutually exclusive goals. Compromising is also expedient when a solution is needed rapidly.

Competing is an all-out effort to win, regardless of the cost. Competing may be needed in situations involving unpopular or critical decisions. Competing is also used in situations in which time does not allow for more cooperative techniques.

Accommodating is an unassertive, cooperative tactic used when individuals neglect their own concerns in favor of others’ concerns. Accommodating frequently is used to preserve har- mony when one person has a vested interest in an issue that is unimportant to the other party. You may recall that Morrison (2008) found that nurses with higher emotional intelligence scores seldom used accommodating as a conflict response.

In situations where conflict is discouraged, suppression is often used. Suppression could even include the elimination of one of the conflicting parties through transfer or termination. Other, less effective techniques for managing conflict include withdrawing, smoothing, and forc- ing, although each mode of response is useful in given situations.

In avoiding, the participants never acknowledge that a conflict exists. Avoidance is the con- flict resolution technique often used in highly cohesive groups. The group avoids disagreement because its members do not want to do anything that may interfere with the good feelings they have for each other.

Withdrawal from the conflict simply removes at least one party, thereby making it impos- sible to resolve the situation. The issue remains unresolved, and feelings about the issue may resurface inappropriately. If the conflict escalates into a dangerous situation, avoiding and with- drawing are appropriate strategies.

Smoothing is accomplished by complimenting one’s opponent, downplaying differences, and focusing on minor areas of agreement, as though little disagreement existed. Smoothing may be appropriate in dealing with minor problems, but in response to major problems, it pro- duces the same results as withdrawing.

Forcing is a method that yields an immediate end to the conflict but leaves the cause of the conflict unresolved. A superior can resort to issuing orders, but the subordinate will lack


commitment to the demanded action. Forcing may be appropriate in life-or-death situations but is otherwise inappropriate.

Resistance can be positive or negative. It may mean a resistance to change or disobedience, or it may be an effective approach to handling power differences, especially verbal abuse.

Filley’s Strategies Filley (1975) identified three basic strategies for dealing with conflict according to the outcome: win–lose, lose–lose, and win–win. In the win–lose strategy, one party exerts dominance, usu- ally by power of authority, and the other party submits and loses. Forcing, competing, and nego- tiating are techniques likely to lead to win–lose competition.

Majority rule is another example of the win–lose outcome, especially within groups. It may be a satisfactory method of resolving conflict, however, if various factions vote differently on different issues and the group functions over time so that members win some and lose some. Win–lose outcomes often occur between groups. Frequent losing, however, can lead to the loss of cohesiveness within groups and diminish the authority of the group leader.

In the lose–lose strategy, neither side wins. The settlement reached is unsatisfactory to both sides. Avoiding, withdrawing, smoothing, and compromising may lead to lose–lose outcomes. One compromising strategy is to use a bribe to influence another’s cooperation in doing some- thing he or she dislikes. For example, the nurse manager may promise a future raise in an at- tempt to coerce a staff member to work an extra weekend.

Using a third party as arbitrator can also lead to a lose–lose outcome. Because an outsider may want to give something to each side, neither gets exactly what he or she desires, resulting in a lose–lose outcome. This is a common strategy in arbitration of labor-management disputes. Another strategy that may result in a lose–lose or win–lose outcome is resorting to rules. The outcome is determined by whatever the rules say, and confrontation is avoided.

The win–lose and lose–lose methods share some common characteristics:

1. The conflict is person-centered (we–they) rather than problem-centered. This is likely to occur when two cohesive groups that do not share common values or goals are in conflict.

2. Parties direct their energy toward total victory for themselves and total defeat for the other. This can cause long-term problems for the organization.

3. Each side sees the issue from her or his own point of view rather than as a problem in need of a solution.

4. The emphasis is on outcomes rather than definition of goals, values, or objectives.

5. Conflicts are personalized.

6. Conflict-resolving activities are not differentiated from other group processes.

7. There is a short-run view of the conflict; the goal is to settle the immediate problem rather than resolve differences.

The win–win strategy focuses on goals and attempt to meet the needs of both parties. Two specific win–win strategies are consensus and integrative decision making. Consensus involves attention to the facts and to the position of the other parties and avoidance of trading, voting, or averaging, where everyone loses something. The consensus decision is often superior to even the best individual one. This technique is most useful in a group setting because it is sensitive to the negative characteristics of win–lose and lose–lose outcomes. True consensus occurs when the problem is fully explored, the needs and goals of the involved parties are understood, and a solution that meets these needs is agreed upon.

Integrative decision making focuses on the means of solving a problem rather than the ends. This strategy is most useful when the needs of the parties are polarized. Integrative deci- sion making is a constructive process in which the parties jointly identify the problem and their needs. They explore a number of alternative solutions and come to consensus on a solution. The


focus of this group activity is to solve the problem, not to force, dominate, suppress, or com- promise. The group works toward a common goal in an atmosphere that encourages the free exchange of ideas and feelings. Using integrative decision-making methods, the parties jointly identify the value needs of each, conduct an exhaustive search for alternatives that could meet the needs of each, and then select the best alternative. Like the consensus methods, integrative decision making focuses on defeating the problem, not each other.

Alternative Dispute Strategies Conflicts that have the potential to lead to legal action are often negotiated using alternative dispute resolution (ADR) (Sander, 2009). Mediation is a form of ADR that involves a third- party mediator to help settle disputes. Mediation agreements can satisfy all parties, cost less and take less time than legal remedies, and lead to improved interprofessional relationships (Gardner, 2010). Mediation has been used successfully in settling disputes in long-term care facilities (Rosenblatt, 2008).

ADR efforts have resulted in the creation of the International Institute of Conflict Prevention and Resolution, expanded state and federal legislation encouraging mediation, a dispute resolu- tion division in the American Bar Association, and development of ADR courses in law schools. The use of ADR in public policy promises to increase in the coming years (Susskind, 2009).

See how one nurse manager handled a conflict between two members of her staff in Case Study 12-1.

CONFLICT MANAGEMENT Mai Tran is the nurse manager of a 20-bed medical- surgical unit in a large university hospital. Her nursing staff is diverse in experience and educational back- ground. Working in a teaching hospital, Mai believes that nurses should be open to new methods and work processes, with an emphasis on evidence-based practice.

Ken Robertson, RN, has worked for two years on the unit and is in his final semester of a master’s program fo- cusing on geriatric care. Eileen Holcomb, RN, has worked on the same unit for the past 28 years and was a gradu- ate of the hospital’s former diploma program. Ken re- cently completed a clinical rotation in dermatology and has worked with the skin care team at the hospital to develop new protocols for preventing skin breakdown. During a recent staff meeting, Ken presents the new protocols to the staff. Eileen makes several comments during the presentation that simply getting patients out of bed and making sure they have adequate nutrition is easier and less time-consuming than the new proto- col. “All these new protocols are just a way to justify all those credentials behind a name,” Eileen says, gathering a chorus of chuckles from some of the older nurses on the staff. Ken frowns at Eileen and responds, “As nurses become educated, we need to reflect a professional practice.” Mai notices that several staff members are un- comfortable as the meeting ends.

Ken and Eileen continue to exchange sarcastic com- ments and glares over the next two shifts they work together. The obvious disagreement is affecting their coworkers, and gossiping is decreasing productivity on

the unit. Mai schedules individual meetings with Ken and Eileen to discuss their perspective. After reviewing the situation and determining that the issue is simply one of personality conflict, Mai brings Ken and Eileen to- gether for a meeting in her office. Mai reviews the facts of the situation with them and shares her opinion that both have acted inappropriately. She states that their actions have affected not only their work, but that of the unit as a whole. She informs Ken and Eileen that they must act in a professional and respectful manner with each other or disciplinary action will be taken. She encourages them to work out any future problems in a cooperative manner and not to bring personal conflicts into the work environment.

Manager’s Checklist The nurse manager is responsible for:

● Understanding how to manage conflict among staff members in a timely manner

● Understanding generational perceptions and how they impact group dynamics

● Understanding when disciplinary action is necessary ● Informing the human resource department of a po-

tential personnel problem and the proposed solution ● Meeting with staff to help them resolve conflict ● Determining whether all staff should be educated on

respect in the workplace ● Documenting interventions and outcomes as




Managing conflict is an essential skill for the manager and, indeed, all nurses. Avoiding unnecessary conflict or allowing conflict to fester and remain unresolved undermines the manag- er’s effectiveness and can result in dissatisfied staff and turnover. Resolving conflict, on the other hand, can lead to better outcomes both with the immediate situation and encourage the manager to resolve conflict in the future.

More strategies for handling conflict can be found in Chapter 10, “Dealing with Difficult People and Situations,” in Becoming Influential: A Guide for Nurses (Sullivan, 2013).

What You Know Now • Conflict is a dynamic process and the consequence of real or perceived differences between individuals

or groups. • Conflict can be positive and the first step in initiating change, or it may be negative and disruptive. • Antecedent conditions that cause conflict include incompatible goals, role conflicts, structural conflict,

competition for scarce resources, and differences in values and beliefs. • A number of strategies exist to handle conflict; choosing the best one to use is based on the situation and

the people involved. • Learning to manage conflict is a requirement for all nurses and managers.

Tools for Handling Conflict 1. Evaluate conflict situations to decide if and when to intervene. 2. Understand the antecedent conditions for the conflict and the positions of those involved. 3. Enlist others to help solve conflicts. 4. Select a conflict management strategy appropriate to the situation. 5. Practice the conflict management strategies discussed in the chapter and evaluate the outcomes.

Questions to Challenge You 1. How are conflicts handled at work or school? Are leaders good conflict managers? Give an example

to explain your answer. 2. Briefly describe a conflict in which you were involved. How did you handle yourself? How did the

others involved? Did it turn out well? Explain. 3. What do you find to be the most difficult part of handling conflicts? Understanding others’ positions?

Devising a successful solution? Enlisting others’ help? Encouraging participants to agree to a solution? 4. Study the chapter for help in improving your areas of weakness. Evaluate your performance.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!


References Behfar, K. J., Peterson, R. S.,

Mannix, E. A., & Trochim, W. M. K. (2008). The critical role of conflict resolution in teams: A close look at the links between conflict type, conflict man- agement strategies, and team outcomes. Journal of Applied Psychology, 93(1), 170–188.

Cole, M. S., Bedeian, A. G., & Bruch, H. (2011). Linking leader behavior and lead- ership consensus to team performance: Integrating direct consensus and disper- sion models of group com- position. The Leadership Quarterly, 22(2), 383–398.

Filley, A. C. (1975). Inter- personal conflict resolu- tion. Glenview, IL: Scott, Foresman.

Gardner, D. (2010). Expanding scope of practice: Inter- professional collaboration or conflict? Nursing Eco- nomics, 28(4), 264–266.

Goleman, D. (2006). Emotional intelligence: Why it can matter more than IQ. New York: Bantam.

Leever, A. M., Hulst, M. V. D., Berendsen, A. J., Boende- maker, P. M., & Rooden- burg, J. L. N. (2010). Conflicts and conflict management in the collabo- ration between nurses and physicians: A qualitative study. Journal of Inter- professional Care, 24(6), 612–624.

Morrison, J. (2008). The rela- tionship between emotional intelligence competencies and preferred conflict- handling styles. Journal of Nursing Management, 16(8), 974–983.

Pondy, L. R. (1967). Organiza- tional conflict: Concepts and models. Administra- tive Science Quarterly, 12, 296–320.

Rosenblatt, C. L. (2008). Using mediation to manage con- flict in care facilities. Nurs- ing Management, 39(2), 16, 17.

Sander, F. E. A. (2009). Ways of handling conflict: What we have learned, what problems remain. Nego- tiation Journal, 25(4), 533–537.

Sullivan, E. J. (2013). Becom- ing influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall.

Susskind, L. (2009). Twenty-five years ago and twenty-five years from now: The future of public dispute resolution. Negotiation Journal, 25(4), 549–556.

Susskind, L. (2010). Mediating values-based and identity- based disputes. The con- sensus building approach. Retrieved July 12, 2011 from http://theconsensus- buildingapproach.blogspot. com/2010/04/mediating- values-based-and-identity. html

The Joint Commission. (2008, July 9). Behaviors that undermine a culture of safety. Retrieved October 15, 2010 from http://www. jointcommission.org/ SentinelEvents/Sentinel- EventAlert/sea_40.htm

Thomas, K. W. (1976). Conflict and conflict management. In M. D. Dunnette (Ed.), The handbook of industrial and organizational psy- chology. Chicago: Rand McNally.

Thomas, K. W., & Kilmann, R. H. (1974). Thomas- Kilmann Conflict Mode Instrument. Tuxedo, NY: Xicom.

Webb, R. (2010). Healthcare reform and inevitable con- flict: Smaller pie means smaller slices. Healthcare Neutral ADR Blog, Re- trieved July 12, 2011 from http://www.healthcareneu- traladrblog.com/2010/02/ articles/ commercial- healthcare-disputes/ healthcare-reform-and- inevitable-conflict-smaller- pie-means-smaller-slices

Whitworth, B. S. (2008). Is there a relationship between per- sonality type and preferred conflict-handling styles? An exploratory study of registered nurses in south- ern Mississippi. Journal of Nursing Management, 16(8), 921–932.

13 Managing Time CHAPTER











Controlling Time in Meetings

Respecting Time

Goal setting Interruption log

Job enlargement Time logs

Time waster To-do list

1. Identify time wasters. 2. Identify goals. 3. Set priorities. 4. Group activities and minimize

routine work.

5. Manage personal organization and self discipline.

6. Minimize time wasters.

Learning Outcomes After completing this chapter, you will be able to:

Key Terms


T ime management is a misnomer. No one manages time: What is managed is how time is used. In today’s downsized health care organization, the pressure to do more in less time has increased. Job enlargement occurs when a flatter organizational structure causes positions to be combined and results in managers having more employees to supervise, a situation common today.

The managerial skills needed today are different from those in the past, according to a study by Gentry and colleagues (Gentry et al., 2008). Changes from the late 1980s until now include flatter organizational structures that result in more responsibilities shared throughout the orga- nization and a greater use of electronic communications. Technology has changed how manag- ers and staff interact. Geographic location is less important, as is time away from work. Being always connected can be both a time-saver and a time-stealer. Nonetheless, instant communica- tion is here to stay.

Teams often do what managers formerly dictated, with the best decisions coming out of the team’s cooperative efforts. Time management is equally important in teamwork as it is for indi- viduals. Teams must plan and organize their work to meet deadlines. Efficiency is paramount.

Time can be used proactively or reactively (Carrick, Carrick, & Yurkow, 2007). If you focus your energy on people and events over which you have some direct or indirect control, you are using a proactive approach. If, on the other hand, you spend most of your time on what concerns you most about other people and events, your efforts are less apt to be effective. For example, you can set and follow your goals and priorities or you can spend your time worrying, blaming, or making excuses about what you do not accomplish. This chapter is designed to help you be proactive in targeting your use of time.

Time Wasters Why do we waste time? It is one of our most valuable resources, and yet everyone admits to wasting it. Box 13-1 answers this question by showing some of the constraints on an individual’s ability to manage time effectively. These patterns of behavior must be understood and dealt with to be effective in managing time.

Why We Fail to Manage Time Effectively

● We do what we like to do before we do what we don’t like to do.

● We do things we know how to do faster than things we do not know how to do.

● We do things that are easiest before things that are difficult.

● We do things that require a little time before things that require a lot of time.

● We do things for which resources are available.

● We do things that are scheduled (for example, meetings) before nonscheduled things.

● We sometimes do things that are planned before things that are unplanned.

● We respond to demands from others before demands from ourselves.

● We do things that are urgent before things that are important.

● We readily respond to crises and emergencies. ● We do interesting things before uninteresting things. ● We do things that advance our personal objectives

or that are politically expedient. ● We wait until a deadline approaches before we

really get moving. ● We do things that provide the most immediate

closure. ● We respond on the basis of who wants it. ● We respond on the basis of the consequences of

our doing or not doing something. ● We tackle small jobs before large jobs. ● We work on things in the order of their arrival. ● We work on the basis of the squeaky-wheel prin-

ciple (the squeaky wheel gets the grease). ● We work on the basis of consequences to the


BOX 13-1


In addition to these patterns of behavior, certain time wasters prevent us from effectively managing time. A time waster prevents a person from accomplishing the job or achieving the goal. Common time wasters include:

1. Interruptions, such as phone calls, text messages, and drop-in visitors

2. Meetings, both scheduled and unscheduled

3. Lack of clear-cut goals, objectives, and priorities

4. Lack of daily and/or weekly plans

5. Lack of personal organization and self-discipline

6. Lack of knowledge about how one spends one’s time

7. Failure to delegate or working on routine tasks

8. Ineffective communication

9. Waiting for others and thus not using transition time effectively

10. Inability to say no

An experienced manager is often called on to help another new manager who requests help. It is always appropriate to mentor, teach, and guide others, but when you realize you are doing the person’s work and your work is not getting done or is late, your time is wasted.

Time Analysis The first step is to analyze how time is being used. The second is to determine whether time use is appropriate to your role. You may find much of your time is taken up doing “busywork” rather than activities that contribute to a particular outcome. Job redesign places emphasis on ensuring that time is spent wisely and that the right individual is correctly assigned the responsibility for tasks.

Time logs, as shown in Box 13-2, are useful in analyzing the actual time spent on various activities. Select a typical week and keep a log of activities in 15 to 60 minute increments. Keep it simple. List columns for the time period and the activity. Review your log for what activities are essential and what can be delegated or eliminated. Alternatively, you can use a planner or ap- pointment calendar in place of a separate log.

Time Activity Purpose Value

7:00–7:30 Review e-mails received overnight; list work to accomplish during shift

To respond to people who have e-mailed and to plan what work must be done

Sets the plan for the day so as much work can be accom- plished as possible

7:30–8:30 Be available for any night shift staff who need to talk with manager before leaving

Manager is accountable to all staff that work on unit. During this time, manager can have face-to-face interaction with night shift staff and follow up on any issues that present

Provides time for night shift staff to see and talk to manager and develop relationships and strong lines of communication

8:30–10:00 Budget planning meeting Meet with VP of patient care and other managers to work on planning next fiscal year budget

Manager has input into the budget that he/she will work to meet during next fiscal year

BOX 13-2 Time Analysis Log


The Manager’s Time A significant difficulty in moving from a staff nurse position to a leadership position is the need to develop different time-management and organizational skills. In a staff nurse role, the regis- tered nurse has little, if any, free or uncommitted time. No planning is required, because every minute is taken. In contrast, when nurses move to a leadership position, they are responsible for defining how time will be spent. Learning to focus on setting goals, determining priorities, and evaluating time use is an important part of the analysis.

Setting Goals Nurses are accustomed to setting both long- and short-range goals, although typically such goals are stated in terms of what patients will accomplish rather than what the nurse will achieve. A critical component of time management is establishing one’s own goals and time frames.

Goals are specific statements of outcomes that are to be achieved. They provide direc- tion and vision for actions as well as a timeline in which activities will be accomplished. Defining goals and time frames helps reduce stress by preventing the panic people often feel when confronted with multiple demands. Although time frames may not be as fast as the nurse manager would like (the tendency is to expect change yesterday), necessary actions have been identified.

Individual or organizational goals encourage thinking about the future and what might hap- pen, what one wants to happen, and what is likely to happen (Sullivan, 2013). Goal setting helps relate current behavior, activities, or operations to the organization’s or individual’s long-range goals. Without this future orientation, activities may not lead to the outcomes that will help achieve the goals and meet the ideals of the individual or organization. The focus should be to develop measurable, realistic, and achievable goals.

It is useful to think of individual or personal goals in categories, such as:

● Department or unit ● Interpersonal (at work) ● Professional ● Financial ● Family and friends (outside of work) ● Vacation and travel ● Physical ● Lifestyle ● Community ● Spiritual

This partial listing is a guide to stimulate thinking about goals. Think about long-term goals, lifetime goals, and short-term goals. These should be divided into job-related goals and personal goals. Job-related goals may revolve around unit or departmental changes, whereas personal goals may include personal life and community involvement.

Short-term goals should be set for the next 6 to 12 months, but need to be related to long- term goals. To manage time effectively, answer five major questions about these goals:

1. What specific objectives are to be achieved?

2. What specific activities are necessary to achieve these objectives?

3. How much time is required for each activity?

4. Which activities can be planned and scheduled for concurrent action, and which must be planned and scheduled sequentially?

5. Which activities can be delegated to staff?


Delegating tasks to others can be an efficient time-management tool. Delegation is the pro- cess by which responsibility and authority are transferred to another individual. It involves as- signing tasks, determining expected results, and granting authority to the individual expected to accomplish these tasks. Delegation is perhaps the most difficult leadership skill for a nurse or a manager to acquire. Today, when more assistive personnel are being used to carry out the nurse’s work and when the manager’s span of control has expanded, appropriate delegation skills are essential for success. Chapter 10 discusses delegation in detail.

Determining Priorities To establish priorities, take into consideration both short- and long-term goals. Categorize them as:

● What you must do ● What you should do if possible ● What you could do if you have time to spare (Jones & Loftus, 2009)

Next determine the importance and urgency of each activity as shown in Table 13-1. Activities can be identified as:

● Urgent and important ● Important but not urgent ● Urgent but not important ● Busywork ● Wasted time

Activities that are both urgent and important must be completed. Activities that are impor- tant but not urgent may make the difference between career progression and maintaining the status quo. Urgent but not important activities must be completed immediately but are not con- sidered important or significant. Busywork and wasted time are self-explanatory.

Additionally, others’ emergencies or crisis can intrude on your priorities. Again, determine if these are truly urgent and important or if the person is overreacting to an immediate situation.

Daily Planning and Scheduling Once goals and priorities have been established, you can concentrate on scheduling activities. Prepare a to-do list each day, either after work hours the previous day or early before work on the same day. The list is typically planned by workday or workweek. If you have a combination of many responsibilities, a weekly to-do list may be more effective. Flexibility must be a major consideration in this plan; some time should remain uncommitted to allow you to deal with

TABLE 13-1 Importance–Urgency Chart

Category of Time Use Examples

Important and urgent Replacing two call-offs and ensuring sufficient staffing for the upcoming shift.

Important, not urgent Drafting an educational program for nurses on the changes in Medicare reimbursement.

Urgent, not important Completing and submitting the “beds available” list for a disaster drill.

Busywork Compiling new charts for future patient admissions.

Wasted time Sitting by the phone waiting for return calls.


emergencies and crises that are sure to happen. The focus is not on activities and events, but rather on the outcomes that can be achieved in the time available.

A system to keep track of regularly scheduled meetings (staff meetings), regular events (annual or quarterly report due dates), and appointments is also necessary. This system should be used when establishing the to-do list; it should include both a calendar and files.

The calendar might include information on the purpose of the meeting, who will be attending, and the time and place. Several commercial planning systems are available, including software for computers or smart phones. Any such system includes a daily, weekly, or monthly calendar; a to-do section; a memo or note section; and an address book with phone numbers. Separate files for projects, committees, or reports should be kept arranged by date.

Grouping Activities and Minimizing Routine Work Work items that are similar in nature and require similar environmental surroundings and resources should be grouped within divisions of the work shift. Set aside blocks of uninterrupted time for the really important tasks, such as preparing the budget.

Group routine tasks, especially those that are not important or urgent, during your least pro- ductive time. For example, list what you can do in five minutes, such as scan your e-mail, check text messages, confirm a meeting, or set up an appointment, or in ten minutes, such as return a phone call, scan a Website, or compose an e-mail. This helps you spend the small allotments of time productively.

Much time spent in transition or waiting can be turned into productive use. Commuting time can be used for self-development or planning work activities. We all have to wait sometimes: waiting for a meeting to start or to talk to someone are just two examples. Keep up with message boards on your phone’s mail system or bring along materials to read or work on in case you are kept waiting. View waiting or transition time as an opportunity, especially to think.

If you are having difficulty completing important tasks and are highly stressed, especially as the day winds down, doing routine tasks for a while often helps reduce stress. Pick a task that can be successfully completed and save it for the end of the day. Reaching closure on even a routine task at the end of the day can reduce your sense of overload and stress.

Implementing the daily plan and daily follow-up is essential to managing your time. You should also repeat your time analysis at least semiannually to see how well you are managing your time, whether the job or the environment has changed, and if changes in planning activities are required. This can help prevent reverting to poor time-management habits.

Personal Organization and Self-Discipline Some other time wasters are lack of personal organization and self-discipline, including the inabil- ity to say no, having to wait for others, and excessive or ineffective paperwork. Effective personal organization results from clearly defined priorities based on well-defined, measurable, and achiev- able objectives. Because the nurse manager does not work alone, priorities and objectives are often related to those of many professionals, as well as to objectives of patients and their families.

How time is used is often a matter of resolving conflicts among competing needs. It is easy to become overloaded with responsibilities and with more tasks to do than can be accomplished in the time available. This is typical. There is never enough time for all the activities, situations, and events in which one might like to become involved. (Review the section on priority setting.)

To be effective, nurses and nurse managers must be personally well organized and possess self-discipline. This often includes being able to say no. Taking on too much work can lead to overload and stress. Being realistic about the amount of work to which you commit is an indi- cation of effective time management. If a superior is overloading you, make sure that person understands the consequences of additional assignments. Be assertive in communicating your own needs to others.

An e-mail system without designated folders for automatic storage, a cluttered desk, work- ing on too many tasks at one time, and failing to set aside blocks of uninterrupted time to do


important tasks indicate a lack of personal self-discipline. Automate e-mails from specified senders, clear your desktop, and get out the materials you need to complete your highest-priority task and start working on it immediately. Focus on one task at a time, making sure to start with a high-priority one.

One manager who felt overwhelmed by all of her responsibilities used the strategies shown in Case Study 13-1 to help her solve her problems.

Controlling Interruptions An interruption occurs any time you must stop in the middle of one activity to give attention to something else. Interruptions can be an essential part of your job, or they can be a time waster. An interruption that is more important and urgent than the activity in which you are involved is a positive interruption: it deserves immediate attention. An emergency or crisis, for instance, may cause you to interrupt daily rounds.

Some interruptions interfere with achieving the job and are less important and urgent than current activities. Because the manager’s role has expanded to a broader span of responsibil- ity, more decision making is placed on teams and the staff. When a manager is interrupted to solve problems within the staff nurse’s scope of accountability, the manager should not become responsible for solving the problem. Gently but firmly directing the individual to search for so- lutions will begin to break old patterns of behavior and help develop individual responsibility. Although it is time-consuming in the beginning, this practice eventually reduces the number of unnecessary interruptions.

TIME MANAGEMENT For the past six years, Jane Schumann has been the manager of staff development for three hospitals in a Catholic health care system. After the health care sys- tem suffered record operating losses last fiscal year, many middle management positions were eliminated. Jane was retained, but had several other departments assigned to her. Now Jane is responsible for staff devel- opment, utilization review staff, in-house float pool, night nursing supervisors, agency staffing, coordination of student nurse clinical rotations, and training of all nursing staff for the new hospital information system at four different hospitals.

Jane has been overwhelmed with her new respon- sibilities. Wanting to establish trust and learn more about her staff, Jane has adopted an “open-door pol- icy” resulting in many drop-in visits each day. She has been working much longer hours and most weekends. She has frequently had to fill in for night supervisors, stretching her workday to 18 hours. Her desk is stacked with paperwork and her voice mailbox is full of mes- sages to be returned. On average, she returns 40 of the 60 e-mails received each day.

When Jane comes across information about a time- management seminar, she quickly signs up. At the seminar, Jane learns a number of strategies that she can use.

Back at work, she makes a plan. First, she makes a list of priorities for each of her departments and a time frame for completing each project. Then she completes daily plans for the next two weeks as well as a three-month plan for the upcoming quarter. Jane also determines who among her new staff members can assume additional responsibilities and notes which tasks can be delegated. She sorts through paperwork and establishes a filing sys- tem for each department. Jane decides that she will train her administrative assistant to file routine paperwork and route other paperwork to Jane or delegated person- nel. Jane also decides that at each departmental meeting, she will establish specific times that she will be available for drop-in visitors. She schedules a meeting with the se- nior nursing executive to discuss the staffing implications for training nurses at the four hospitals to use the new hospital information system. Finally, she takes advantage of an upcoming four-day weekend to catch up on some well-deserved rest.

Manager’s Checklist The nurse manager is responsible for:

● Prioritizing the workload ● Effectively delegating tasks and projects to others ● Respecting one’s own time and the time of others ● Asking for help when appropriate



Keeping an interruption log on an occasional basis may help. The log should show who interrupted, the nature of the interruption, when it occurred, how long it lasted, what topics were discussed, the importance of the topics, and time-saving actions to be taken. An example is shown in Box 13-3.

Analysis of these data may identify patterns for you to plan ways to reduce the frequency and duration of interruptions. They may also indicate that certain staff members are the most frequent interrupters and require individual attention to develop problem-solving skills.

Phone Calls, Voice Mail, Text Messages Phone calls are a major source of interruption, and the interruption log will provide considerable insight for the nurse manager regarding the nature of phone calls received. You will see how some people do not use the phone effectively. A ringing phone or beep from an incoming text is

BOX 13-3 Interruption Log

Name Purpose Time Topics Importance Actions

Joan, RN Stopped in manager’s office to talk

10 minutes Kids’ baseball games, husband’s new job

Not related to work activities, but helps build relationship with staff

Proactively plan time for occasional personal conversa- tions with staff to build relationships; plan to eat lunch in breakroom one day per week with staff to have informal conversations

Bill, janitor Ask manager if he/she has seen any furniture in hallways because a chair was missing from a patient room

5 minutes Patient’s room furniture was missing

Patient rooms need a chair so the pa- tient can get out of bed and have a place to sit. There is an issue with furniture that is sent for repair being misplaced when returned to the unit.

Ask the unit clerk to keep a log of all furniture sent off the unit for repair. When the furniture is returned, rather than putting it in the hall- way until someone says a chair is needed in a room, the unit clerk proactively finds out where the chair belongs and takes it to that location.

Jason, nurse aide

Tells the manager that he has tried four different machines, but no one machine can measure blood pressure, temperature, and oxygen saturation

15 minutes When equipment fails, manager works with employee to call bio med de- partment to get equipment in for repairs; four rental machines are brought to unit while oth- ers are being fixed

Staff need function- ing equipment to do their jobs efficiently

Partner with bio med department to have unit equipment checked once per week to ensure each component of the machines is function- ing properly


highly compelling; few people can allow it to go unanswered. All of us receive numerous phone calls and texts, and some of them time wasters. Handling them effectively is a must:

● Minimize socializing and small talk. If you answer the phone with, “Hello, what can I do for you?” rather than, “Hello, how are you?” the caller is encouraged to get to business first. Be warm, friendly, and courteous, but do not allow others to waste time with inappro- priate or extensive small talk. Calls placed and returned just prior to lunchtime, at the end of the day, and on Friday afternoons tend to result in more business and less socializing.

● Plan calls. The person who plans phone calls does not waste anyone’s time, including that of the person called. Write down the topics you want to discuss before you make the call. That way, you will not need to call back to give additional information or ask a forgotten question.

● Set a time for calls. You may have a number of calls to return and make. It is best to set aside a time for routine phone calls, especially during your “downtime.” Try not to inter- rupt what is being done at the moment. If an answer is necessary before a project can be continued, phone immediately; if not, phone for the information at a later time.

● State the reason for the call and ask for preferred call times. If a party is not available, explain why you are calling and provide several time frames when you will be available for a return call. Find out when the person you are calling is free. This makes it easier for him or her to be prepared for the call and helps prevent “phone tag.”

Voice mail is an excellent way to send and receive messages when a real-time interaction is not essential. For example, one person or a large group of people can learn about an upcoming meeting in one voice mail message. They can phone their responses at their convenience (with no need to reach each other directly). Like other forms of communication, voice mail must be used appropriately.

Long messages or sensitive information is better conveyed one-on-one. Moreover, another per- son (e.g., unit clerk) may be responsible for taking voice mail messages off the system, so it is im- portant to state the message in a professional manner, omitting personal or confidential information.

Text messages demand attention unless the phone is turned off. Even then, frequently glancing at the phone’s screen alerts you to the message. Few of us can resist checking “just this one” message. Text messages are a combination of voice messages and e-mail, so establish a time to return them.

E-Mail Incoming Messages E-mail can enhance time management or be a further time waster. E-mail minimizes the time you waste trying to contact individuals, enables you to contact many people simultaneously, and allows you to code the urgency of the message. Tone, however, is difficult to convey by e-mail. Therefore, it is better to use more personal forms of communication, such as the phone or in- person contact, for potentially sensitive or troublesome issues.

Checking e-mail too often can waste time. Each time you read a message, you are forced to think about it and you lose your focus on the task at hand. Turn off your e-mail alert and set specific times of day to check your in-box.

Also discourage people who forward you unwanted messages. Set your e-mail filter to di- rect these messages to your spam folder or tell the sender that you cannot receive personal mes- sages at work (Merritt, 2009).

Outgoing Messages Writing clear messages helps increase prompt and useful responses. Here are some tips:

● Direct messages only to the people involved (e.g., committee members) and copy others (e.g., the department chair).

● Title the subject line appropriately. For example, write “Meeting Friday morning” rather than “Information.”


● Avoid salutations, if possible. “Dear” and “Hi” are often not needed on routine messages. ● Craft your message succinctly, but politely: “The division meeting will be held in confer-

ence room C at 9 a.m.”

Drop-In Visitors Although often friendly and seemingly harmless, the typical “got-a-minute?” drop-in visit is rarely as short as that. Take charge of the visit by identifying the issue or question, arranging an alternative meeting, referring the visitor to someone else, or redirecting the visitor’s problem- solving efforts.

If you are fortunate enough to have an office, you will find that open doors are open invita- tions for interruption. Although it is essential that you be available and accessible, you also need time to concentrate. Tell staff that you will be available for a specific block of time (a few hours at most) to address issues.

Of course, some interruptions are important and/or urgent. You must attend to those. For others, however, you can control the duration of the drop-in visitor (Jones & Loftus, 2009). Stand and remain standing. This appears gracious, yet is obvious enough to encourage a short visit. Before the person leaves, politely suggest that he or she visit during your office hours or send an e-mail to make a future appointment.

You can also control interruptions through the way you arrange your office furniture. You are asking for interruptions when you arrange your desk in a way that permits eye contact with passersby or drop-in visitors. A desk turned 90 or even 180 degrees from the door minimizes potential eye contact.

Encouraging people to make appointments to deal with routine matters also reduces inter- ruptions. Regularly scheduled meetings with people who need to see you allow them to hold routine matters for those appointments. Meeting in someone else’s office places you in charge of the time spent: it is easier to leave someone’s office than to ask someone to leave yours.

Paperwork Health care organizations cannot function effectively without good information systems. In addition to phone calls and face-to-face conversations, nurses and managers spend consider- able time writing and reading communications. Increasing government regulations, measures to avoid legal action, stronger privacy requirements, new treatments and medications, data process- ing, work processing, and electronics place pressure on everyone to cope with increasing paper- work (including electronic “paperwork”).

1. Plan and schedule paperwork. Writing and reading reports, forms, e-mail, letters, and memos are essential elements of a job. They will, however, become a major source of frus- tration if their processing is not planned and scheduled as an integral part of daily activi- ties. Learn the organization’s information system and requirements, analyze the paperwork requirements of the position, and make significant progress on that part of the job daily.

2. Sort paperwork for effective processing. A system of file folders either for paper mail or e-mail can be very helpful. Here is a system to handle it:

• Place all paperwork (or e-mail) requiring personal action in a red file or in an “action” folder on your computer’s hard drive. Handle that according to its relative importance and urgency.

• Place work that can be delegated in a separate file, and distribute it appropriately. • Place all work that is informational and related to present work in a yellow file folder or

in an “informational” folder on your hard drive. • Place other reading material, such as professional journals, technical reports, and other

items that do not relate directly to the immediate work, in a blue file folder or a “read” file.


The informational file contains materials that must be read immediately, whereas the reading file materials are not as urgent and can be read later.

Do not be afraid to throw things away or erase them from your computer’s memory. Do not let them become clutter when they no longer have value. Use trash receptacles in the office and on the electronic system.

3. Send every communication electronically. Unless a paper memo, report, or letter is re- quired, send your work electronically.

4. Analyze paperwork frequently. Review filing policies and rules regularly and purge files at least once each year. All standard forms, reports, and memos should be reviewed annu- ally. Each should justify its continued existence and its present format. Do not be afraid to recommend changes and, when possible, initiate those changes.

5. Do not be a paper shuffler. “Handle a piece of paper only once” is a common adage, but impossible to follow if taken literally. Rather, each time you handle a piece of paper or e-mail message, take action to further process it. Paper shufflers are those who continually move things around on their desks or accumulate unread e-mails. They delay action unrea- sonably, and the problem mounts.

Controlling Time in Meetings Meetings consume much of the manager’s time, and much of that time is wasted. To manage meetings follow these rules (Merritt, 2009):

● Do not meet simply because you always meet on Monday morning. If no meeting is needed, cancel it.

● Invite only key people to initial meetings. Others can be sent the minutes or invited to fu- ture meetings.

● Establish the meeting’s goal and outcomes expected at the outset. ● Send information before the meeting so time is not spent reading it. ● Set a time limit for all meetings. Routine meetings should last no more than one hour. If

more time is needed, schedule another meeting. ● Determine the agenda and keep to the topic. ● Follow-up with actions assigned.

Respecting Time The key to using time-management techniques is to respect one’s own time as well as that of others. Using the above suggestions for time management communicates to those who interact with you that you expect them to respect your time. You, however, must reciprocate by respect- ing their time too. If you need to talk to someone, make an appointment, particularly for routine matters.

You should continually ask, “What is the best use of my time right now?” and should an- swer in three ways:

● For myself and my goals ● For my staff and their goals ● For the organization and its goals

Efforts to manage time may seem to take more time, but the reverse is true. Any activity that helps set goals, determine priorities, organize the workday, and minimize interruptions will pay off in increased efficiency and effectiveness.


What You Know Now • The first step in time management is to analyze how you use your time by keeping a time log. • Determine priorities and set goals to establish daily planning and scheduling. • Personal organization strategies help use time productively. • An interruption log helps identify patterns that can be used to reduce unnecessary interruptions. • Control phone calls by minimizing small talk, planning calls, setting aside time for calls, stating preferred

call times, and using voice mail. • To control interruptions by drop-in visitors, stand to meet visitors, encourage appointments, and arrange

furniture to discourage unscheduled visitors. • Written communication can also cause interruptions. These can be minimized by planning and scheduling

paperwork and e-mails and using an effective filing system. • People who respect their own time are likely to find others respecting it also.

Tools for Managing Time 1. Recognize that there will never be enough time to accomplish everything you want. 2. Use a time log to identify and reduce time wasters. 3. Use a planning system to list goals, their priorities, and schedule the workday. 4. Set aside uninterrupted time to complete important tasks. 5. Group routine tasks and use short blocks of time to complete them. 6. Monitor interruptions and decide on ways to minimize them.

Questions to Challenge You 1. What are your major time wasters? Keep a time log for one week. Compare how you thought you

wasted time with what your time log revealed. 2. Write down your goals for the next week. What action steps can you take to realize your goals? At

the end of the week, evaluate your progress. Then write down the next week’s goals. 3. What is keeping you from accomplishing your goals? Think about how you can change the circum-

stances to better reflect your priorities. 4. Do you use a planner or other scheduling device? If not, investigate the choices and select the one

that will work best for you. Then use it! 5. Think about how you handle interruptions. During the next week, try various strategies to minimize

the effect of interruptions.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

References Carrick, L., Carrick, L., &

Yurkow, J. (2007). A nurse leader’s guide to managing priorities. American Nurse Today, 2(7), 40–41.

Gentry, W. A., Harris, L. S., Baker, B. A., & Leslie, J. B. (2008). Managerial skills: What has changed since the

late 1980s. Leadership & Organization Development Journal, 29(2), 167–181.

Jones, L., & Loftus, P. (2009). Time well spent: Getting things done through effective time management. Philadel- phia, PA: Kogan Page.

Merritt, C. (2009). Too busy for your own good. New York: McGraw Hill.

Sullivan, E. J. (2013). Becom- ing influential: A guide for nurses (2nd ed.). Upper Sad- dle River, NJ: Prentice Hall.


14 Budgeting and Managing Fiscal Resources

The Budgeting Process

Approaches to Budgeting INCREMENTAL BUDGET



The Operating Budget THE REVENUE BUDGET


Determining the Salary (Personnel) Budget








Managing the Supply and Nonsalary Expense Budget

The Capital Budget

Timetable for the Budgeting Process

Monitoring Budgetary Performance During the Year



Problems Affecting Budgetary Performance



1. Describe how the budgeting process works. 2. Differentiate among types of budgets. 3. Demonstrate how to monitor and control

budgetary performance.

4. Explain how to determine budget variance. 5. Describe how staff affect budgetary


Learning Outcomes After completing this chapter, you will be able to:

Key Terms Benefit time Budget Budgeting Capital budget Cost center Direct costs Efficiency variance Expense budget Fiscal year

Fixed budget Fixed costs Incremental (line-by-line)

budget Indirect costs Nonsalary expenditure

variances Operating budget Position control

Profit Rate variances Revenue budget Salary (personnel) budget Variable budget Variable costs Variance Volume variances Zero-based budget


B udgeting is the process of planning and controlling future operations by comparingactual results with planned expectations (Finkler & Kovner, 2007). A budget is a detailed plan that communicates these expectations and serves as the basis for compar- ing them to actual results. The budget shows how resources will be acquired and used over some specific time interval; its purpose is to allow management to project activities into the future so that the objectives of the organization are coordinated and met. It also helps ensure that the resources necessary to achieve these objectives are available at the appropriate time. Lastly, a budget helps management control the organization.

Budgeting is performed by business, government, and individuals. In fact, nearly everyone budgets, even though he or she may not identify the process as such. Even if a budget exists only in an individual’s mind, it is nonetheless a budget. Anyone who has planned how to pay a particular bill at some time in the future—say, six months—has a budget. Although it is very simple, that plan accomplishes the essential budget functions. One now knows how much of a resource (money) is needed and when (in six months) it is needed. Note that the “when” is just as important as the “how much.” The money has to be available at the right time.

Demands for patient safety, reimbursement changes with health care reform, technological advances, and the changing roles of health care providers require that budgets be constructed as accurately as possible and variances be as low as possible (Dunham-Taylor & Pinczuk, 2009). This is no small task. Attention to the budgeting process is the first step in understanding how to use resources most effectively.

The Budgeting Process A budget is a quantitative statement, usually in monetary terms, of the plans and expectations of a defined area over a specified period of time. Budgets provide a foundation for managing and evaluating financial performance. Budgets detail how resources (money, time, people) will be acquired and used to support planned services within the defined time period.

The budget process also helps ensure that the resources needed to achieve these objectives are available at the appropriate time and that operations are carried out within the resources available. The budgeting process increases the awareness of costs and also helps employees understand the relationships among goals, expenses, and revenues. As a result, employees are committed to the goals and objectives of the organization, and various departments are able to coordinate activities and collaborate to achieve the organization’s objectives. Budgets also help management control the resources expended through an organizational awareness of costs. Finally, budget per- formance provides management with feedback about resources management and the impact on the budget.

Budgeting is a process of planning and controlling future operations by comparing actual results with planned expectations. Planning first involves reviewing established goals and objectives of both nursing and the organization. Goals and objectives help identify the organiza- tion’s priorities and direct the organization’s efforts. To plan, the organization must know the following:

● Demographics of the population served, community influences, and competitors ● Sources of revenue, especially with changes in reimbursement due to enactment of health

care reform ● Statistical data, including:

• Number of admissions or patient appointments • Average daily census • Average length of stay • Patient acuity • Projected occupancy or volume base for ambulatory or procedure-based units

or home care visits


● Wage increases of market adjustments ● Price increases, including inflation rate, for supplies and other costs ● Costs for new equipment or technologies (e.g., wound vacs, sequential compression

devices, monitoring equipment) ● Staff mix (e.g., RNs, LPNs, UAPs) ● Regulatory changes (e.g., legislation mandating nurse-to-patient ratios, state board of

health regulations) for the budgetary period ● Organizational changes (e.g., decentralization of pharmacy or respiratory therapy

services) that result in salary and benefit dollars being charged in portion to the unit

Management normally uses the past as the common starting point for projecting the future, but in today’s volatile payment environment, the past may be a poor predictor of the future. This is one of the major drawbacks of the budgeting process. In a rapidly changing industry, basing budgets on historical data often requires readjustment during the actual budget period.

Controlling is the process of comparing actual results with the results projected in the budget. (See the section on monitoring performance during the year later in the chapter.) Two techniques for controlling budgetary performance are variance analysis and position control. By measuring the differences between the projected and the actual results, management is better able to make modifications and corrections. Therefore, controlling depends on planning.

Approaches to Budgeting Budgets may be developed in various formats depending on how the organization is structured. They may be considered as:

● Cost centers. Managers are responsible for predicting, documenting, and managing the costs (staffing, supplies) of the division.

● Revenue centers. Managers are responsible for generating revenues (previously by increasing patient volume, although health care reform may make the future of revenue-generating centers obsolete).

● Profit centers. Managers are responsible for generating revenues and managing costs so that the department shows a profit (revenues exceed costs).

● Investment centers. Managers are responsible for generating revenues and managing costs and capital equipment (assets).

Nursing units are typically considered to be cost centers, but they may also be viewed as revenue centers, profit centers, or investment centers. How the unit is considered is crucial in determining the manager’s approach to budgeting.

Also, some nursing managers are responsible for service lines, and their staff are from multiple disciplines and departments. Other nurse managers are responsible for a single unit, such as a telemetry unit or the staff in a multiple-physician office.

The organization may choose various approaches, or combinations of approaches, for requesting departmental managers to prepare their budget requests. These approaches are incre- mental (line-by-line), zero-based, fixed, and variable.

Incremental Budget With an incremental, or line-by-line, budget, the finance department distributes a budget worksheet listing each expense item or category on a separate expense line. The expense line is usually divided into salary and nonsalary items. A budget worksheet is commonly used for mathematical calculations to be submitted for the next year. It may include several columns for the amount budgeted for the current year, the amount actually spent year-to-date, the pro- jected total for the year based on the actual amount spent, increases and decreases in the expense amount for the new budget, and the request for the next year with an explanation attached.


The base or starting point for calculating next year’s budget request may be either the previ- ous year’s actual results or projected expenditures for the current year. For salary expenses, the adjustment might be the average salary increase projected for next year. For nonsalary expenses, the finance department may provide an estimate of the average increase for supplies or opt to use a standard measure of cost increases, perhaps the consumer or medical price index projected for the next year.

To complete budget worksheets accurately, managers must be familiar with expense account categories. What type of expenses, such as instruments and minor equipment, are included under each line item? In addition, the manager has to keep abreast of different factors that have affected the expenditure level for each expense line during the current year. The projected impact of next year’s activities will be translated into increases or decreases in expense levels of the nursing unit’s expenditures for the coming year.

The advantage of the line-by-line budget method is its simplicity of preparation. The dis- advantage of this method is that it discourages cost efficiency. To avoid budget cuts for the next year, an astute manager learns to spend the entire budget amount established for the current year, because this amount becomes the base for the next year.

Zero-Based Budget The zero-based budget approach assumes the base for projecting next year’s budget is zero. Manag- ers are required to justify all activities and programs as if they were being initiated for the first time. Regardless of the level of expenditure in previous years, every proposed expenditure for the new year must be justified under the current environment and its fit with the organization’s objectives.

The advantage of zero-based budgeting is that every expense is justified. The disadvantage is that the process is time-consuming and may not be necessary. For that reason, organizations may not use this process every year. An adaptation of the zero-based budget is to start the budget with a lower base, for example, 80 percent of the current expenses. Managers then have to jus- tify any budgetary expenses requested above the 80 percent base.

Fixed or Variable Budgets Budgets can also be categorized as fixed or variable. In a fixed budget, the budgeted amounts are set without regard to changes that may occur during the year, such as patient volume or program activities, that have an impact on the cost assumptions originally used for the coming year. In contrast, variable budgets are developed with the understanding that adjustments to the budget may be made during the year based on changes in revenues, patient census, utilization of supplies, and other expenses.

The Operating Budget The operating budget, also known as the annual budget, is the organization’s statement of expected revenues and expenses for the coming year. It coincides with the fiscal year of the organization, a specified 12-month period during which the operational and financial perfor- mance of the organization is measured. The fiscal year may correspond with the calendar year— January to December—or another time frame. Many organizations use July 1 to June 30; the federal government begins its fiscal year on October 1. The operating budget may be further broken down into smaller periods of six months or four quarters; each quarter may be further sepa- rated into three one-month periods. The revenues and expenses are organized separately, with a bottom-line net profit or loss calculated.

The Revenue Budget The revenue budget represents the patient care income expected for the budget period. Most commonly, health care payers pay a predetermined rate based on discounts or allowances. In many cases, actual payment generated by a given service or procedure will not equal the charges


that appear on the patient bill. Instead, the health care provider will be reimbursed based on a variety of methods. These include:

● Reimbursement of a predetermined amount, such as fixed costs per case (Medicare recipients);

● Negotiated rates, such as per diems (a specified reimbursement amount per patient, per day);

● Negotiated discounts; and ● Capitation (one rate per member, per month, regardless of the service provided).

Revenue projections for the next year are based on the volume and mix of patients, rates, and discounts that will prevail during the budget period. Projections are developed from histori- cal volume data, impact of new or modified clinical programs, shifts from inpatient to outpatient procedures, and other influences. Today, however, these projections may not be viable, especially in the light of health care reform.

With implementation of accountable care organizations and medical homes, Medicare reim- bursement is expected to change (Buerhaus, 2010). Instead of paying for inpatient services at a predetermined specific rate for each Medicare recipient based on the patient’s diagnosis (DRGs), providers will be reimbursed for care of patient groups.

The Expense Budget The expense budget consists of salary and nonsalary items. Expenses should reflect patient care objectives and activity parameters established for the nursing unit. The expense budget should be comprehensive and thorough; it should also take into consideration all available information regarding the next year’s expectations. Described in the next section are several concepts and definitions related to the budgetary process in a health care setting.

Cost Centers In health care organizations, nursing units are typically considered cost centers. A cost center is described as the smallest area of activity within an organization for which costs are accumu- lated. Cost centers may be revenue producing, such as laboratory and radiology, or non–revenue producing, such as environmental services and administration. Nursing managers are com- monly given the responsibility for costs incurred by their department, but they have no revenue responsibilities.

In contrast, if managers are responsible for controlling both costs and revenues and if their financial performance is measured in terms of profit (the difference between revenues and expenses), then the manager is responsible for a profit center. Customarily, nursing is not directly reimbursed for its services. As stated previously, nursing costs today are included in the room charge although that may change as methods to match nurses’ skills to patient needs improve.

Classification of Costs Costs are commonly classified as fixed or variable. Fixed costs are costs that will remain the same for the budget period regardless of the activity level of the organization, such as rental payments and insurance premiums. Variable costs depend on and change in direct proportion to patient volume and patient acuity, such as patient care supply expenses. If more patients are admitted to a nursing unit, more supplies are used, causing higher supply expenses.

Expenditures may also be direct or indirect. Direct costs are expenses that directly affect patient care. For example, salaries for nursing personnel who provide hands-on patient care are considered direct costs. Indirect costs are expenditures that are necessary but don’t affect patient care directly. Salaries for security or maintenance personnel, for example, are classified as indi- rect costs.


Determining the Salary (Personnel) Budget The salary budget, also known as the personnel budget, projects the salary costs that will be paid and charged to the cost center in the budget period (see Table 14-1). Managing the salary budget is directly related to the manager’s ability to supervise and lead the staff. Better manag- ers tend to have more stable staff with fewer resources spent on supplementary staff, turnover, or absenteeism. In addition to anticipated salary expenses, factors such as benefits, shift differen- tials, overtime, on-call expenses, and bonuses and premiums may affect the salary budget as well.

Benefits After the number of required full-time equivalents (FTEs) is determined (see Chapter 16 on scheduling), it is also necessary to determine how many FTEs are necessary to replace personnel for benefit time (vacations, holidays, personal days, etc). This factor can be calculated by deter- mining the average number of vacation days, paid holidays, personal days, bereavement days, or other days off with pay that the organization provides and the average number of sick days per employee as experienced by the cost center.

To determine FTEs required for replacement:

1. Determine hours of replacement time per individual.

2. Then determine FTE requirement.

Benefit Time Hours/shift Replacement Hours

15 vacation days * 8 hours = 120

8 holidays * 8 hours = 64

4 personal days * 8 hours = 32

5 sick days * 8 hours = 40

Total = 256

TABLE 14-1 Monthly Salary Budget and Year-to-Date Budget Comparison Report Fiscal Year Ending June 30


June Actual Salary

June Budgeted Salary

June Variance

Year-to- Date Actual Salary

Year-to-Date Budgeted Salary

Year-to-Date Variance

Nurse Manager $6,250 $6,250 $0 $68,750 $75,000 $6,250

Registered Nurses

95,722 93,825 (1,897) 1,048,813 1,125,878 77,065

Licensed Practical Nurses

19,025 20,800 1,775 231,426 249,600 18,174

Nursing Assistants

14,886 13,200 (1,686) 159,500 158,400 (1,100)

Unit Clerks 5,483 5,495 12 60,391 65,273 4,882

Float Pool RNs 1,426 1,000 (426) 16,800 12,500 (4,300)

TOTAL SALARY: $142,792 $140,570 ($2,222) $1,585,680 $1,686,651 $100,971


Divide replacement time by annual FTE base


2,080 = 0.12

An FTE budget is calculated from the FTE calculations (Table 14-1). This budget provides the base for the salary budget. However, shift differentials, overtime, and bonuses or premiums may also affect budget performance and need to be considered.

Shift Differentials Some facilities use a set percentage to determine shift differential: 10 percent for evenings, 15 percent for nights, and 20 percent for weekends and holidays, for example. If the hourly rate is $18.00, for instance, then the cost for a nurse working evenings would be $18.00 plus $1.80 for each hour worked. On an eight-hour shift, the total cost would be $158.40, and for the year, $41,184. Other facilities use a set dollar amount per hour as the shift differential. For instance, evenings adds $2.50 per hour to base pay, night shift $4.00, and weekends $2.50 additional pay.

Overtime Fluctuations in workload, patient volume, variability in admission patterns, and temporary replacement of staff due to illness or time off all create overtime in the nursing unit. A projection of overtime for the next year can be calculated by determining by staff classification (RN, LPN, nursing assistant, and other employee classifications) the historical or typical number of hours of overtime worked and multiplying that number by 1.5 times the hourly rate. For example, if the average number of overtime hours paid in a unit for RNs is 35 hours per two-week pay period, and the average hourly rate is $18.00, the projected overtime cost for the year would be $24,570 for the RN category.

To determine overtime costs:

1. Multiply average salary for classification $18.00 by factor * 1.50 to obtain overtime rate $27.00

2. Multiply average overtime hours 35 by overtime rate * $27.00 to obtain expenditure per pay period $945.00

3. Multiply number of pay periods 26 by overtime expenditure * $945.00 to obtain annual overtime costs $24,570.00

Clearly, overtime can rapidly deplete finite budget dollars allocated to a nursing unit. The nurse manager should explore options to overtime, such as using part-time or per diem work- ers in order to keep the cost per hour more in line with the regular hourly rates. A competent manager certainly would also evaluate unit productivity to decrease overtime.

On-Call Hours If the nursing unit uses a paid on-call system, the approximate number of hours that employees are put on call for the year should be estimated and that cost added to the budget. Typically under the on-call system, staff members are requested to be available to be called back to work if patient need arises, and the number of hours on call are paid at a flat rate per hour.

Premiums Some organizations offer premiums for certifications or clinical ladder steps. In this situation, a fixed dollar amount may be added to the base hourly rate of eligible personnel; for example, an


additional $1.00 per hour paid for professional certifications. This would result in the hourly rate of the employee being adjusted from a base of $18.00 to $19.00. In this case, if the employee is full time and works 2,080 hours a year (40 hours a week multiplied by 52 weeks a year), the annual new salary would be $39,520, or $19.00 multiplied by 2,080.

Salary Increases Merit increases and cost-of-living raises also need to be factored into budget projections. These increases are usually calculated on base pay. For example, if a three percent cost-of-living raise is projected and the base salary for an RN is $40,000, then the new base becomes $41,200.

Additional Considerations Other important factors to consider when developing the salary budget are changes in technology, clinical supports, delivery systems, clinical programs or procedures, and regulatory requirements. Changes in patient care technology or the introduction of new equipment may influence the num- ber, skill, or time that unit personnel may spend in becoming trained to use the new equipment and, later, operating and maintaining it. If significant, the projected number of additional labor hours for the new budgetary period should be incorporated into the request.

The Joint Commission, the organization that accredits health care organizations, evaluates an institution to determine whether it is adhering to the level of staffing required to maintain a safe patient care environment (Joint Commission, 2011). For example, the institution may have established a standard for critical care units and some other specialty units that a minimum of two staff members are required at all times, regardless of patient number or acuity. Additionally, some states have mandated staffing levels.

Departments such as environmental services, dietary, escort, or laboratory may provide the nursing unit with support in performing certain tasks, such as transporting patients or speci- mens. Any change in the level of support they provide should be reviewed, and the effect of such change on the unit’s staffing levels should be quantified for the next year’s budget request. Changes in staffing can place new demands on the unit. Therefore, orientation and additional workload needs should also be considered.

In addition, changes might be made to the way the organization charges costs. For ex- ample, some direct or indirect costs formerly charged under other divisions might now be allocated to the various units. You might find your unit charged its fair share of the heating or security budget. Major changes, of course, are planned ahead of time but some changes occur during the budget year, and the unit might be expected to absorb those additional costs within its original budget.

Managing the Supply and Nonsalary Expense Budget The supply and nonsalary expense budget identifies patient-related supplies needed to operate the nursing unit. In addition to supplies, other operating expenses—such as office supplies, rental fees, maintenance costs, and equipment service contracts—may also be paid out of the nursing unit’s nonsalary budget.

An analysis of the current expense pattern and a determination of its applicability for the next budget period should be performed first. Any projected changes in patient volume, acuity, and patient mix should also be considered because they will affect next year’s supply use and other nonsalary expenses. As an example, if patient days for a particular type of patient are projected to multiply and cause a five percent increase in the use of intravenous solutions, this increase should be addressed in the budget request by requesting an additional five percent for intravenous solu- tion supplies for the next year.

Increases due to an inflation rate index, or at a rate estimated by the finance or purchasing department, are included as part of the budget request. A simple way of calculating the effect of


a price increase is to take the estimated total ending expense for the year and multiply it by the inflationary factor.

To determine projected price increases:

Multiply current total line item expense $12,758 by inflation factor plus 1.0 * 1.05


Increases in expenses, such as maintenance agreements and rental fees, should also be incorporated as part of the budget request. The introduction of new technology and changes in programs and regulatory requirements may require additional resources for supplies as well as increased salaries.

The Capital Budget The capital budget is an important component of the plan to meet the organization’s long-term goals. This budget identifies physical renovations, new construction, and new or replacement equipment planned within a specified time period. Organizations define capital items based on certain conditions or criteria. Usually, capital items must have an expected performance of one year or more and exceed a certain dollar value, such as $500 or $1,000.

The capital budget is limited to a specified amount, and decisions need to be made how best to allocate available funds. Priority is given to those items needed most. Not all items that fall under capital budget will necessarily get funding in a given year.

Today, few nurse managers are asked to prepare a capital budget because most organiza- tions are buying through consortiums or negotiated agreements with one supplier. Many health care organizations have departments that coordinate bringing in selected vendors and items and limit choices to that equipment. The nurse manager would then be responsible for reporting what needs exist, helping select and determine the amount of equipment needed. The capital pool is expensed out across all units that use the equipment.

The impact of the new equipment on the unit’s expenses, such as the number of staff needed to run the equipment, use of supplies, and maintenance costs, needs to be considered as part of the operating budget, however. Likewise, the need for additional nursing and nonnursing per- sonnel to operate the new equipment, additional workload, and training of personnel should be quantified for the next year’s budget.

Timetable for the Budgeting Process Depending on the size and complexity of the organization, the budgeting process takes between three and six months. The process begins with the first-level manager. The individual at this level of management may or may not have formalized budget responsibilities, but he or she is key to identifying needed resources for the upcoming budget period.

The manager seeks information from staff about areas of needed improvement or change and reviews unit productivity and the need for updated technology or supplies. The manager uses this information to prepare the first draft of the budget proposal.

Depending on the levels of organizational management, this proposal ascends through the managerial hierarchy. Each subsequent manager evaluates the budget proposal, making adjust- ments as needed. By the time the budget is approved by executive management, significant changes to the original proposal usually have been made.

The final step in the process is approval by a governing board, such as a board of direc- tors or designated shareholders. Typically, the budget process timetable is structured so that the budget is approved a few months before the beginning of the new fiscal year.


Clearly articulating budgetary needs is essential for the manager to be successful in bud- get negotiations. Senior management must prioritize budget requests for the entire organiza- tion, and they base those decisions on strong supporting documentation. Nurse managers should not expect to receive all of their budget requests, but they need to be prepared to defend their priorities.

Monitoring Budgetary Performance During the Year The difference between the amount that was budgeted for a specific revenue or cost and the actual revenue or cost that resulted during the course of activities is known as the variance. Variance might occur in the actual cost of delivering patient care for a certain expense line item in a speci- fied period of time. Nurse managers are commonly asked to justify the reason for variances and present an action plan to reduce or eliminate these variances.

Managers receive reports summarizing the expenses for the department (see Table 14-1). In the past, monthly reports on paper were sent to managers, but technology makes such a system obsolete today. Reports can be compiled and communicated rapidly, allowing managers to ad- just quicker.

The reports show expense line items with the budgeted amount, actual expenditure, variance from budget, and the percentage from the budgeted amount that such variance represents. These reports often also show the comparison between actual year-to-date results and the year-to-date budget.

To assess variance:

● Identify items that are over or under budgeted amounts ● Find out why the variance occurred (e.g., a one-time event or an ongoing occurrence) ● Keep notes on what you have learned in preparation for next year’s budget ● Examine the payroll and note overtime or use of agency personnel ● Validate the use of overtime or additional personnel and keep a note for your files

Keeping notes throughout the year will help prevent the annual budget process from becom- ing an overwhelming challenge. Trying to reconstruct what happened and why during the past 12 months is unlikely to present a complete and accurate picture of events and makes creating a future budget more difficult.

Variance Analysis In the daily course of events, it is unlikely that projected budget items will be completely on target in all situations. One of the manager’s most important jobs is to manage the financial re- sources for the department and to be able to respond to variances in a timely fashion.

When expenses occur that differ from the budgeted amounts, organizations usually have an established level at which a variance needs to be investigated and explained or justified by the manager of the department. This level may be a certain dollar amount, such as $500, or it may be a percentage, such as a five percent or ten percent increase above the budget.

In determining causes for variance, the nurse manager must review the activity level of the unit for the same period. There may have been increases in census or patient acuity that gener- ated additional expense in salary and supplies.

Also, in many situations, variances might not be independent of one another. Variances may result from expenses that follow a seasonal pattern and occur only at determined times in the year (renewal of a maintenance agreement is one example). Expenses may also follow a ten- dency or trend either to increase or to decrease during the year. Even if the situation is outside the manager’s usual responsibility or control, the manager needs to understand and be able to identify the cause or reason for the variance.


To determine when a variance is favorable or unfavorable, it is important to relate the vari- ance to its impact on the organization in terms of revenues and expenses. If more earnings came in than expected, the variance is favorable; if less, the variance is negative. Likewise, if less was spent than expected, the variance is favorable; if more was spent, the variance is negative.

For instance, the nurse manager might receive the following expense report:

Budgeted Expenditures

Actual Expenditures

Variance (in $)

Percent (in %)

$34,560 $36,958 (2,398) (6.9)

This expense variance is considered unfavorable because the actual expense was greater than the budget. In this example, more money was spent on medical/surgical supplies than was projected in the budget.

If the variance percentage of the actual budget amount is not presented in the reports, it can be calculated as follows:


$34,560 = 0.069

Divide the dollar variance by the budget amount, then multiply by 100:

0.069 * 100 = 6.9% over budget

Salary Variances With salary expenditures, variances may occur in volume, efficiency, or rate. Typically these factors are related and have an impact on each other. Volume variances result when there is a difference in the budgeted and actual workload requirements, as would occur with increases in patient days. An increase in the actual number of patient days will increase the salary expense, resulting in an unfavorable volume variance. Although the variance is unfavorable, concomi- tant increases in revenues for the organization should be apparent. Thus, the impact to the organization should be welcomed, even though it generated higher salary costs at the nursing unit level.

Efficiency variance, also called quantity or use variance, reflects the difference between budgeted and actual nursing care hours provided. Patient acuity, nursing skill, unit manage- ment, technology, and productivity all affect the number of patient care hours actually pro- vided versus the original number planned or required. At the same time, if the census had been higher than expected, it would be understandable if more hours of nursing care were provided and paid. A favorable efficiency, or fewer nursing care hours paid, could suggest that patient acuity was lower than projected, that staff was more efficient, or that higher- skilled employees were used. An unfavorable efficiency may be due to greater patient acuity than allowed for in the budget, overstaffing of the unit, or the use of less experienced or less efficient employees.

Rate variances, also known as price or spending variance, reflect the difference in budgeted and actual hourly rates paid. A favorable rate variance may reflect the use of new employees who were paid lower salaries. Unfavorable rate variance may reflect unanticipated salary increases or increased use of personnel paid at higher wages, such as agency personnel.

Nonsalary Expenditure Variances A nonsalary expenditure variance may be due to changes in patient volume, patient mix, supply quantities, or prices paid. New, additional, or more expensive supplies used at the nursing unit because of technology changes or new regulations could also influence expenditure totals.


Position Control Another monitoring tool used by nurse managers is the position control. The position control is used to compare actual numbers of employees to the number of budgeted FTEs for the nursing unit. The position control is a list of approved, budgeted FTE positions for the nursing cost cen- ter. The positions are displayed by category or job classification, such as nurse manager, RNs, LPNs, and so on. The nurse manager updates the position control with employee names and FTE factors for each individual with respect to personnel changes, new hires, and resignations that take place during the year.

Problems Affecting Budgetary Performance Reimbursement Problems The manager may be called upon to help with problems of reimbursement. Here are some examples:

● Insurance company disputes charges for a patient stay and refuses to pay them. The insurance company thinks patient should have been discharged a day sooner and refuses to pay for last day of stay because a good clinical reason to be in the hospital isn’t documented.

Here are three alternative solutions:

1. Ask the physician to elaborate on the clinical reasons why the patient necessitated another day stay in the hospital and submit that documentation to the insurance company.

2. Negotiate the charge with the insurance company and take a settlement on payment that is agreeable to both parties.

3. Have an internal utilization review group go through the patient’s chart and extract lab values, clinical presentation symptoms, testing, etc., that were done on day of stay being disputed and submit to insurance company as an appeal to denial to pay, demonstrating necessity to stay.

● Patient disputes charges during stay and refuses to pay them. The patient gets a PICC line (invasive procedure, longer term intravenous line) placed for IV antibiotics to be infused for one to two weeks. The PICC line is placed because one to two weeks of antibiotics is not something typically a peripheral IV line would be used for because they don’t hold up as well and can’t infiltrate or the patient could get phlebitis. Then, after the PICC line is placed, two days later the doctor decides to discontinue IV antibiotics and remove the PICC line. The patient refuses to pay for the PICC line because it wasn’t used for one to two weeks as the doctor had originally said and feels he should not pay for the doctor’s “change of mind.”

Here are three alternative solutions:

1. Meet with the patient to discuss his case and explain that with his initial clinical presentation, the physician’s decision to place the PICC line was reasonable and the hospital will not waive charges.

2. Agree to negotiate charge with the patient because the PICC line was placed with reasonable and prudent judgment but was not utilized as long as was initially discussed with the patient.

3. Agree to drop charges for PICC line placement.

● Patient is not able to obtain resources needed when discharged. A patient is ready for discharge to home but is on an expensive antibiotic. Even with insurance, she can’t afford the co-pay of $200. So the health care team has to try to find a resource to help the patient pay for the antibiotic or find a replacement drug.


Staff Impact on Budget Staff can acutely affect the organization’s finances. Misuse of sick time, excessive overtime or turnover, and wasteful use of resources can result in negative variance. The manager plays a key role in explaining the unit’s goals, the organization’s financial goals, and how each individual is responsible for helping the organization meet those goals.

Improving Performance Organizations have implemented a number of different programs and incentives for increasing employee awareness and minimizing costs. Techniques to decrease absenteeism and turnover may be instituted (see Chapter 20). Displaying equipment costs on supply stickers or requisitions and indicating medication costs on medication sheets increase staff awareness of costs. Participa- tion in quality improvement and action teams also serves to inform staff of cost factors. Bonuses based on net gains have been shared with employees, in addition to cost-of-living raises.

When one staff member wants to take time off, the shift still must be covered. Nurse man- agers must hire enough staff to cover the unit even when people are on vacation without using excessive overtime. Float pool or PRN staff (staff scheduled on an as-needed basis) are often used to cover staff time off. Managers must plan how to cover each employee’s nonproductive time (vacation, sick, education, etc.) in the least expensive way.

BUDGET MANAGEMENT Byron Marshall is a nurse manager for the surgical ser- vices department of a private orthopedic hospital. Byron has received notice from the vice president of clinical services that next year’s budget is due to her for review at the end of the month. Byron has kept careful records during the previous 12 months for use in preparing the surgical services department budget.

Each month, Byron has received and reviewed monthly reports of revenue and expense for his department. He validated each month’s budget targets, carefully noting areas that didn’t meet budget projections. For example, when April pharmacy charges were 15 percent above budget projections, Byron noted that surgery volume was up 30 percent over the previous year, accounting for the increase in preanesthesia drug charges. Nursing salaries were also over budget for the year, but again, increased surgery volume had resulted in the addition of two full-time surgery technicians to the department. When summer vacations resulted in agency staffing in the OR, Byron saved copies of the approval from the vice president and the human resources department and noted the total cost to his department.

Byron will use the budget information for the past 12 months to project the next fiscal year’s budget for his department. Information from the human resources department provides data for cost of living and merit increases in salary, while materials management has pro- jected a 20 percent across-the-board increase in surgi- cal supplies and pharmaceutical charges. Byron will also

request replacement of two OR tables and three gur- neys as part of the capital budget. These items had been requested by staff during the last department meeting when Byron asked for changes and improvements in the budget. Budget discussion is part of each staff meeting and Byron provides copies of actual budget numbers to the staff each month. He has found that showing rev- enue and expense reports to staff increases compliance with overtime expenses and supply usage.

With monthly preparation, good record keeping, and accurate analysis, Byron is confident that his budget pre- sentation will be on time and on target.

Manager’s Checklist The nurse manager is responsible for:

● Learning and understanding the responsibilities of financial planning for the department

● Reviewing monthly revenue and expense reports for accuracy and completeness

● Understanding and tracking the reasons why particular areas did not meet the budget

● Communicating to staff the importance of fiscal responsibility

● Planning for capital items on an ongoing basis ● Identifying and incorporating increasing or

decreasing expenses into the department budget ● Preparing and presenting a complete departmental

budget to administration



Magnet Hospital Performance In Magnet-certified hospitals, staff are taught about budgeting and how the unit’s money “works.” Bedside staff make excellent, informed decisions about what resources should be used and understand the give and take of budget management. Bedside staff are empowered to make decisions that impact how they work. For example, the charge nurse on the unit takes phone calls about unit staffing. The float pool might have an additional aide coming in to work who is not assigned yet. The charge nurse takes the phone call from the staffing office to ask if the unit needs another aide and makes the decision.

Another example includes flexing staff for needs on the unit. The charge nurse, along with the coworkers, decide whether someone can be sent home on a slow day or if another staff mem- ber should be called in if the unit is excessively busy.

Managing fiscal resources is a challenge for all nurse managers. This is even more true to- day as legislation and regulation of health care reform is implemented. Close attention to costs, balanced by awareness of quality and patient safety, is essential.

Case Study 14-1 illustrates how one nurse manager handled his budget.

What You Know Now • A budget is a quantitative statement, usually written in monetary terms, of plans and expectations over a

specified period of time. • The operating or annual budget is the organization’s statement of expected revenues and expenses for the

coming year. • The revenue budget represents the patient care revenues expected for the budget period based on volume

and mix of patients, rates, and discounts that will prevail during the same period of time. • Nursing units are typically considered cost centers, but may be considered revenue centers, profit centers,

or investment centers. • Nurse managers may be responsible for service lines and staff from multiple disciplines and departments. • Nurse managers have input into capital expenses and are responsible for salary and operating costs related

to new equipment. • A full-time equivalent (FTE) is a full-time position that can be equated to 40 hours of work per week for

52 weeks, or 2,080 hours per year. • The position control is a list of approved, budgeted FTEs that compares the budgeted number of FTEs by

classification (RN, LPN), shift, and status to the actual available employees of the unit. • Variance is the difference between the amount that was budgeted for a specific revenue or cost and the

actual revenue or cost that resulted during the course of activities. • Monitoring the budget throughout the year requires attention to variances and the reasons they occurred.

Tools for Budgeting and Managing Resources 1. Understand the budgeting process in your organization. 2. Determine the number of full-time equivalents necessary to staff the unit. 3. Compute the salary and nonsalary budget, including salary increases and various additional factors. 4. Monitor variances over the budget period and identify negative variances, keeping notes in your

files. 5. Understand that factors out of your control, such as changes in technology or indirect or direct costs

that may be assigned to your budget, affect your budget and its performance. 6. Encourage staff to monitor resource use, including time and supplies.

Questions to Challenge You 1. Do you have a budget for your personal and professional income and expenses? If so, how well

do you manage it? If not, begin next month to track your income and expenses for one month. See if you are surprised at the results.


2. How well does your organization manage its resources? Can you make suggestions for improvement?

3. Are there tasks or functions in your work that you believe are redundant, unnecessary, or repetitive or that could be done by a lesser-paid employee? Explain.

4. Does your organization waste salary or nonsalary resources? If not, think of ways that organizations could waste resources. Describe them.

References Buerhaus, P. I. (2010). Health

care payment reform: Impli- cations for nurses. Nursing Economics, 28(1), 49–54.

Dunham-Taylor, J., & Pinczuk, J. Z. (2009). Financial man- agement for nurse manag- ers: Merging the heart with the dollar. Burlington, MA: Jones & Bartlett.

Finkler, S. A., & Kovner, C. T. (2007). Financial manage- ment for nurse managers and executives (3rd ed.). St. Louis, MO: Saunders.

Joint Commission. (2011). Com- prehensive accreditation manual for hospitals: The official handbook. Retrieved July 28, 2011 from

http://www. jcrinc.com/ Accreditation-Manuals/ PCAH11/2130/

Welton, J. M., Zone-Smith, L., & Bandyopadhyay, D. (2009). Estimating nursing intensity and direct cost using the nurse-patient assignment. Journal of Nursing Admin- istration, 39(6), 276–284.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!


The Recruitment and Selection Process

Recruiting Applicants WHERE TO LOOK





Selecting Candidates







Legality in Hiring

Recruiting and Selecting Staff 15

Key Terms Four Ps of marketing Age Discrimination Act Americans with Disabilities Act Behavioral interviewing Bona fide occupational

qualification (BFOQ)

Business necessity Interrater reliability Interview guide Intrarater reliability Negligent hiring Personnel decisions

Position description Validity Work sample questions

1. Describe how to recruit applicants. 2. Discuss how to select candidates. 3. Describe how to interview prospective

candidates. 4. Distinguish between appropriate and

inappropriate questions to ask during an interview.

5. Determine how to make a hiring decision.

6. Discuss the legal issues involved in hiring.

Learning Outcomes After completing this chapter, you will be able to:


The Recruitment and Selection Process Recruiting and selecting staff who will contribute positively to the organization is crucial in the fast-paced world of health care and in the face of ever-increasing nursing shortages (U.S. Department of Labor, 2011). The direct costs of recruiting, selecting, and training an employee who must later be terminated because of unsatisfactory performance is expensive and unneces- sary. The hidden costs may be even more expensive and include poor quality of work, disruption of morale, and patients’ ill will and dissatisfaction, which may contribute to later liability.

The purpose of the recruitment and selection process is to match people to jobs. Respon- sibility for selecting nursing personnel in health care organizations is usually shared by the hu- man resources (HR) department, which may include a nurse recruiter, and nursing management. First-line nursing managers are the most knowledgeable about job requirements and can best describe the job to applicants. HR performs the initial screening and monitors hiring practices to be sure they adhere to legal stipulations.

Before recruiting or selecting new staff, those responsible for hiring must be familiar with the position description. The position description (see Box 15-1) describes the skills, abilities, and knowledge required to perform the job.

The position description should reflect current practice guidelines and include:

● Principal duties and responsibilities involved in a particular job ● Tasks required to carry out those duties ● Personal qualifications (skills, abilities, knowledge, and traits) needed for the position ● Competency-based behaviors (perhaps)

Recruiting Applicants The purpose of recruitment is to locate and attract enough qualified applicants to provide a pool from which the required number of individuals can be selected. Even though recruiting is pri- marily carried out by HR staff and nurse recruiters, nurse managers and nursing staff play an important role in the process. Recruiting is easier when current employees spread the recruiting message, reducing the need for expensive advertising and reward methods.

The best recruitment strategy is the organization’s reputation among its nurses. Aiken and colleagues (Aiken et al., 2008) found that a positive hospital care environment not only reduced patient mortality but improved nurses’ perception of the work setting. Brady-Schwartz (2005) found that nurses in Magnet hospitals demonstrated higher levels of job satisfaction than those in non-Magnet hospitals. It follows that satisfied nurses are more likely to speak highly of the organization.

Individual nurse managers also affect how well the unit is able to attract and retain staff. A nurse manager who is able to create a positive work environment through leadership style and clinical expertise will have a positive impact on recruitment efforts, because potential staff members will hear about and be attracted to that area (e.g., hospital unit, home health team). In contrast, an autocratic manager is more likely to have a higher turnover rate and less likely to attract sufficient numbers of high-quality nurses.

Any recruiting strategy includes essentially four elements:

1. Where to look

2. How to look

3. When to look

4. How to sell the organization to potential recruits

Each of these elements may be affected by market competition, nursing shortages, reputa- tion, visibility, and location.


BOX 15-1 Position Description: Registered Nurse Adult Medical Intensive Care Unit (MICU)

Job Overview The medical intensive care unit registered nurse is re- sponsible for direct patient care of adults admitted to the MICU for management of complex life-threatening ill- ness. The RN reports directly to the MICU nurse manager.


● Current licensure in good standing in the state of practice.

● Minimum of one year previous adult ICU experi- ence within the past three years or two years telemetry experience within the past three years.

● Current BLS mandatory, ACLS or TNCC preferred. ACLS must be obtained with six months of employment.


● Performs complete, individualized patient assess- ment within unit time frames and determines patient care priorities based on assessment findings.

● Completes additional patient assessments as re- quired, based on patient status, protocols, and/or physician orders.

● Administers medications and appropriate treat- ments as ordered by the physician accurately and within specified time frames.

● Initiates and maintains an individualized patient plan of care for each patient, using nursing interventions as appropriate.

● Provides ongoing education to the patient and the patient’s family.

● Documents patient assessments, medication and therapy administration, patient response to treat- ments, and interventions in an accurate and timely manner.

● Initiates emergency resuscitation procedures according to ACLS protocols.

● Maintains strict confidentiality of all information related to the patient and the patient’s family.

● Provides nursing care in a manner that is respectful and sensitive to the needs of the patient and the patient’s family and protects their dignity and rights.

● Communicates changes in patient condition to appropriate staff during the shift.

● Maintains (or obtains within six months of initial hire) certification in ACLS.

● Completes unit-based training modules for critical care competency on an annual basis.

Where to Look For most health care organizations, the best place to look is in their own geographic area. Dur- ing nursing shortages, however, many organizations conduct national searches. This effort is frequently futile because most nurses look for jobs in their local area. If the agency is in a ma- jor metropolitan area, a search may be relatively easy; if it is located in a rural area, however, recruitment may need to be conducted in the nearest city. Organizations tend to recruit where past efforts have been the most successful. Most organizations adopt an incremental strategy whereby they recruit locally first and then expand to larger and larger markets until a sufficient applicant pool is obtained.

Because proximity to home is a key factor in choosing a job, recruitment efforts should focus on nurses living nearby. The state board of nursing can provide the names of registered nurses by zip code to allow organizations to target recruitment efforts to surrounding areas. Also, personnel officers in large companies or other organizations in the area can be asked to assist in recruiting nurse spouses of newly hired employees.

Collaborative arrangements with local schools of nursing offer opportunities for recruit- ment. Providing preceptors or mentors for students during their clinical rotation or offering externships or residencies encourages postgraduation students to consider employment in the organization. Nurses who work with students play a key role in recruitment. Students are more likely to be attracted to the organization if they see nurses’ work valued and appreciated and perceive a positive impression of the work group.


Employing students as aides may provide another recruitment tool because it allows students to learn first hand about the organization and what it has to offer. In turn, the organization can eval- uate the student as a potential employee post-graduation. Some organizations provide assistance with student loan payments if the student continues to work after graduation. Of major importance to new graduates is the orientation program. Graduates look for an orientation that provides suc- cessful transition into professional practice. Other top factors they consider are the reputation of the agency, benefits, promotional opportunities, specialty area, and nurse– patient ratio.

How to Look Posting online on general job search sites (e.g., www.monster.com) or on nurse-specific job referral sites (www.nurse.com) is a common practice. Professional associations such as Sigma Theta Tau International (http://stti.monster.com) and the American Nurses Association (www. nursingworld.org/careercenter) offer job search services. Specialty organizations, such as the American Organization of periOperative Nurses (http://www.aorn.org) could be used for a sur- gical nurse position.

Employee referrals, advertising in professional journals, attendance at professional conven- tions, job fairs, career days, visits to educational institutions, employment agencies (both private and public), and temporary help agencies are all recruiting sources. Advertising in professional journals, Websites, newspapers, or on public access TV can be an effective recruiting tool as well.

During extreme nursing shortages, some organizations offer bonuses to staff members who refer candidates and to the recruits themselves. Direct applications and employee referrals are quick and relatively inexpensive ways of recruiting people, but these methods also tend to perpetuate the current cultural or social mix of the workforce. It is both legally and ethically necessary to recruit individuals without regard to their race, ethnicity, gender, or disability. In addition, organizations can benefit from the diversity of a staff composed of people from a wide variety of social, experiential, cultural, generational, and educational backgrounds.

On the other hand, nurses referred by current employees are likely to have more realistic information about the job and the organization and, therefore, their expectations more closely fit reality. Those who come to the job with unrealistic expectations may experience dissatisfaction. In an open labor market, these individuals may leave the organization, creating high turnover. When nursing jobs are less plentiful or the economy is in a recession, dissatisfied staff members tend to stay in the organization because they need the job, but they are not likely to perform as well as other employees.

When to Look The time lag in recruiting is a concern to nursing because of the shortage. Positions in certain locations (e.g., rural areas) or specialty areas (e.g., critical care) may be especially difficult to fill. Careful planning is necessary to ensure that recruitment begins well in advance of antici- pated needs.

How to Promote the Organization A critical component of any recruiting effort is marketing the organization and available posi- tions to potential employees. The nursing division and/or HR should develop a comprehensive marketing plan. Generally, four strategies are included in marketing plans and are called the four Ps of marketing:

1. Product

2. Place

3. Price

4. Promotion


The consumer is the key figure toward which the four concepts are oriented, and in the recruiting process, the consumer is the potential employee.

Product is the available position(s) within the organization. Consider several aspects of the position and organization, such as:

● Professionalism ● Standards of care ● Quality ● Service ● Respect

Place refers to the physical qualities and location, such as:

● Accessibility ● Scheduling ● Parking ● Reputation ● Organizational culture

Price includes:

● Pay and differentials ● Benefits ● Sign-on bonuses ● Insurance ● Retirement plans

Promotion includes:

● Advertising ● Public relations ● Direct word of mouth ● Personal selling (e.g., job fairs, professional meetings)

Developing an effective marketing message is important. Sometimes the tendency is to use a “scatter-gun” approach (recruit everywhere), sugarcoat the message, or make it very slick. A more balanced message, which includes honest communication and personal contact, is prefer- able. Overselling the organization creates unrealistic expectations that may lead to later dissatis- faction and turnover.

Realistically presenting the job requirements and rewards improves job satisfaction, in that the new recruit learns what the job is actually like. Promising a nurse every other weekend off and only a 25 percent rotation to nights on a severely understaffed unit and then scheduling the nurse off only every third weekend with 75 percent night rotations is an example of unrealistic job information. It is important to represent the situation honestly and describe the steps that management is taking to improve situations that the applicant might find undesirable. He or she can then make an informed decision about the job offer.

Cross-Training as a Recruitment Strategy In today’s rapidly changing health care environment, the patient census fluctuates rapidly, and staffing requirements must be adjusted appropriately. These conditions may bring about lay- offs and daily cancellations and contribute to low morale. Offering cross-training to potential employees may increase the applicant pool.

Cross-training has the benefits of increasing morale and job satisfaction, improving effi- ciency, increasing the flexibility of the staff, and providing a means to manage fluctuations in the


census. It gives nurses, such as those in obstetrics and neonatal areas, an opportunity to provide more holistic care. On the other hand, some nurses do not want to be cross-trained, and thus requiring cross-training could reduce retention.

If cross-training is used, care should be taken to provide a didactic knowledge base in ad- dition to clinical training. How broadly to cross-train is an important decision, because training in too many areas may overload the nurse and reduce the quality of care. (See Chapter 17 on the use of floating to improve retention.)

Selecting Candidates Once an applicant makes contact with the organization, HR reviews the application and may conduct a preliminary interview (see Table 15-1). If the applicant does not meet the basic needs of the open position or positions, he or she should be so informed. Rejected applicants may be qualified for other positions or may refer friends to the organization and thus should be treated with utmost courtesy.

Reference checks and managerial interviews are next. In most cases, the interview is last, but practices may vary. Even if an applicant receives poor references, it is prudent to carry out the interview so that the applicant is not aware that the reference checking led to the negative decision. In addition, applicants may feel they have a right to “tell their story” and may sponta- neously provide information that explains poor references.

The nurse manager should participate in the interview process because he or she is:

● Best able to assess applicants’ technical competence, potential, and overall suitability ● Able to answer applicants’ technical, work-related questions more realistically.

In some organizations, the candidate’s future coworkers also participate in the interview process to assess compatibility.

The nurse manager must keep others involved in the selection process informed. The man- ager is usually the first to be aware of potential resignations, requests for transfer, and maternity or family medical leaves that require replacement staff. The manager is also aware of changes in the work area that might necessitate a redistribution of staff, such as the need for a night rather than a day nurse. Communicating these needs to HR promptly and accurately helps ensure effec- tive coordination of the selection process.

TABLE 15-1 Selection Process

1. Review application (nurse manager and HR)

2. Conduct screening interview (HR).

3. Contact references (HR).

4. Conduct second interview (nurse manager).

5. Compare applicants (nurse manager/nursing department).

6. Make hire/no hire decision (nurse manager/nursing department).

7. Perform background check (HR).

8. Make phone offer, conditional on clean drug test within 24 hours (nurse manager).

9. With clean drug test, offer is official.


Interviewing Candidates The most common selection method, the interview, is an information-seeking mechanism be- tween an individual applying for a position and a member of an organization doing the hiring. After the applicant’s initial screening with HR, the nurse manager usually conducts an interview.

The interview is used to clarify information gathered from the application form, evaluate the applicant’s responses to questions, and determine the fit of the applicant to the position, unit, and organization. In addition, the interviewer should provide information about the job and the organization. Finally, the interview should create goodwill toward the employing organization through good customer relations.

An effective interviewer must learn to solicit information efficiently and to gather relevant data. Interviews typically last between one and one and a half hours, and include an opening, an information-gathering and information-giving phase, and a closing. The opening is important because it is an attempt to establish rapport with the applicant so she or he will provide relevant information.

Gathering information, however, is the core of the interview. Giving information is also im- portant because it allows the interviewer to create realistic expectations in the applicant and sell the organization, if that is needed. However, this portion of the interview should take place after the information has been gathered so that the applicant’s answers will be as candid as possible. The interviewer should answer any direct questions the candidate poses. Finally, the closing is intended to provide information to the candidate on the mechanics of possible employment.

Principles for Effective Interviewing Developing Structured Interview Guides Unstructured interviews present problems: if interviewers fail to ask the same questions of every candidate, it is often difficult to compare them. The interview is most effective when the infor- mation on the pool of interviewees is as comparable as possible. Comparability is maximized via a structured interview supported by an interview guide. An interview guide is a written document containing questions, interviewer directions, and other pertinent information so that the same process is followed and the same basic information is gathered from each applicant. The guide should be specific to the job, or job category.

Instead of the traditional interview questions, such as “tell me about yourself, what are your strengths and weaknesses, and why do you want to work for us,” specific questions that target job-related behaviors are more common today. Behavioral interviewing, also called competency-based interviewing, uses the candidate’s past performance and behaviors to predict behavior on the job. The questions are based on requirements of the position. Examples of spe- cific behaviors expected of staff nurses and related sample questions are found in Table 15-2.

In addition, you can develop additional questions based on the specific job. For example, you may want to add questions on teamwork and collaboration as they relate to the position. Box 15-2 lists job-related questions for a medical telemetry unit position that candidates could be asked.

Interview guides reduce interviewer bias, provide relevant and effective questions, minimize leading questions, and facilitate comparison among applicants. Space left between the questions on the guide provides room for note taking, and the guide also provides a written record of the interview. An example of an interview script is shown in Box 15-3.

Preparing for the Interview Most managers do not adequately prepare for the interview, which should be planned just like any business undertaking. All needed materials should be on hand, and the interview site should be quiet and pleasant. If others are scheduled to see the applicant, their schedules should be checked to make sure they are available at the proper time. If coffee or other refreshments are to be offered, advance arrangements need to be made. Lack of advance preparation may lead to insufficient interviewing time, interruptions, or failure to gather important information. Other problems include losing focus in the interview because of a desire to be courteous or because


TABLE 15-2 Examples of Behavioral Interview Questions

Behavior Sample Question

Decision making What was your most difficult decision in the last month, and why was it difficult?

Communication What do you think is the most important skill in successful communication?

Adaptability Describe a major change that affected you and how you handled it.

Delegation How do you make the decision to delegate? Describe a specific situation.

Initiative What have you done in school or in a job that went beyond what was required?

Motivation What is your most significant professional accomplishment?

Negotiation Give an example of a negotiation situation and your role in it.

Planning and organization

How do you schedule your time? What do you do when unexpected circum- stances interfere with your schedule?

Critical thinking Describe a situation in which you had to make a decision by analyzing informa- tion, considering a range of alternatives, and selecting the best choice for the circumstances.

Conflict resolution Describe a situation in which you had to help settle a conflict.

BOX 15-2 Job Related Questions for Medical Telemetry Unit

Describe your actions in the following situations.

1. You are documenting your patient’s heart rhythms in his medical record for the shift. A peer is sit- ting near you and doing the same. You see that RN document the patient’s heart rhythm as sinus rhythm, when you know the patient has had a trial fibrillation the whole shift.

2. The physician is rounding on your patient. The pa- tient has had an elevated blood pressure of 160/90 despite already having received all of her antihy- pertensive medications for the day. The patient has reported to you that she is also experiencing a head- ache. You tell the doctor about the blood pressure reading and the patient’s headache. You request that the physician order another medication to help lower the patient’s blood pressure. The physician says to you, “Oh, she’ll be fine” and begins to walk away.

3. You are caring for an elderly woman. Her daugh- ter is at her bedside. The patient has been having recurrent flare-ups of congestive heart failure and has been readmitted to the hospital three times in the last month. Each time she returns, the swelling in her extremities and her difficulty breathing is worse than the time before. The physician rounds on the patient and her daughter and shares that the health care team will work to help her, but it appears that her heart is getting weaker again,

and the congestive heart failure is going to con- tinue to get harder to manage. After the doctor leaves, you enter the room. The patient is sleeping and the daughter is quietly crying.

4. You run to the room of a patient where the code blue alarm has been activated. Your team is doing CPR and attaching the code cart to the patient. You put on gloves and step in to help. As you approach the bed of the patient, you look at the patient’s wrist and see a do not resuscitate brace- let on his arm.

5. You are caring for a patient with paranoid schizo- phrenia and a heart dysrhythmia. It is time to ad- minister his 9 A.M. meds. When you enter the room with the medications that the patient takes to prevent ventricular tachycardia, he begins scream- ing, “No, I won’t take those medications, you’re trying to poison me!”

6. You are caring for a patient who is recovering from a myocardial infarction. You have been talk- ing to her about her new cardiac diet and what she can do to be healthy when she leaves the hospital. You discuss eating low amounts of salt, a well-rounded diet rich in fruits and vegetables, and avoiding fried and sugary foods. Later in the day, you pass the patient’s room and see her eat- ing fried chicken and French fries that her family brought.


the interviewee is particularly dominant. This typically keeps the interviewer from obtaining the needed information.

In general, when time is limited, it is better to use part of it for planning rather than spend it all on the interview itself. Before the interview, the interviewer should review job requirements, the application and résumé, and note specific questions to be asked. Planning should be done on the morning of the interview or the evening before for an early morn- ing interview. If you are sure that time will be available, planning is best done immediately before an interview or between interviews. Unfortunately, a busy manager may have to deal with unexpected crises between interviews and may not be able to use the time to plan the next interview.

A cardinal rule is to review the application or résumé before beginning the interview. If the interviewee arrives with the résumé or application in hand, ask him or her to wait for a few min- utes while you review the material. In doing a quick review, look for the following four things:

1. Clear discrepancies between the applicant’s qualifications and the job specifications. If you find them, then only a brief interview may be necessary to explain why the applicant will not be considered. (If a preliminary screening is performed by the HR, such applicants should not be referred to nurse managers.)

2. Specific questions to ask the applicant during the interview.

3. A rapport builder (something you have in common with the applicant) to break the ice at the beginning of the interview.

4. Areas where you need more information. Remember that the résumé is prepared by the applicant and is intended to market an applicant’s assets to the organization. It does not give a balanced view of strengths and weaknesses. So, examine the résumé critically for gaps.

The setting of the interview is important in order to provide a relaxed, informal atmosphere. Both you and the applicant should be in comfortable chairs, as close together as comfortably possible. No table or desk should separate you. If you are using an office, arrange the chairs so that the applicant is at the side of the desk. There should be complete freedom from distracting phone calls and other interruptions. If the view is distracting, do not seat the applicant so that she or he can look out a window.

BOX 15-3 Interview Script for Hiring

1. Why did you choose to become a nurse? 2. Why would you like to work at this hospital? 3. What about this patient specialty interests you? 4. Tell me about your previous work experiences. 5. How do your previous work experiences prepare

you for this job? 6. How would your previous coworkers describe you? 7. What does teamwork mean to you? 8. Tell me about a time when you were successful

because of great teamwork. 9. Tell me about a time you experienced a lack of

teamwork. Describe what happened. 10. Describe a situation in which you had a conflict

with a patient or family member. What happened? 11. Tell me about a time you had a conflict with a

coworker or teacher. Explain what happened.

12. Tell me about a time you were working with someone who wasn’t putting his or her full effort forward, and it was impacting patient care. What did you do?

13. What makes you most nervous about coming to this job?

14. What do you find exciting about coming to this job?

15. What are you most proud of professionally? 16. What is something about you that makes you bet-

ter than any other candidate for this job? 17. What are you looking for from your manager? 18. What do you plan to do in the next five and

ten years of nursing and beyond? What are your goals?

19. What questions do you have about this job?


Opening the Interview Begin the interview on time. Give a warm, friendly greeting, introduce yourself, and ask the applicant for her or his preferred name. Try to minimize your status; do not patronize or domi- nate. The objective is to establish an open atmosphere so applicants reveal as much as pos- sible about themselves. Establish and maintain rapport throughout the interview by talking about yourself, discussing mutual interests such as hobbies or similar experiences, and using nonver- bal cues, such as maintaining eye contact. Finally, start the interview by outlining what will be discussed and setting a limit on the meeting time.

Be careful not to form hasty first impressions. Interviewers tend to be influenced by first impressions of a candidate, and such judgments often lead to poor decisions. First impressions may degrade the quality of the interview; interviewers may search for information to justify their first impressions, good or bad. If you have gotten a negative first impression and thus decide not to hire a potentially successful candidate, you have wasted an hour or so and possibly lost a good recruit. If, you hire an unsuccessful candidate based on a positive first impression, problems may continue for months. Conversely, your personal characteristics may influence the applicant’s de- cisions. You create first impressions with your tone of voice, eye contact, personal appearance, grooming, posture, and gestures.

Take notes, using the structured interview guide. Explain that you are doing this in order to remember more about what is discussed in the interview, and tell the candidate that you hope he or she does not mind. There are various ways to ask questions, but ask only one at a time. When possible, ask open-ended questions, such as those listed in Table 15-1. Open-ended questions cannot be answered with a yes, no, or one-word answer and usually elicit more information about the applicant (Parrish, 2006). Closed questions (e.g., what, where, why, when, how many) should only be used to elicit specific information.

Work sample questions are used to determine an applicant’s knowledge about work tasks and his or her ability to perform the job. It is easy to ask a nurse whether she or he knows how to care for a patient who has a central intravenous line in place. A yes answer does not necessarily prove the candidate’s ability, so you might ask some very specific ques- tions about central lines. Avoid leading questions, in which the answer is implied by the question (e.g., “We have lots of overtime. Do you mind overtime?”). You may also want to summarize what has been said, use silence to elicit more information, repeat the applicant’s statements back to him or her to clarify an issue, or indicate acceptance by urging the appli- cant to continue.

Giving Information Before reaching the information-giving part of the interview, consider whether the candidate is promising enough to warrant spending a lot of time on this. Unless the candidate is clearly unac- ceptable, be careful not to communicate a negative impression, because your evaluation of the candidate may change when the entire packet of material is reviewed or if more promising can- didates decline the job offer. You must also know what information you should give, and what is being provided by others. Detailed benefit or compensation questions are usually answered by HR. If you cannot answer a promising candidate’s questions, arrange for someone to contact the candidate later with that information.

Closing the Interview You may want to summarize the applicant’s strengths at the end of the interview. Make sure to ask the applicant whether she or he has anything to add or ask about the job and the or- ganization. You may also want to mention the candidate’s weaknesses, particularly if they are objective and clearly related to the job (such as lack of experience in a particular field). Mentioning a perception of a subjective weakness, such as poor supervisory skills, may lead to legal problems. Wrap up by thanking the applicant and completing any notes that you have been taking.


Involving Staff in the Interview Process Today’s trend toward decentralization of decision making may lead to sharing interview re- sponsibilities with staff. Involving staff in interviews helps strengthen teamwork, improves work-group effectiveness, increases staff involvement in other unit activities, and increases the likelihood of selecting the best candidate for the position.

If staff are involved in interviews, several steps must be taken to protect the integ- rity of the interview process. An organized orientation to interviewing should be given that includes:

● Federal, state, and local laws and regulations governing interviewing, as well as any collective-bargaining agreements that may affect the process

● Tips on handling awkward interviewing situations ● Time for rehearsing interviewing skills; like the manager, staff should follow a structured

interview guide to help standardize the process

Graham Nelson is nurse manager of a dialysis center. Training a new renal dialysis nurse is an expensive process. To reduce turnover among nursing staff, Graham includes peer interviews as part of the overall interview process. Peer interviews can help ensure that potential employees will interact well with existing staff and ensure a cultural fit with the dialysis team. Additionally, an interviewee can gain a better understanding of the day- to-day workflow of the center.

Interview Reliability and Validity Numerous research studies have been performed on the reliability and validity of employment interviews. In general, agreement between two interviews of the same measure by the same in- terviewer (intrarater reliability) is fairly high, agreement between two interviews of the same measure by several interviewers (interrater reliability) is rather low, and the ability to predict job performance (validity) of the typical interview is very low. Research has also shown that:

1. Structured interviews are more reliable and valid.

2. Interviewers who are under pressure to hire in a short time or meet a recruitment quota are less accurate than other interviewers.

3. Interviewers who have detailed information about the job for which they are interviewing exhibit higher interrater reliability and validity.

4. The interviewer’s experience does not seem to be related to reliability and validity.

5. There is a decided tendency for interviewers to make quick decisions and therefore be less accurate.

6. Interviewers develop stereotypes of ideal applicants against which interviewees are evalu- ated. Individual interviewers may hold different stereotypes, which decreases interrater reliability and validity.

7. Race and gender may influence interviewers’ evaluations.

The greatest weakness in the selection interview may be the tendency for the interviewer to try to assess an applicant’s personality characteristics. Although it is difficult to eliminate such subjectivity, evaluations of applicants are often more subjective than they need to be. Informa- tion collected during an interview should answer three fundamental questions:

1. Can the applicant perform the job?

2. Will the applicant perform the job?

3. Will the candidate fit into the culture of the unit and the organization?


The best predictor of the applicant’s future behavior in these respects is past performance. Previous work and other experience, past education and training, and current job performance should be considered rather than personality characteristics, which even psychologists cannot measure very accurately.

Making a Hire Decision Education, Experience, and Licensure Education and experience requirements for nurses have long been important screening factors and bear a close relationship to work sample tests. Educational requirements are a type of job knowledge sample because they tend to ensure that applicants have at least a minimal amount of knowledge necessary for the job.

Educational preparation is particularly important for nurses. For example, nurses who are graduates of associate degree and diploma programs are prepared to care for individuals in struc- tured settings and use the nursing process, the decision-making process, and their management skills in the care of those individuals. Baccalaureate graduates can provide nursing care for in- dividuals, families, groups, and communities using the nursing and decision-making processes. Baccalaureate graduates are also prepared for beginning community health positions and pos- sess the leadership and management skills needed for entry-level management positions.

Avoid making assumptions about the type of experience and number of years of experience that an applicant has. Factors such as job requirements, patient acuity, clinic populations, au- tonomy, and degree of specialization vary from organization to organization. Therefore, careful interviewing is needed to determine the applicant’s knowledge and skill level.

References and letters of recommendation are also used to assess the applicant’s past job experience, but there is little evidence that these have any validity. Because few people write unfavorable letters of recommendation, such letters do not really predict job performance. Criti- cisms are likely to be mild and may be reflected by the lack of positive language. Letters with any criticism should be verified with a telephone call, if possible, to avoid overreacting to an unusually honest author.

To avoid legal problems, many organizations only include employment dates, salary, and whether the applicant is eligible for rehire in letters of recommendation. Many organizations do not allow supervisors to write letters of recommendation. Negative references may be viewed as a potential for slander or other legal recourse. Almost every organization will at least verify position title and dates of employment, which helps detect the occasional applicant who falsifies an entire work history. Unfortunately, leaving out a position from a work history is more common than in- cluding a position not actually held. The only way to detect such omissions is to ask that candidates list the year and month of all their educational and work experiences. Caution is necessary when asking about time between jobs; be careful not to inquire about marital or family status.

In almost every selection situation, an applicant fills out an application form that requests information about previous experience, education, and references. As application forms are re- viewed, the critical question to be asked is whether the applicant has distorted responses, either intentionally or unintentionally. Studies indicate that there is usually little distortion, at least not on the easily verifiable information. Applicants may stretch the truth a bit, but rarely are there complete falsehoods. Relative to other predictors, the application form may be one of the more valid predictors in a selection process.

Licensure status can be verified online with the state board of nursing. Because results of the computerized NCLEX-RN® examination are available in 7 to 10 days, most organizations wait for new graduates to obtain a license before starting employment.

Integrating the Information When comparing candidates, first weigh the qualities required for the job in order of importance, placing more emphasis on the most important elements. Second, weigh the qualities desired on the basis of the reliability of the data. The more consistent the observation of behavior from different


elements in the selection system, the more weight that dimension should be given. Third, weigh job dimensions by trainability—consider the amount of education, experience, and additional training the applicant can reasonably be expected to receive, and consider the likelihood that the behavior in that dimension can be improved with training. Dimensions most likely to be learned in training (e.g., using new equipment) should be given the least weight so that more weight is placed on dimensions less likely to be learned in training (e.g., being emotionally able to care for terminally ill children).

Attempt to compare data across individuals in making a decision. It is more accurate to make decisions based on a comparison of several persons than to make a decision for each indi- vidual after each interview. Analysis of the entire applicant pool requires good interview records but lessens the impact of early impressions on the hiring decision because the interviewer must consider each job element across the entire pool.

Making an Offer Before an offer is made, most organizations obtain permission to do criminal background checks. After the interview, if the nurse manager wants to offer a position to a candidate, HR is notified. HR then does a thorough background check on the candidate to confirm reported criminal history, licensure, and employment history. After that clears, the candidate is called and offered the position, with the condition that a drug screen completed within 24 hours of the phone offer is clean. If so, the offer is official.

In addition, organizations are liable for the character and actions of the employees they hire. To satisfy this requirement, the employer must check applicants’ backgrounds before hiring in regard to licensure, credentials, and references. Failure to do so constitutes negligent hiring if that employee harms a patient, visitor, or another employee.

Legality in Hiring As a result of Title VII of the Civil Rights Act of 1964, the Equal Pay Act of 1963, the Age Discrimination Act of 1967, and Title I of the Americans with Disabilities Act of 1990 and its amendments of 2009, recruitment and selection activities are subject to considerable scrutiny regarding discrimination and equal employment opportunity. Title VII of the Civil Rights Act specifically prohibits discrimination in any personnel decision on the basis of race, color, sex, religion, or national origin. “Any personnel decision” includes not only selection but also en- trance into training programs, performance appraisal results, termination, promotions, compen- sation, benefits, and other terms, conditions, and privileges of employment.

The Act applies to most employers with more than 15 employees, although there are several exemptions—among them, a bona fide occupational qualification (BFOQ), a business necessity, and the validity of the procedure used to make the personnel decision. Discrimination is allowed on the basis of national origin (citizenship or immigration status), religion, sex, and age; for in- stance, if that discrimination can be shown to be a “bona fide occupational qualification reasonably necessary for the normal operation of a business.” Examples include a woman playing a female part in a play, a Sunday school teacher of a certain religion, or a female correctional counselor at a women’s prison. Claims of “customer preference” for female flight attendants or gross gender characteristics such as “women cannot lift over 30 pounds” have not been supported as BFOQs.

A BFOQ allows an organization to exclude members of certain groups (such as all men or all women) if the organization can demonstrate that a selection method is a business necessity. A business necessity is likely to withstand a legal challenge only in the unusual instances when a selection method that discriminates against a protected group is necessary to ensure the safety of workers or customers.

The Equal Employment Opportunity Commission (EEOC) is charged with enforcing and interpreting the Civil Rights Act and has issued Uniform Guidelines on Employee Selection Procedures (43 Federal Register, 1978). The guidelines specify the kinds of methods and infor- mation required to justify the job relatedness of selection procedures. These guidelines are not described in detail here; however, the methods of selection discussed in this chapter do follow


their specifications. Remember that the law does not say one cannot hire the best person for the job. What it says is that race, color, sex, religion, disability, national origin, or any other pro- tected factor must not be used as selection criteria. As long as the decision is not made on the basis of protected status, one is complying with the Equal Employment Opportunity (EEO) law.

EEO law and successive court decisions have had three major impacts on selection proce- dures. First, organizations are more careful to use predictors and techniques that can be shown not to discriminate against protected classes. Second, organizations are reducing the use of tests, which may be difficult to defend if they screen out a large number of minority applicants. Third, organizations are relying heavily on the interview process as a selection device. Interviews are also subject to EEO and other regulations.

Table 15-3 presents appropriate questions to ask in an interview. The basic rule of thumb for interviewing is when you are in doubt about a question’s legality, ask, How is this question related to job performance? If it can be proved that only job-related questions are asked, EEO law will not be violated.

The Age Discrimination Act prohibits discrimination against applicants and employees over the age of 40. Questions in recruitment and selection that are appropriate with respect to age are also presented in Table 15-3.

TABLE 15-3 Preemployment Questions

Appropriate to Ask Inappropriate to Ask

Name Applicant’s name. Whether applicant has school or work records under a different name.

Questions about any name or title that indicate race, color, religion, sex, national origin, or ancestry.

Questions about father’s surname or mother’s maiden name.

Address Questions concerning place and length of current and previous addresses.

Any specific probes into foreign addresses that would indicate national origin.

Age Requiring proof of age by birth certificate after hiring. Can ask if applicant is over 18.

Requiring birth certificate or baptismal record before hiring.

Birthplace or national origin

Any question about place of birth of applicant or place of birth of parents, grandparents, or spouse.

Any other question (direct or indirect) about applicant’s national origin.

Race or color Can request after employment as affirmative action data.

Any inquiry that would indicate race or color.

Sex Any question on an application blank that would indicate sex.

Religion Any questions to indicate applicant’s religious denomination or beliefs.

A recommendation or reference from the applicant’s religious denomination.

Citizenship Questions about whether the applicant is a U.S. citizen; if not, whether the applicant intends to become one.

Questions of whether the applicant, parents, or spouse are native born or naturalized.

Questions regarding whether applicant’s U.S. residence is legal; requiring proof of citizenship after hiring.

Requiring proof of citizenship before hiring.


TABLE 15-3 Continued

Appropriate to Ask Inappropriate to Ask

Photographs May require after hiring for identification purposes only.

Requesting a photograph before hiring.

Education Questions concerning any academic, professional, or vocational schools attended.

Questions specifically asking the nationality, racial, or religious affiliation of any school attended.

Inquiry into language skills, such as reading and writing of foreign languages.

Inquiries as to the applicant’s mother tongue or how any foreign language ability was acquired (unless it is necessary for the job).

Relatives Name, relationship, and address of a person to be notified in case of an emergency.

Any unlawful inquiry about a relative or residence mate(s) as specified in this list.

Children Questions about the number and ages of the applicant’s children or information on child-care arrangements.

Transportation Inquiries about transportation to or from work (unless a car is necessary for the job).

Organization Questions about organization memberships and any offices that might be held.

Questions about any organization an applicant belongs to that may indicate the race, age, disabilities, color, religion, sex, national origin, or ancestry of its members.

Physical condition/ disabilities

Questions about being able to meet the job requirements, with or without some accommodation.

Questions about general medical condition, state of health, specific diseases, or nature/severity of disability.

Military service Questions about services rendered in armed forces, the rank attained, and which branch of service.

Questions about military service in any armed forces other than the United States.

Requiring military discharge certificate after being hired.

Requesting military service records before hiring.

Work schedule Questions about the applicant’s willingness to work the required work schedule.

Questions about applicant’s willingness to work any particular religious holiday.

References General and work references not relating to race, color, religion, sex, national origin or ancestry, age, or disability.

References specifically from clergy (as specified above) or any other persons who might reflect race, age, disability, color, sex, national origin, or ancestry of applicant.

Financial Questions about banking, credit rating, outstanding loans, bankruptcy, or having wages garnished.

Other qualifications Any question that has direct reflection on the job to be applied for.

Any non-job-related inquiry that may present information permitting unlawful discrimination. Questions about arrests or convictions (unless necessary for job, such as security clearance).


The Americans with Disabilities Act that took effect in July 1990 prohibits discrimination based on an individual’s disability. A disability is defined as a physical or mental impairment that substantially limits one or more of the major life activities, or has a record of such impair- ment (e.g., attended a school for the deaf), or is regarded as having such an impairment (e.g., uses a cane to walk). A qualified individual is one who, with or without reasonable accommoda- tion, can perform the essential functions of the position under consideration.

The Act was amended in 2009 (U.S. Department of Justice, 2009). The definition of a dis- ability was broadened in several ways beneficial to employees: The amended Act includes dis- abilities not previously covered (e.g., epilepsy, diabetes, bipolar disorder). The amendments expand the definition of major life activities to include major bodily functions (e.g., immune system, brain functions) and eliminate the ameliorative effects of mitigating measures from con- sideration (e.g., medication, prosthetics).

Employers with 15 or more employees are required to make accommodations to the known disability of a qualified applicant if it will not impose “undue hardship” on the operation of the business. Reasonable accommodations may include making existing facilities used by employ- ees readily accessible to and usable by individuals with disabilities; job restructuring; part-time or modified work schedules; reassignment to a vacant position; acquiring or modifying equip- ment or devices; adjusting or modifying examinations, training materials, or policies; and pro- viding qualified readers and interpreters.

SELECTING STAFF Jack Turner is nurse manager of the emergency depart- ment in a large metropolitan area hospital. He has four full-time RN positions open in his department. There are three nursing programs located in the city: a state uni- versity program, a community college program, and an RN-to-BSN completion program.

Jack recently participated in a nursing job fair hosted by his hospital. The event was well attended by nursing students, and he received several promising résumés of soon-to-be graduate nurses. Jack notes that one of the applicants, Sabrina Ashworth, will graduate next month with a BSN. She has been working for the past year as a nursing assistant in the ER of another local hospital. In addition to her ER work, Sabrina has a high grade point average and indicates a strong interest in trauma and critical care. Jack contacts the human resource depart- ment to set up an interview with Sabrina.

Sabrina agrees to an interview for an RN position in the ER department. Jack schedules a conference room adjacent to the ER for the interview. Prior to Sabrina’s arrival, he reviews her résumé and application, noting her educational background, previous work history, and recent volunteer trip to Mexico to assist with a vaccina- tion program. Jack has assembled a packet for Sabrina, including a job description and materials from human resources that outline the application process.

The interview begins promptly. Jack warmly greets Sabrina and establishes rapport. He follows the interview guide provided by the human resource department. Jack

informs Sabrina that he will be taking notes during the interview process. After reviewing her educational and work history, Jack asks Sabrina several situational ques- tions related to work in the ER. He also allows time for Sabrina to ask questions about the RN position. Jack also has two RN staff members give Sabrina a tour of the ER department. Finally, Jack outlines the next steps in the application process and indicates that he will follow up with Sabrina in 7 to 10 days.

Following the interview, Jack works with the human resource department and asks for transcript and refer- ence checks for Sabrina. After verifying her transcript and receiving positive references, Jack extends an offer to Sabrina, which she accepts.

Manager’s Checklist The nurse manager is responsible for:

● Understanding the organization’s human resource policies and procedures related to selecting staff

● Working closely with the human resource department to facilitate the selection and hiring of qualified staff

● Knowing state and federal regulations related to the application and interview process

● Preparing for the interview process ● Conducting the interview ● Following up with applicants in a timely manner



The 2009 amendments included some employer-friendly provisions as well. Reverse dis- crimination claims by nondisabled individuals are not in violation of the Act. Although the pool of individuals covered in the amendments is expanded, the reasonable accommodation features remain the same, as do existing exclusions for criminal behavior and current drug use.

Recruiting and selecting the most appropriate staff is one of the most important jobs in an organization. Candidates whose qualifications fit the job requirements are more likely to be pro- ductive and to remain on the job. The tendency, especially during times of shortages, is to short- cut the process, but this is ill advised. The effort to attract and select the best candidates pays off over time for the organization.

One nurse manager used the recommendations in this chapter to hire a nurse as shown in Case Study 15-1.

What You Know Now • The selection of staff is a critical function that requires matching people to jobs, and responsibility for

hiring is often shared by HR and nurse managers. • Position description is fundamental to all selection efforts because it defines the job. • Recruitment is the process of locating and attracting enough qualified applicants to provide a pool from

which the required number of new staff members can be chosen. • Selection processes should be job related and most often include screening application forms, résumés,

medical examinations, reference and background checks, and interviews. • Interviewing is a complex skill that is intended to obtain information about the applicant and to give the

applicant information about the organization. • Successful interviews require planning, implementation, and follow-up in order to make the best

decisions. • Developing a structured interview guide is a critical element in interviewing. • Selection decisions are subject to provisions in the Civil Rights Act of 1964, Equal Pay Act of 1963, the

Age Discrimination Act of 1967, and the Americans with Disabilities Act of 1990 as amended in 2009.

Tools for Recruiting and Selecting Staff 1. Conduct or modify a job description as needed. 2. Coordinate recruitment efforts with the human resource department. 3. Ensure that your area of responsibility sends the message you want (see Box 15-1). 4. Prepare adequately for interviews. 5. Conduct interviews following recommendations presented in the chapter. 6. Process the information obtained in interviews and reference and background checks to make a final


Questions to Challenge You 1. What approach does your organization use to recruit employees? Is it effective? How could the pro-

cess be improved? 2. Imagine that a potential candidate asks you to describe your present workplace. What would you say? 3. Have you ever participated in a staff interview, either as a candidate or as a member of the staff?

Describe your experience. Would you do anything differently now that you’ve read the chapter? 4. Cross-training has been used as a recruitment strategy. What are the pros and cons of using this

strategy? 5. Consider the last interview you had for a job or school. Did the interviewer follow the principles dis-

cussed in this chapter? Explain.



Web Resources Job search websites:

Monster.com: www.monster.com Nurse.com: www.nurse.com Sigma Theta Tau International Honor Society of Nursing: http://stti.monster.com Nurse’s CareerCenter: www.nursingworld.org/careercenter

Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake, E. T., & Cheney, T. (2008). Effects of hospital care environment on patient mor- tality and nurse outcomes. Journal of Nursing Adminis- tration, 38(5), 223–229.

Brady-Schwartz, D. C. (2005). Further evidence on the Magnet Recognition

Program: Implications for nursing leaders. Journal of Nursing Administration, 35(9), 397–403.

Parrish, F. (2006). How to recruit, interview, and retain employees. Dermatology Nursing, 18(2), 179–180.

U. S. Department of Justice. (2009). Americans with disabilities act of 1990, as

amended. Retrieved July 25, 2011 from http://www. ada.gov/pubs/ada.htm

U. S. Department of Labor, Bureau of Labor Statistics. (2011). Statistics on regis- tered nurses. Retrieved July 25, 2011 from http://www. dol.gov/wb/factsheets/ Qf-nursing-05.htm

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!










Staffing and Scheduling 16

1. Determine staffing needs. 2. Demonstrate how to use patient classifica-

tion systems to calculate nursing care hours necessary.

3. Calculate FTEs.

4. Determine the appropriate staffing mix and distribution of staff.

5. Describe the various ways to schedule staff. 6. Explain how to supplement staff when


Learning Outcomes After completing this chapter, you will be able to:

Baylor plan Block staffing Demand management Full-time equivalent (FTE)

Key Terms Nursing care hours (NCHs) Patient classification systems (PCSs) Pools Self-scheduling

Staffing Staffing mix


S taffing and scheduling is an important responsibility of the nurse manager and a critical aspect of providing nursing care. Higher nurse staffing levels reduce mortality in hospi-talized patients (Schilling et al., 2010; Needleman et al., 2011). Furthermore, failing to match patient needs to nurses’ skills also increases patient mortality (Needleman et al., 2011).

The impact of California’s mandated nurse staffing supports these findings. Not only did higher nurse staffing levels translate into lower mortality, but hospitals reported better nurse retention rates as a result (Aiken et al., 2010). In addition, Magnet hospitals report higher nurse staffing levels (Hickey et al., 2010) and improved teamwork (Kalisch & Lee, 2011).

Staffing The goal of staffing is to provide the appropriate numbers and mix of nursing staff (nursing care hours) to match actual or projected patient care needs (patient care hours) to provide effective and efficient nursing care. There is no single or perfect method to achieve this. In addition, vari- ability in patient census requires continuous fine-tuning.

A hospital unit may experience a steady census during the seven days of the week or a higher census from Monday to Friday. Its patient days may be distributed evenly during the year, or it may consistently experience peaks in occupancy in certain months (seasonality pattern) such as during an outbreak of influenza. Outpatient clinics may be busier on days when special- ists are available or vaccines are offered. Staffing is a challenge in all health care settings.

To determine the number of staff needed, managers must examine workload patterns for the designated unit, department, or clinic. For a hospital, this means determining the level of care, average daily census, and hours of care provided 24 hours a day, seven days a week.

Both the Joint Commission, hospitals’ accrediting body, and the American Nurses Association identify staffing requirements. The Joint Commission (2011) requires that the right number of competent staff be provided to meet patients’ needs based on organization-selected criteria. The American Nurses Association (ANA) (Manojlovich, 2009) specifies requirements for staffing systems as shown in Box 16-1.

Patient Classification Systems Patient classification systems (PCSs), sometimes referred to as patient acuity systems, use patient needs to objectively determine workload requirements and staffing needs. To be most effective, patient classification data are collected midpoint for every shift by the unit nursing staff and analyzed before the next shift to ensure appropriate numbers and mix of nursing staff.

Ideally, this system would accurately predict the number and skill level of nurses needed for the next shift. But much can go amiss. Some nurses may call in sick; the nurses scheduled may not have the skill set necessary for a new admission, for example; or, most important, the patient’s condition may change.

BOX 16-1 Requirements for Staffing Systems

A reliable and valid staffing plan must:

● Be created with input from direct-care registered nurses

● Be based on the number of patients and patient-acuity level with consideration of patient admissions, discharges, and transfers on each shift

● Reflect the level of preparation and experience of those providing care

● Reflect staffing levels recommended by specialty organizations

● Provide that an RN not be forced to work in a unit without having established that he or she is able to provide professional care on such a unit

Adapted from Manojlovich, M. (2009). Seeking staffing solutions. American Nurse Today, 4(3), 26.


Picard and Warner (2007) suggest fine-tuning PCS systems to predict the demand for nursing expertise several days in advance. They complain that basing staffing on immediate patient needs is short-sighted and often results in failure as mentioned above. Their system, called demand man- agement, uses best-practices staffing protocols to predict and control the demand for nurses based on patient outcomes. Based on historical data, a patient progress pattern typifies expected patient outcomes throughout a stay. Deviations are tracked and staffing adjusted accordingly. This system allows the manager to staff into the next few days with more assurance than predicting from one shift to the next. Whatever system is used, the next step is to determine the necessary nursing care hours.

Determining Nursing Care Hours Patient workload trends are analyzed for each day of the week (each hour in critical care) or for a specific patient diagnosis to determine staffing needs, known as nursing care hours (NCHs). For example, if 26 patients with the following acuities required 161 nursing care hours, then an average of 6.19 nursing hours per patient per day (NHPPD) are required. NHPPD are calculated by divid- ing the total nursing care hours by the total census (number of patients).

There are no specific standards for NCHs for any type of patient or patient care unit. NCHs may vary on the average from five to seven hours of care for patients on medical and/or surgi- cal units, to 10 to 24 hours of care for patients in critical care units, to 24 to 48 hours of care for selected patients, such as new, severely burned patients.

Number of Patients

Acuity Level

Associated Hours of Care

Total Hours of Care

3 I 2 6

10 II 6 60

11 III 7 77

2 IV 9 18

Total 26 161

Determining FTEs Positions are defined in terms of a full-time equivalent (FTE). One FTE equals 40 hours of work per week for 52 weeks, or 2,080 hours per year. In a two-week pay period, one FTE would equal 80 hours. For computational purposes, one FTE can be filled by one person or a combination of staff with comparable expertise. For example, one nurse may work 24 hours per week, and two other nurses may each work 8 hours per week. Together, the three nurses fill one FTE (24 + 8 + 8 = 40).

Several methods are available for determining the number of FTEs required to staff a unit 24 hours a day, seven days a week. One technique incorporates information regarding the hours of work for the staff for two weeks, average daily census, and hours of care. The average daily census can be determined by dividing the total patient days (obtained from daily census counts for the year) by the number of days in the year.


Total patient days = 9490

365 = 26 patients per day

Data Number of hours worked per FTE in two weeks = 80 Number of days of coverage in two weeks = 14 Average daily census = 26 Average nursing care hours (from PCS) = 6.15



x = average nursing care hours * days in staffing period * average patient census

hours of work per FTE in two weeks

x = 6.15 * 14 * 26

80 =


80 = 27.98, or 28 FTFEs

A second technique uses nursing care hours and annual hours of work provided by one FTE:

Data Number of hours worked per FTE in one year = 2080 Total nursing care hours (from PCS) = 161


x = Total nursing care hours * days in a year

Total annual hours per one FTE

x = 161 * 365

2080 =


2080 = 28.25, or 28 FTEs

One person working full-time usually works 80 hours (10 eight-hour shifts) in a two-week period. However, to staff an eight-hour shift takes 1.4 FTEs, one person working 10 eight-hour shifts (1.0 FTE) and another person working four eight-hour shifts (0.4 FTE) in order to provide for the full-time person’s two days off every week. For 12-hour shifts, it takes 2.1 FTEs to staff one 12-hour shift each day, each week; two people each working three 12-hour shifts and one person working one 12-hour shift each week (0.9 FTE = 0.9 FTE = 0.3 FTE = 2.1 FTEs). Therefore, the same number of FTEs is required to staff a unit for 24 hours a day for two weeks, regardless of whether the staff are all on 8-hour shifts (1.4 FTEs × 33 shifts = 4.2 FTEs) or 12-hour shifts (2.1 FTEs × 32 shifts = 4.2 FTEs).

Determining Staffing Mix The same data used to determine FTEs are used to identify staffing mix. For example, for patient care needs involving general hygiene care, feeding, transferring, or turning patients, licensed practical nurses (LPNs) or unlicensed assistive personnel (UAPs) can be used. For patient care needs involving frequent assessments, patient education, or discharge planning, RNs will be needed because of the skills required. A high RN-skill mix allows for greater staffing flexibility. Again, information on typical or usual patient needs is obtained by using trends from the patient classification system.

Determining Distribution of Staff For many patient care units, the distribution of staff varies from shift to shift and by days of the week. Patient census on a surgical unit will probably fluctuate throughout the week, with a higher census Monday through Thursday and a lower census over the weekend. In addition, some surgical units may have more complex cases earlier in the week and short-stay surgical cases later in the week. Surgical patients may have a shorter length of stay (LOS) than many medical patients. The patient census on a medical unit rarely fluctuates Monday through Friday, but may be less on weekends, when diagnostic tests are not done.

The workload on many units also varies within the 24-hour period. The care demands on a surgical unit will be heaviest early in the morning hours prior to the start of the surgical schedule; mid-morning, when the unit receives patients from critical care units; late in the afternoon, when patients return from the postanesthesia recovery unit; and in the evening hours, when same-day surgical patients are discharged.

Critical care units may have greater care needs in the mornings when transferring patients to medical or surgical units and in the early afternoon hours when admitting new surgical cases.


Medical units usually have the heaviest care needs in the morning hours, when patients’ daily care needs are being met and physicians are making rounds. On skilled nursing and rehabilitation units, care needs are greatest before and immediately after mealtimes and in the evening hours; during other times of the day, patients are often away from the unit and involved in various therapeutic activities.

In contrast with the medical, surgical, critical care, and rehabilitation units that have definite patterns of patient care needs, labor-and-delivery and emergency department areas cannot predict when patient care needs will be most intense. Thus, labor-and-delivery and emergency department areas must rely on block staffing to ensure that adequate nursing staff are available at all times.

Here’s what a nurse manager told a new nurse candidate when asked about the nurse to staff ratio:

“On the surgical step-down floor, we most typically staff at a one-RN-to-four-patient ratio. We also plan to have a charge nurse who is not taking patients to assist staff with extra tasks and needs. On occasion, a nurse may have three patients or five patients. We always work to be flexible, looking at the acuity of the patients and the competencies of the staff who are working. During each shift, we reassess every four hours and as needed to ensure assignments are still appropriate and patient needs haven’t significantly changed, necessitating a reassignment of patients. We also have nurse aides on this floor. They help with vital signs, bed changes, baths, and ambulation. There is most typically one aide for every 8 to 12 patients. Also, a unit clerk answers the phones and greets guests. This team dynamic creates for great patient care.”

Block staffing involves scheduling a set staff mix for every shift. However, there may be trends in peak workload hours in emergency departments, when additional staff (RN, UAP, or secretary) beyond the block staff are necessary. Examples of peak workload hours within the emergency department may be from 6:00 p.m. to 10:00 p.m. to accommodate patient needs after physicians’ offices close, or from 12:00 a.m. to 3:00 a.m. to accommodate alcohol-related injuries. All these needs in patterns of care must be known when staffing requirements and work schedules are established. Data reflecting peak workload times must be continuously monitored to maintain the appropriate levels and mix of staff.

Scheduling Creative and Flexible Staffing Nurse shortages and current restrictions in salary budgets have made creative and flexible staffing patterns necessary and probably everlasting. Combinations of 4-, 6-, 8-, 10-, and 12-hour shifts and schedules that have nurses working six consecutive days of 12-hour shifts with 13 days off, and staffing strategies, such as weekend programs and split shifts, are common.

Flexible staffing patterns can be a major challenge and, in some cases, a mathematical challenge. However, once a schedule is established and agreed to by the nurse manager and the staff, it can become a cyclic schedule for an extended period of time, such as 6 to 12 months. This allows staff members to know their work schedule many months ahead of time.

The use of 8-hour and 12-hour shifts is fairly straightforward. Problems with combined staffing patterns may include:

● The perception that nurses don’t work full-time when they work several days in a row and then are off for several days in a row

● Disruption in continuity of care if split shifts are used (7:00 to 11:00 a.m.; 11:00 a.m. to 3:00 p.m.; 3:00 p.m. to 7:00 p.m.; 7:00 p.m. to 1:00 a.m.; 1:00 a.m. to 7:00 a.m. shifts)

● Immense challenges for nurse managers to communicate with all staff in a timely manner


Advantages of using combined staffing patterns are that it:

● Better meets patient care needs during peak workload times ● Improves staff satisfaction ● Maximizes the availability of nurses

Ten-hour shifts provide greater overlap between shifts to permit extra time for nurses to complete their work; for this reason, they may increase salary expenditures. There are a few specialty units in which 10-hour shifts would be cost-efficient: postanesthesia recovery areas, operating departments, and emergency departments are examples.

Self-staffing and Scheduling Some hospitals have instituted self-staffing. This is an empowerment strategy that allows unit staff the authority to use their backup staffing options if the patient workload increases or if unscheduled staff absences occur. Likewise, staff can and must go home early if the patient workload decreases.

Self-scheduling allows the staff to create and manage the schedule. Self-scheduling can be positive for the staff and for the manager, but attention must be paid to balancing unit needs with individual requests (Bailyn, Collins, & Song, 2007). Whether the schedule is determined by the manager or by staff, the schedule can be transparent for all staff by posting it online (also see section on automated scheduling). In this way, the organization can demonstrate fairness in scheduling and leverage staff expertise in an equitable manner.

Shared Schedule A new tool currently in use is a shared schedule. Two people share one full-time schedule by splitting the day of 12 hours into half days of 6.5 hours each, alternating morning and afternoon shift. This allows nurses who might not be able to work the full 12 hours to share the shift.

Open Shift Management Open shift management is an innovative technique to allow an organization’s staff to self- schedule additional shifts (Bantle, 2007). With the schedule posted online, as described above, staff members can select assignments and shifts that fit their expertise and accommodate their personal schedules. This strategy is especially valuable to health care systems with several hos- pitals in which nurses from one hospital can select assignments at any of the others. The organi- zation itself could establish an internal staffing pool (see next section).

Case Study 16-1 shows how one hospital used open scheduling to decrease its use of agency staff and improve staff morale.

Weekend Staffing Plan Hospitals can no longer arbitrarily staff patient care units on weekends or at nights with mar- ginal numbers or levels of qualified staff. The acuity of patients in hospitals, including medical and surgical patients, mandates staffing units on the weekends by the same principles used for weekdays. Thorough trend analysis of patient data can provide the justification necessary to appropriately decrease the number of RNs, at least for some levels, because of differences in patient care needs throughout the day.

A creative method for weekend staffing is the Baylor plan. Developed at Baylor University Medical Center, nurses agree to work only 12-hour shifts on the weekend and are paid for a standard work week. Numerous hospitals have adopted this model for weekend staffing (Cedar Community Hospital, 2011; St. Vincent’s Hospital, 2011).

Automated Scheduling Technology today makes automated scheduling feasible (Douglas, 2010). Matching patient demand to nurse staffing is better done by automated systems than by individuals. To aid in scheduling decisions, data should include patient information, nurse characteristics, and hospital


data (Frith, Anderson, & Sewell, 2010). Automated systems improve patient care outcomes because nurses spend more time with the patients who need the most nursing care. In addition, using nurses’ time appropriately improves financial outcomes as well (Barton, 2011).

Data are often displayed on a dashboard. A dashboard is a computer display of real-time data collected from various sources and categorized for use in decision making.

Supplementing Staff When there is a need for additional staff because of scheduled or unscheduled absences, increased workload demands, or existing staff vacancies, the nurse manager or staffing person must find additional staff. Options include using PRN staff (staff scheduled on an as-needed basis), part-time staff, internal float pools, or outside agency nurses.

Supplemental staff are needed when workload increases beyond that which the existing staff can manage, staff absences and resignations occur, and staff vacancies exist. Chronic staffing problems need to be addressed in a proactive manner involving the nurse manager, the chief nurse executive, and the nursing personnel on the unit with the problem. Strategies for dealing with turnover and for managing absenteeism are discussed in Chapter 20.

Internal Pools Acute staffing problems can be addressed by establishing internal float pools using nurs- ing staff and unlicensed assistive personnel (UAPs). Internal float pools of nurses can provide

SCHEDULING Tori Abraham and Jillian Moore are both nurse manag- ers of general med/surg units at separate hospitals that are part of a large metropolitan health care system. Staffing among the med/surg units has been problem- atic due to increased patient volume and cost control measures enacted by the health care corporation. Staff members have complained numerous times that extra shifts are only offered to part-time employees and that premium pay shifts are given to those with more senior- ity. As the holidays approach, staff tension increases as a lottery system has traditionally been used to assign shifts for major holidays. Additionally, since employees are free to transfer within any of the eight metropoli- tan hospitals, there has been significant turnover on the med/surg units as employees decide to transfer to ambu- latory care and same day surgery facilities.

Tori and Jillian have volunteered to be part of a new scheduling system for their health care system. Nurses and nursing assistants will be able to view open shifts on each unit and e-mail Tori or Jillian with requests to staff shifts for which they are qualified. By allowing staff to have greater control over which additional shifts and at which facility they prefer to work, the nurse managers hope to decrease agency staffing and increase employee satisfaction. Additional units are expected to come on- line, which will also allow staff to have experience on oncology, skilled nursing, and orthopedic patients. The education department will provide a database of employee certifications to managers to ensure that staff

wishing to work away from their home units are quali- fied for the job.

After 90 days of using the new open shift schedul- ing system, Tori and Jillian are pleased with the results. Agency staff use has decreased by 60 percent, and staff members report they are happier with the ability to schedule their own additional shifts as well as work at a different facility without having to transfer. Holiday staffing has been easier, as those employees who pre- fer to work premium pay for holidays are able to self- schedule. Tori and Jillian present their findings to the chief nursing officer and will be part of the team imple- menting systemwide use of open shift scheduling.

Manager’s Checklist The nurse manager is responsible for:

● Understanding the scheduling and staffing needs for his or her areas of responsibility

● Analyzing the economic impact of using agency staffing for open shifts and the financial impact on budget

● Ensuring adequate staffing for safe and appropriate patient care

● Communicating with staff members regarding con- cerns or frustrations over scheduling and staffing

● Using creative problem solving to address scheduling and staffing issues

● Improving employee job satisfaction and patient care skills



supplemental staffing at a substantially lower cost than external agency nurses. In addition, in- ternal staff are familiar with the organization. All staff participating in the internal float pool must be adequately trained for the type of patient care they will be giving.

Internal float pools can be centralized or decentralized. A centralized pool is the most efficient. A pool of RNs, LPNs, UAPs, and unit clerks are available for placement anywhere in the institution. However, it may be difficult to place the person with the correct skills for a particular unit at the needed time.

In decentralized pools, a staff member usually works only for one nurse manager or on only one unit. The advantages of decentralized pools include better accountability, improved staffing response, and improved continuity of care. Critical care units, operating rooms, maternal–child units, and other highly specialized or technical areas tend to use a decentralized system.

In addition, staff can receive cross-training in preparation for assignment to another unit. A critical-care nurse might be cross-trained for the step-down unit, for example. Dual-unit positions could be established in the recruiting phase to give the organization the maximum flexibility in scheduling and the employee an opportunity to acquire additional skills.

External Pools For some institutions, agency nurses become part of the regular staff contracted to fill vacancies for a specified period of time (e.g., a nurse on maternity leave). However, most agency nurses are used as supplemental staff. All agency nurses require orientation to the facility and unit, and they must work under the supervision of an experienced in-house nurse. Management must verify valid licen- sure, ensure that either the agency or agency nurse has current malpractice insurance, and develop a mechanism to evaluate the agency nurse’s performance. Although an agency nurse may meet an urgent staffing need, continuity of care may be compromised and there may be some staff resent- ment because these nurses may earn two to three times the salary of in-house nurses.

Concern about the quality of agency nurses appears to be unfounded, according to a study analyzing adverse events in Pennsylvania hospitals (Aiken, Xue, Clarke, & Sloane, 2007). Rather, adverse outcomes resulted from deficits in the hospital environments, not from the quality of the agency nurse assigned there.

Ensuring that sufficient staff are available and that they are scheduled appropriately is a demanding task and one that is constantly in flux. Nevertheless, such activities are critical to achieving positive patient outcomes and providing safe, effective, and cost-conscious staffing.

What You Know Now • The goal of staffing and scheduling is to provide an adequate mix of nursing staff to match patient care

needs. • The Joint Commission requires that organizations determine criteria for nurse staffing and provide

adequate numbers of competent staff to meet that criteria. • Patient classification systems use patient needs to determine workload requirements and staffing needs. • Scheduling involves assigning available staff in a way that patient care needs are met. • Flexible and creative staffing and scheduling techniques are increasingly necessary. • Self-staffing and scheduling, including open shift management, is an option in which nursing staff partici-

pate in designing the schedule and accept responsibility for ensuring attendance. • Automated scheduling improves patient outcomes and uses fiscal resources appropriately.

Tools for Handling Staffing and Scheduling 1. Familiarize yourself with the current patient classification, acuity system, or automated system in

use. 2. Determine the nursing care hours needed.


3. Determine FTEs needed. 4. Create or modify a schedule that best meets your patients’ needs. 5. Supplement staff as needed. 6. Consider self-staffing if appropriate.

Questions to Challenge You 1. What has been your experience with staffing? Use any work setting where you are or have been an

employee. How well did it work? Was there adequate coverage to meet the needs of the organiza- tion? Explain.

2. Using the formulas for calculating FTEs in the chapter, create your own examples and work the problems from them. Were you able to compute needed FTEs? Now calculate the hours needed when nursing staff work 8-hour or 12-hour shifts.

3. On occasion, there are more staff available than are needed. As a nurse manager, how would you handle this? How might the staff respond?

4. No one is ever completely satisfied with the schedule. How would you handle a staff member who repeatedly asks to have his schedule changed?

Aiken, L. H., Xue, Y., Clarke, S., & Sloane, D. M. (2007). Supplemental nurse staffing in hospitals and quality of care. Journal of Nursing Administration, 37(7/8), 335–342.

Aiken, L. H., Sloane, D. M., Cimiotti, J. P., Clarke, S. P., Flynn, L., Seago, J. A., Spetz, J., & Smith, H. L. (2010). Implications of the California nurse staffing mandate for other states. Health Services Research, 45(3), 904–921.

Bailyn, L., Collins, R., & Song, Y. (2007). Self-scheduling for hospital nurses: An attempt and its difficulties. Journal of Nursing Management, 15(1), 72–77.

Bantle, A. (2007). Automated workforce tracking keeps

you flexible. Nursing Management, 38(9), 29.

Barton, N. S. (2011). Matching nurse staffing to demand. Nursing Management, 42(2), 37–39.

Cedar Community Hospital. (2011). Baylor weekend staffing program. Retrieved July 29, 2011 from http:// www.cedarcommunity. org/opportunities_92_ 2341037709.pdf

Douglas, K. (2010). Digital dashboards and staffing: A perfect match. American Nurse Today, 5(5), 52–53.

Frith, K. H., Anderson, F., & Sewell, J. P. (2010). Assessing and selecting date for a nursing services dashboard. Journal of Nursing Administration, 40(1), 10–16.

Hickey, P., Gauvreau, K., Connor, J., Sporing, E., & Jenkins, K. (2010). The relationship of nurse staffing, skill mix, and Magnet recognition to in- stitutional volume and mor- tality for congenital heart surgery. Journal of Nurs- ing Administration, 40(5), 226–232.

Joint Commission. (2011) Comprehensive ac- creditation manual for hospitals: The official handbook. Retrieved July 28, 2011 from http://www.jcrinc.com/ Accreditation-Manuals/ PCAH11/2130/

Kalisch, B. J., & Lee, K. H. (2011). Nurse staffing levels and teamwork: A cross-sectional study of

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!



patient care units in acute care hospitals. Journal of Nursing Scholarship, 43(1), 82–88.

Manojlovich, M. (2009). Seeking staffing solutions. American Nurse Today, 4(3), 25–27.

Needleman, J., Buerhaus, P., Pankratz, S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse staffing and inpatient hospital mortal- ity. New England Journal of Medicine, 364(11), 1037–1045.

Picard, B., & Warner, M. (2007). Demand management: A methodology for outcomes-driven staffing and patient flow manage- ment. Nurse Leader, 5(2), 30–34.

Schilling, P. L., Campbell, D. A., Englesbe, M. J., & Davis, M. M. (2010). A comparison of in-hospital mortality risk conferred by high hospital occupancy, differences in nurse staffing levels, weekend admission, and seasonal influenza.

Medical Care, 48(3), 224–232.

St. Vincent’s Hospital. (2011). Baylor staffing plan agreement. Retrieved July 28, 2011 from http:// intranet.stv.org/documents/ docmanager/nursingservices/ display/formnumber8720_/ 87200350baylors/8720- 0350BaylorStaffing- PlanAgreement.pdf


A Model of Job Performance EMPLOYEE MOTIVATION


Manager as Leader

Staff Development ORIENTATION








Succession Planning

Motivating and Developing Staff 17

Key Terms Content theories Equity theory Expectancy theory Extinction Goal-setting theory Horizontal promotion

1. Describe how motivation and ability affect job performance.

2. Discuss how different theories explain motivation.

3. Explain how orientation, preceptors, and on-the-job instruction can help motivate staff.

4. Describe the benefits of nurse residency programs, career advancement strate- gies, and leadership development on motivation.

5. Discuss why succession planning is essential to the future.

Learning Outcomes After completing this chapter, you will be able to:

Motivation On-the-job instruction Operant conditioning Orientation Preceptor Process theories

Punishment Reinforcement theory

(behavior modification) Shaping


A continual and troublesome question facing managers today is why some employees perform better than others. Making decisions about who performs what tasks in a particular manner without first considering individual behavior can lead to irreversible, long-term problems.

Each employee is different in many respects. A manager needs to ask how such differences influence the behavior and performance of the job requirements. Ideally, the manager performs this assessment when the new employee is hired. In reality, however, many employees are placed in positions without the manager having adequate knowledge of their abilities and/or interests. This often results in problems with employee performance, as well as conflict between employ- ees and managers. Employee performance literature ultimately reveals two major dimensions as determinants of job performance: motivation and ability (Hersey, Blanchard, & Johnson, 2007).

A Model of Job Performance Nurse managers spend considerable time making judgments about the fit among individuals, job tasks, and effectiveness. Such judgments are typically influenced by both the manager’s and the employee’s characteristics. For example, ability, instinct, and aspiration levels—as well as age, education, and family background—account for why some employees perform well and others poorly. Based on these factors, a model that considers motivation and ability as determinants of job performance is presented in Table 17-1.

This performance model identifies six categories likely to be viewed as important:

1. Daily job performance

2. Attendance

3. Punctuality

4. Adherence to policies and procedures

5. Absence of incidents, errors, and accidents

6. Honesty and trustworthiness

Although there is conceptual overlap in these categories, separate designation of each helps emphasize their importance.

When using this model, carefully consider several factors. First, the health care organiza- tion should establish and communicate clear descriptions of daily job performance so that de- viations from expected behaviors can be easily identified and documented. Second, behaviors

TABLE 17-1 A Simplified Model of Job Performance

Motivation And Ability = Employee Performance

Compensation Responsibilities Daily job performance

Benefits Education—basic/advanced Attendance

Job design Continuing education Punctuality

Leadership style Skills/abilities Adherence to policies and procedures

Recruitment and selection Absence of incidents/errors/accidents

Employee needs/goals/abilities Honesty and trustworthiness


considered troublesome in one department may be acceptable in another department. Finally, some behaviors are viewed as serious only when repeated (e.g., being late to work), whereas others are classified as troublesome following only one incident (e.g., a medication error with severe consequences).

Employee Motivation Motivation describes the factors that initiate and direct behavior. Because individuals bring to the workplace different needs and goals, the type and intensity of motivators vary among employees. Nurse managers prefer motivated employees because they strive to find the best way to perform their jobs. Motivated employees are more likely to be productive than are nonmotivated workers. This is one reason that motivation is an important aspect of enhancing employee performance.

Motivational Theories Historically, motivational theories were concerned with three things:

1. What mobilizes or energizes human behavior

2. What directs behavior toward the accomplishment of some objective

3. How such behavior is sustained over time

The usefulness of motivational theories depends on their ability to explain motivation adequately, to predict with some degree of accuracy what people will actually do, and, finally, to suggest practical ways of influencing employees to accomplish organizational objectives. Motivational theories can be classified into at least two distinct groups: content theories and process theories.

Content Theories Content theories emphasize individual needs or the rewards that may satisfy those needs. There are two types of content theories: instinct and need. Instinct theorists characterized instincts as inherited or innate tendencies that predisposed individuals to behave in certain ways. These theo- ries were attacked for their difficulty in pinpointing the specific motivating behaviors and the acute awareness of the variability in the strengths of instincts across individuals. In addition, the development of need theories supported the concept that motives were learned behaviors.

Process Theories Whereas content theories attempt to explain why a person behaves in a particular manner, process theories emphasize how the motivation process works to direct an individual’s effort into performance. These theories add another dimension to the manager’s understanding of mo- tivation and help predict employee behavior in certain circumstances. Examples of process theo- ries are reinforcement theory, expectancy theory, equity theory, and goal-setting theory.

Reinforcement theory, also known as behavior modification, views motivation as learn- ing (Skinner, 1953). According to this theory, behavior is learned through a process called oper- ant conditioning, in which a behavior becomes associated with a particular consequence. In operant conditioning, the response–consequence connection is strengthened over time—that is, it is learned.

Consequences may be positive, as with praise or recognition, or negative. Positive reinforc- ers are used for the express purpose of increasing a desired behavior.

Kyle, a staff nurse, offered a creative idea to redesign work flow on the unit. His manager supported the idea and helped Kyle implement the new process. In addition, the man- ager praised Kyle for the extra effort and publicly recognized him for the idea. Kyle was encouraged by the outcome and sought other solutions to work-flow problems.


Negative reinforcers are used to inhibit an undesired behavior. Punishment is a common technique.

To get Rose to chart adequately, the manager required her to come to his office daily with her patient charts, and they reviewed her charting together. She was required to do this until she achieved an acceptable level of charting. Rose found the task laborious and humiliating. As a result, Rose was soon charting appropriately.

Because punishment is negative in character, an employee may fail to improve and also may avoid the manager and the job, as well. The effects of punishment are generally temporary. Undesirable behavior will be suppressed only as long as the manager monitors the situation and the threat of punishment is present. Conversely, positive reinforcement is the best way to change behavior.

Extinction is another technique used to eliminate negative behavior. By removing a positive reinforcer, undesired behavior is extinguished.

Consider the case of Jasmine, a chronic complainer. To curb this behavior, her man- ager chose to ignore her many complaints and not try to resolve them. Initially, Jasmine complained more, but eventually she realized her behavior was not getting the desired response and stopped complaining.

A problem with operant conditioning (behavior modification) is that there is no sure way to elicit the desired behavior so that it can be reinforced. In addition, staff and the manager may view consequences differently.

Take Thad, for example. As a new employee, Thad conscientiously completed critical paths for his assigned patients. When the manager recognized Thad for his good work, his peers began to exclude him from the group. Although the manager was attempting positive reinforcement, Thad quit completing critical paths because he felt the manager had aliena- ted him from his coworkers.

Another procedure is shaping. Shaping involves selectively reinforcing behaviors that are successively closer approximations to the desired behavior. When people become clearly aware that desirable rewards are contingent on a specific behavior, their behavior will eventually change.

Behavior modification works quite well, provided that rewards can be found that, in fact, employees see as positive reinforcers, and provided that supervisory personnel can control such rewards or make them contingent on performance. This does not mean that all rewards work equally well or that the same rewards will continue to function effectively over a long time. If someone is praised four or five times a day every day, the praise would soon begin to wear thin: it would cease to be a positive reinforcer. Care must be taken not to over do a good thing.

Like reinforcement theory, expectancy theory (Vroom, 1964) emphasizes the role of re- wards and their relationship to the performance of desired behaviors. Expectancy theory regards people as reacting deliberately and actively to their environment.

In an effort to improve the amount of delegation by the nurses on her unit, Andrea ap- proached the situation from an expectancy theory perspective. She identified that the nurses wanted to assign more duties to assistive personnel but were reluctant because of concerns about liability. Once Andrea was able to clarify liability issues, the nurses were eager to delegate tasks that could be performed by nonlicensed staff in order to devote more time to their professional responsibilities.

Expectancy theory also considers multiple outcomes. Consider the possibility of a promo- tion to nurse manager. Even though a staff nurse believes such a promotion is positive and is a


desirable reward for competent performance in patient care, the nurse also realizes that there are possibly some negative outcomes (e.g., working longer hours, losing the close camaraderie en- joyed with other staff members). These outcomes may influence the staff nurse’s decision.

Similarly, equity theory suggests that a person perceives that one’s contribution to the job is rewarded in the same proportion that another person’s contribution is rewarded. Job contribu- tions include such things as ability, education, experience, and effort, whereas rewards include job satisfaction, pay, prestige, and any other outcomes an employee regards as valuable (Adams, 1963, 1965).

Unlike expectancy theory and equity theory, goal-setting theory suggests that it is not the rewards or outcomes of task performance per se that cause a person to expend effort, but rather the goal itself (Locke, 1968).

Timothy was new to a home care hospice program. An important skill in care with the termi- nally ill is therapeutic communication. Timothy and his manager recognized that he needed help to improve his skills in communicating with these patients and their families. His man- ager asked him to write two goals related to communication. Timothy expressed a desire to attend a communications workshop and also indicated he would try at least one new com- munication technique each week. Within a month, Timothy’s therapeutic communication skills had already improved. As a result, Timothy was more satisfied with his position, his patients received more compassionate care, and Timothy found his work more rewarding.

Each theory of work motivation contributes something to our understanding of, and ulti- mately our ability to influence, employee motivation.

Manager as Leader The manager serves as a role model, exemplifying leadership qualities that reflect the organiza- tion’s values, mission, and vision and plays a key role in staff members’ job satisfaction and retention (Failla & Stichler, 2008). Additionally, the manager can create conditions that enhance employee motivation (Doucette, 2009) and provide opportunities and encouragement for staff development (Urquhart, 2009).

Staff Development Orientation Getting an employee started in the right way is essential. A well-planned orientation reduces the anxiety that new employees feel when beginning the job. In addition, socializing the employee into the workplace contributes to unit effectiveness by reducing dissatisfaction, absenteeism, and turnover (see Chapter 20).

Orientation is a joint responsibility of both the organization’s staff development personnel and the nursing manager. In most organizations, the new staff nurse completes the orientation program, whereupon the nurse manager (or someone appointed to do this) provides an on-site orientation. Staff development personnel and unit staff should have a clear understanding of their respective, specific responsibilities so that nothing is left to chance. The development staff should provide information involving matters that are organization-wide in nature and relevant to all new employees, such as benefits, mission, governance, general policies and procedures, safety, quality improvement, infection control, and common equipment. The nurse manager should concentrate on those items unique to the employee’s specific job.

New employees often have unrealistically high expectations about the amount of challenge and responsibility they will find in their first job. If they are assigned fairly undemanding, entry- level tasks, they feel discouraged and disillusioned. The result is job dissatisfaction, turnover, and low productivity.


So, one function of orientation is to correct any unrealistic expectations. The nurse manager needs to outline specifically what is expected of new employees. Such realistic job previews help prevent early departures from the organization and, possibly, the nursing profession.

Socializing new employees can sometimes be difficult because of the anxiety people feel when they first come on the job. They simply do not hear all of the information they are given. They spend a lot of energy attempting to integrate and interpret the information presented, and consequently they miss some of it. So repetition may be necessary the first few days or weeks on the job. Ongoing follow-up is important.

Trina Prescott, RN, joined the pediatric oncology unit of a large university teaching hospital. Her nurse manager, Lily Yuen, scheduled a lunch with Trina 30 days after she started. Lily had a relaxed conversation with Trina about the first 30 days of her employ- ment. Trina expressed how much she enjoyed her new job, but that she still felt uncomfort- able accessing implanted vascular ports without assistance. Lily makes a note to schedule one-on-one teaching for Trina with a nurse from the IV team. Scheduling a lunch with new employees approximately 30 to 60 days into their employment has improved new employee retention and increased open communication between Lily and her staff.

On-the-Job Instruction The most widely used educational method is on-the-job instruction. This often involves assign- ing new employees to experienced nurse peers, preceptors, or the nurse manager. The learner is expected to learn the job by observing the experienced employee and by performing the actual tasks under supervision.

On-the-job instruction has several positive features, one of which is its cost-effectiveness. New nurses learn effectively at the same time they are providing care. Moreover, this method re- duces the need for outside instructional facilities and reliance on professional educators. Trans- fer of learning is not an issue because the learning occurs on the actual job. However, on-the-job instruction often fails because there is no assurance that accurate and complete information is presented, and the instructor may not know learning principles. As a result, presentation, prac- tice, or feedback may be inadequate or omitted.

On-the-job instruction fulfills an important function; however, staff members involved may not view it as having equal value to more standardized and formal classroom instruction.

To implement effective on-the-job instruction, the following are suggested:

1. Employees who function as educators must be convinced that educating new employees in no way jeopardizes their own job security, pay level, seniority, or status.

2. Individuals serving as educators should realize that this added responsibility will be instrumental in attaining other rewards for them.

3. Pair teachers and learners to minimize any differences in background, language, personal- ity, attitudes, or age that may inhibit communication and understanding.

4. Select teachers on the basis of their ability to teach and their desire to take on this added responsibility.

5. Staff nurses chosen as teachers should be carefully educated in the proper methods of instruction.

6. Formalize assignments so that nurses do not view on-the-job instruction as happenstance or second-class instruction.

7. Rotate learners to expose each one to the specific know-how of various staff nurses or education department teachers.


8. Employees serving as teachers should understand that their new assignment is by no means a chance to get away from their own jobs but that they must build instructional time into their workload.

9. The efficiency of the unit may be reduced when on-the-job instruction occurs.

10. The learner must be closely supervised to prevent him or her from making any major mistakes and carrying out procedures incorrectly.

Preceptors One method of orientation is the preceptor model, which can be used to assist new employees and to reward experienced staff nurses. The preceptor model provides a means for orienting and socializing the new nurse as well as providing a mechanism to recognize exceptionally compe- tent staff nurses. Staff nurses who serve as preceptors are selected based on their clinical com- petence, organizational skills, ability to guide and direct others, and concern for the effective orientation of new nurses.

The primary function of the preceptor is to orient the new nurse to the unit. This includes proper socialization of the new nurse within the group as well as familiarizing her or him with unit functions. The preceptor teaches any unfamiliar procedures and helps the new nurse develop any necessary skills. The preceptor acts as a resource person on matters of unit func- tions as well as policies and procedures. The preceptorship is for approximately three weeks, although the time may vary depending to the nurse’s individual learning needs or the organi- zation’s policies.

New nurses may need to use their preceptors as counselors as they make their transition to the unit. If new nurses experience discrepancy between their educational preparation or their expectations and the realities of working in the unit, the preceptor’s role as counselor can prove invaluable in helping them cope with “reality shock.”

The preceptor also serves as a staff nurse role model demonstrating work-related tasks, how to set priorities, solve problems and make decisions, manage time, delegate tasks, and interact with others. In addition, the preceptor evaluates the new nurse’s performance and provides both verbal and written feedback to encourage development.

The staff development department’s function is to teach the experienced nurse the role of a preceptor, principles of adult education applicable to learning needs, how to teach necessary skills, how to plan teaching, how to evaluate teaching and learning objectives, and how to pro- vide both formal and informal feedback.

Mentoring Mentoring is another strategy to improve retention. Mentors take a greater role than preceptors in developing staff. Precepting usually is associated with orientation of staff, whereas mentoring occurs over a much longer period and involves a bigger investment of personal energy. Mentor- ing is suggested as a strategy to retain new graduates (Butler & Felts, 2006).

A mentor is a wiser and more experienced person who guides, supports, and nurtures a less experienced person. Mentors are usually the same sex as the protégé, eight to fifteen years older, highly placed in the organization, powerful, and willing to share their experiences. They are not threatened by the mentee’s potential for equaling or exceeding them. Mentees are selected by mentors for several reasons: good performance, loyalty to people and the organization, a similar social background or a social acquaintance with each other, appropriate appearance, an opportu- nity to demonstrate the extraordinary, and high visibility.

Mentor–mentee relationships seem to advance through several stages. The initiation stage usually lasts six months to a year, during which the relationship gets started. The mentee stage is that in which the mentee’s work is not yet recognized for its own merit, but rather as a byproduct


of the mentor’s instruction, support, and encouragement. The mentor thus buffers the mentee from criticism.

A breakup stage may occur from six months to two years after a significant change in the relationship, usually resulting from the mentee taking a job in another department or organiza- tion so that there is a physical separation of the two individuals. It also can occur if the mentor refuses to accept the mentee as a peer or when the relationship becomes dysfunctional for some reason. The lasting friendship stage is the final phase and will occur if the mentor accepts the mentee as a peer or if the relationship is reestablished after a significant separation. The com- plete mentoring process usually includes the last stage.

Coaching Coaching is a strategy suggested to address nurses’ job dissatisfaction (Stedman & Nolan, 2007). A coach helps the staff member focus on solving a specific problem or conflict that in- terferes with the employee’s satisfaction at work. Coaches are often nurses or human resources staff within the organization prepared to help resolve conflicts. Conflicts could be between two nurses, between a nurse and a patient, or between a nurse and a physician. In a confidential en- vironment, the coach helps the staff member explore the exact nature of the problem, consider various alternatives (e.g., transfer, quit, do nothing), delve into embedded issues (e.g., values conflict with organization, unmatched expectations), discover links (e.g., working with friends), and the disadvantages of leaving (e.g., start over with vacation time, benefits, leave friends). The goal is to reduce turnover from issues that can be resolved.

Nurse Residency Programs Residency programs, 12 or 18 months in length, are designed to acclimate new graduates to the work environment. One example is the Versant RN Residency Program™, an 18-month resi- dency that includes both educational and emotional components. Novice nurses receive lectures and online access to best practices as well as a nurse partner who maintains an ongoing relation- ship and teaches professional accountability and critical thinking. In addition, residents partici- pate in emotional support groups to share experiences and feelings. New-graduate turnover rates have gone from 35 percent to less than 6 percent, according to surveys of hospitals using the program (Mcpeck, 2006).

One-year residency programs for new graduates implemented at 12 sites have been shown to be effective in reducing turnover (Williams et al., 2007). Each residency involved a partner- ship between a school of nursing and a hospital. The program included a core curriculum, clini- cal guidance by a nurse preceptor, and a resident facilitator for professional role development assistance in addition to the usual orientation at the institution. The results showed that turnover of new graduates averaged 12 percent, more than half the national average.

Later reports of the residency program, implemented in 26 sites, found turnover rates de- clined to a low 5.7 percent (Lynn, 2008). The program continues to be refined with recent offer- ings including peer, preceptor, and manager participation and employee recognition components (Goode et al., 2009). It follows that programs that reduce turnover have been successful in mo- tivating employees.

Career Advancement One example of a career advancement development strategy is the clinical ladder program. It uses a system of performance indicators to advance an employee within the organization. The three key components are:

1. Horizontal promotion

2. Clinical ladder

3. Clinical mentee


Horizontal promotion rewards the excellent clinical nurse without promoting the nurse to management. A clinical ladder, based on Benner’s (2000) novice-to-expert concepts, includes:

1. Clinical apprentice—new nurse or nurse new to the area

2. Clinical colleague—a full partner in care

3. Clinical mentee—demonstrates preceptor ability

4. Clinical leader—demonstrates leadership in practice

5. Clinical expert—combines teaching and research with practice

The strength of the system is that superb, clinical nurses can remain at the bedside, clinical excellence can be rewarded, and nurses can move back and forth among the levels based on their personal and professional goals and needs.

Another example of clinical advancement program was used at a Magnet-certified insti- tution, Cincinnati Children’s Hospital Medical Center (Allen, Fiorini, & Dickey, 2010). The program’s goal was to improve the quality of patient care, provide career opportunities for par- ticipating nurses, and to enhance job satisfaction and nurse retention. Evaluation of the program illustrated that goals were met. An additional finding revealed that the program had a substantial positive fiscal impact on the organization as well.

Leadership Development Developing internal staff is a cost-effective way to build leaders within the organization. The advantages include knowledge of the skills and strengths of the candidates, the cost saving in retaining high-performing staff, and the ability to design a program that fits the organization’s specific needs. In fact, many nurse leaders fail not because they don’t want to do the job, but because they don’t have the leadership tools required.

Built around Benner’s novice to expert concepts (Benner, 2000), one hospital designed a leadership curriculum that targeted the learning needs of staff at different developmental levels, e.g., 200 level for charge nurses, 300 level for assistant nurse managers, 400 level for nurse managers (Swearingen, 2009). As a result, the organization developed a pool of candidates available for promotion to higher-level positions. In addition, they found nurse retention rates improved.

Succession Planning Due to an aging nursing workforce, as well as the overall shortage of nurses, succession plan- ning at all levels of nursing management is essential to ensure a smooth transition after a man- ager leaves or retires (Ponti, 2009). Succession planning is a strategic process that is a natural outgrowth of leadership development. It involves identifying core competencies required at each level of management, recognizing potential recruits, and providing opportunities for develop- ment and growth.

One institution developed a nurse management internship program to prepare first-line man- agers from an internal pool of interested nurses (Wendler, Olson-Sitki, & Prater, 2009). The one- year program successfully prepared several nurses for management positions in its first year. Those costs were recouped when a long term management opening was filled by one of the nurses who completed the internship.

There is no one single way to motivate people. The organization and the manager must use various tools to offer incentives and rewards that satisfy their staff. Increased productivity, pa- tient care quality, job satisfaction, and retention are all outcomes that can result in appropriate motivational activities.

Case Study 17-1 illustrates how one nurse manager used her ingenuity to motivate staff.


What You Know Now • Job performance is determined by motivation and ability. • Motivational theories (e.g., reinforcement, expectancy, equity, and goal-setting theories) describe the fac-

tors that initiate and direct behavior. • The manager serves as a role model for staff. • Staff development methods include orientation, preceptors, and on-the-job instruction.

MOTIVATING STAFF Jamie Edgar is nurse manager of the mental health out- patient clinic for a large county health department. Her staff includes nurses, licensed clinical social workers, li- censed mental health technicians, and clerical support staff. State funding for mental health services has been drastically cut. Jamie had a difficult decision to make re- garding who on the staff would receive pay increases and who would not. Compounding her problem is the shortage of qualified psychiatric nurses and two vacant nursing positions that she has been unable to fill due to the low starting salary.

Jamie decides that the nursing staff will receive a four percent raise and the licensed clinical social work- ers will receive a three percent raise. The mental health technicians and clerical staff will not receive a wage in- crease this year. The mental health technicians and cleri- cal staff members are upset when Jamie tells them there will not be any pay increases this year. Kevin Adams, a licensed mental health technician, and Charlotte Du- Bois, an administrative assistant, have both expressed frustration about the disparity in pay increases. Over the past two workweeks, Kevin has been clocking in 10 minutes late each work day and taking longer lunch periods than scheduled. The quality of Charlotte’s work has decreased, and she is using more business time for personal telephone calls and personal business.

Jamie is concerned that Kevin’s and Charlotte’s nega- tive attitudes will continue to affect their work as well as the morale of the staff. Initially, she tried more fre- quent praise of Kevin’s and Charlotte’s work, but after three weeks, noted no improvement in their attitude or performance. She counseled each employee individu- ally about performance expectations; however, neither employee made an effort to improve his or her behav- ior. After receiving a final budget for her clinic, Jamie allocated $800 for training of clerical staff and mental health technicians. She met with Kevin, Charlotte, and two other staff members. Jamie asked the group to assist her in determining how to best spend the $800 training budget. The group agreed that time-management skills could be improved among many of the staff. After review- ing the cost associated with several time- management

training programs, the group was surprised at the ex- pense. Jamie challenged her group to think of alterna- tive ideas other than sending staff members to a semi- nar and offered a restaurant gift certificate for the most creative ideas.

At their next meeting, Kevin produced reviews of several interactive CD-ROM training programs. Kevin had searched the Internet for the best price for the programs and brought in several demonstration CDs of the top two time-management programs. Charlotte proposed purchasing planners for those staff members who didn’t already have a planner or electronic calen- dar. Charlotte had spoken to the supplier who had the contract for county office supplies. They had agreed to a price of $12 per planner for a complete year of time- planning supplies. The group agreed that both Kevin and Charlotte’s ideas were excellent, as well as coming in under the $800 limit.

Kevin and Charlotte were responsible for implement- ing their ideas with staff who requested training in time management. Although neither employee received a raise in base salary, Jamie was able to secure approval for both to work extra hours to complete training for the clinic staff. Jamie continued to praise both employees for their commitment to the clinic and their coworkers. Kevin began to arrive promptly for each work shift and kept his lunch periods to 30 minutes. Charlotte was ea- ger to demonstrate to coworkers how her new planner helped her prioritize work and personal tasks. Her use of work time for personal business greatly decreased.

Manager’s Checklist The nurse manager is responsible for:

● Understanding motivating factors for employees and how motivation affects job performance

● Using motivational techniques to enhance employee performance

● Utilizing creative techniques to motivate staff when traditional rewards such as pay or benefit increases are unavailable

● Empowering staff to use creativity to enhance job performance



• Nurse residencies, career advancement opportunities, and leadership development programs can help motivate staff members.

• Succession planning is a strategic process to develop future nurse leaders.

Tools for Motivating and Developing Staff 1. Recognize that an employee’s job performance includes both ability to do the job and motivation. 2. Become familiar with various theories of motivation and use the information to help you motivate

others. 3. Be aware that you may be a role model to other staff regardless of your formal position. 4. Identify core competencies involved in specific positions and high performers with the potential

to fill those positions. 5. Encourage staff development at all levels, including your own.

Questions to Challenge You 1. What motivational theory appeals to your sense of how you learn? Why? 2. You are a new nurse manager: a. How would you discover what motivates the individuals on your staff? b. How could you utilize the organization’s resources to motivate your staff? c. What staff development programs are available in your organization or community? d. How could you make those resources available to your staff? 3. What recommendations would you make to a new nurse manager regarding motivating staff? Have

you seen any of these work? Explain.

Adams, J. S. (1963). Toward an understanding of inequity. Journal of Abnormal and Social Psychology, 67, 422.

Adams, J. S. (1965). Injustice in social exchange. In L. Berkowitz (Ed.), Advances in experimental social psy- chology (Vol. 2). New York: Academic Press.

Allen, S. R., Fiorini, P., & Dickey, M. (2010). A streamlined clinical ad- vancement program im- proves RN participation and retention. Journal of Nurs- ing Administration, 40(7/8), 316–322.

Benner, P. (2000). From novice to expert: Excellence and

power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall.

Butler, M. R. & Felts, J. (2007). Tool kit for the staff men- tor: Strategies for improv- ing retention. Journal of Continuing Education in Nursing, 37(5), 210–213.


Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!


Doucette, J. N. (2009). Create a great work culture. Ameri- can Nurse Today, 4(6), 13–14.

Failla, K. R., & Stichler, J. F. (2008). Manager and staff perceptions of the man- ager’s leadership style. Journal of Nursing Admin- istration, 38(11), 480–487.

Goode, C. J., Lynn, M. R., Krsek, C., & Bednash, G. D. (2009). Nurse residency programs: An essential requirement for nursing. Nursing Econom- ics, 27(3), 142–159.

Hersey, P., Blanchard, K. H., & Johnson, D. E. (2007). Management of organiza- tional behavior (9th ed.). Upper Saddle River, NJ: Prentice Hall.

Locke, E. A. (1968). Toward a theory of task motives and incentives. Organizational Behavior and Human Performance, 3, 157.

Lynn, M. R. (2008). UHC/AACN nurse residency programs. Paper presented at the University Health-System Consortium Performance Excellence Forum, Dallas, TX.

McPeck, P. (2006). Residencies ease new grads into practice. NurseWeek, September 11, 2006. Retrieved January 2008 from http://www.ver- sant.org/item.asp?id=70

Ponti, M. D. (2009). Transi- tion from leadership de- velopment to succession management. Nursing Administration Quarterly, 33(2), 125–141.

Skinner, B. F. (1953). Science and human behavior. New York: Free Press.

Stedman, M. E., & Nolan, T. L. (2007). Coaching: A differ- ent approach to the nursing dilemma. Nursing Admin- istration Quarterly, 31(1), 43–49.

Swearingen, S. (2009). A jour- ney to leadership: Design- ing a nursing leadership development program. Journal of Continuing Edu- cation in Nursing, 40(3), 107–112.

Urquhart, C. (2009). How to mo- tivate your staff. American Nurse Today, 4(7), 27–28.

Vroom, V. H. (1964). Work and motivation. New York: Wiley.

Wendler, M. C., Olson-Sitki, K., & Prater, M. (2009). Suc- cession planning for RNs. Journal of Nursing Admin- istration, 39(7/8), 326–333.

Williams, C. A., Goode, C. J., Krsek, C., Bednash, G. D., & Lynn, M. R. (2007). Postbaccalaureate nurse residency 1-year option. Journal of Nursing Admin- istration, 37(7/8), 357–365.


The Performance Appraisal EVALUATION SYSTEMS





Potential Appraisal Problems LENIENCY ERROR





Improving Appraisal Accuracy APPRAISER ABILITY


Rules of Thumb

Evaluating Staff Performance 18

Key Terms Ambiguous evaluation

standards problem Behavior-oriented rating


Critical incidents Group evaluation Halo error Leniency error

Performance appraisal Recency error Written comments problem

1. Describe criteria that can be used to evaluate staff performance.

2. Discuss different methods used to evaluate performance.

3. Describe problems to expect when evaluating performance.

4. Explain how to use critical incidents to improve annual evaluations.

5. Explain how to conduct a performance appraisal interview.

Learning Outcomes After completing this chapter, you will be able to:


T he goal of a performance evaluation is to support nursing practice development (Schoessler et al., 2008). Evaluating past performance, compared to specified stan-dards, enables the employee and the manager to identify developmental needs. Performance-related behaviors are directly associated with job tasks and need to be accom- plished to achieve a job’s objectives (Topjian, Buck, & Kozlowski, 2009).

The Performance Appraisal The primary purpose of performance evaluations is to give constructive feedback. A good appraisal system ensures that staff know what is expected and how well they meet those expecta- tions. Performance appraisals serve as developmental tools as well as providing information for salary increases and promotions.

The performance appraisal process includes:

● Day-to-day manager–employee interactions (coaching, counseling, dealing with policy violations, and disciplining are discussed in Chapter 19)

● Making notes about an employee’s behavior ● Encouraging the employee to complete a self evaluation ● Directing peer evaluation, if used ● Conducting the appraisal interview ● Following up with coaching and/or discipline when needed

In addition, performance appraisals and the decisions based on those appraisals, such as lay- offs, are covered by several federal and state laws. In the past, employees have successfully sued their organizations over discriminatory employment decisions that were based on questionable performance appraisal results.

There are several steps to help ensure that an appraisal system is nondiscriminatory.

1. The appraisal is in writing and carried out at least once a year.

2. The performance appraisal information is shared with the employee.

3. The employee has the opportunity to respond in writing to the appraisal.

4. Employees have a mechanism to appeal the results of the performance appraisal.

5. The evaluator has adequate opportunity to observe the employee’s job performance during the course of the evaluation period. If adequate contact is lacking (e.g., the appraiser and the apprai- see work different shifts), then appraisal information should be gathered from other sources.

6. Anecdotal notes on the employee’s performance are kept during the entire evaluation period (e.g., three months, one year). These notes, called critical incidents, and discussed later, are shared with the employee during the course of the evaluation period.

7. Evaluators are trained to carry out the performance appraisal process, including

a. What is reasonable job performance; b. How to complete the form; and c. How to carry out the feedback interview.

8. The performance appraisal focuses on employee behavior and results rather than on per- sonal traits or characteristics, such as initiative, attitude, or personality.

Regardless of how an organization uses performance appraisals, they must accurately reflect the employee’s actual job performance. If performance ratings are inaccurate, an inferior em- ployee may be promoted, another employee may not receive needed training, or there may not be a tie between performance and rewards (thus lessening employee motivation). For appraisals to be successful, the needs of the staff and requirements of the organization must be bridged.


Evaluation Systems Nurses engage in a variety of job-related activities. To reflect the multidimensional nature of the job, the performance appraisal form should cover different performance dimensions, such as pain management. In addition, the form should state specific criteria to be evaluated, such as “Evaluates pain levels and administers appropriate medications.” Finally, the form should in- clude the individual’s goals for the year based on the previous year’s evaluation.

Results-Oriented System All organizations need to be concerned with the bottom line. If a hospital has a 35 percent occupancy rate or a 20 percent employee absenteeism rate, its future is in jeopardy. In recent years, therefore, top management has turned to appraising some employees at least partly on results. With a results-oriented appraisal system, employees know in advance what is expected. Results are quantifiable, objective, and easily measured.

A focus on results requires setting objectives for what the employee is to accomplish. Although this technique has many variations, basically it involves two steps.

First, a set of work objectives is established at the start of the evaluation period for the employee to accomplish during some future time frame. These objectives can be developed by the employee’s supervisor and given to the employee; however, it is better if the manager and employee work together to develop a set of objectives for the employee.

Each performance objective should be defined in concrete, quantifiable terms and have a specific time frame. For example, one objective may need to be accomplished in one month (e.g., “Revise the unit orientation manual to reflect the new Joint Commission standards”); another objective may not have to be met for 12 months (e.g., “Take and pass the CCRN examination within the next year”). In setting objectives, it is important that the employee perceive them as challenging yet attainable.

Sylvia is an experienced critical care nurse. Her goals for the year include:

● Complete advanced cardiac life support (ACLS) recertification. ● Obtain CCRN credentialing. ● Precept one new graduate nurse. ● Serve on hospital shared governance committee.

The second step involves the actual evaluation of the employee’s performance. At this time, the supervisor and employee meet and focus on how well the employee has accomplished his or her objectives.

At Sylvia’s annual performance review, her manager noted that she had:

● Become ACLS recertified. ● Obtained CCRN credentialing. ● Precepted a new graduate nurse who was functioning above expectations. ● Chaired subcommittee of hospital shared governance committee.

Behavior-Oriented System Behavior-oriented systems focus on what the employee actually does, as exemplified in Table 18-1.

Focusing on specific behaviors in appraising performance gives new employees specific in- formation on how they are expected to behave and facilitates development of current staff mem- bers. Although there are several varieties of behavior-oriented rating scales, they all have a number of things in common:

1. Groups of workers who are very familiar with the target job (generally, individuals doing the job and their immediate supervisors) provide written examples (critical incidents) of superior and inferior job behaviors.


Employee Performance Evaluation Form

Employee Name: ______________________

Position: Registered Nurse

Department: ______________________

Hire Date: ______________________

Evaluation Review Period: ______________________

Manager Reviewer: ______________________

This appraisal contains a five-point scale that each performance expectation is rated on. The description of each number ranking on the five point scale is:

5 Significantly Exceeds Expectations—Staff member consistently goes above and beyond ordinary expectations. Staff member is the pillar role model of excellence 100% of the time.

4 Exceeds Expectations—Staff member frequently does things that are beyond their ordinary expectations. Peers and patients comment that staff member goes beyond others and routine expectations.

3 Meets Expectations—Staff member always meets expectation as expected.

2 Usually Meets Expectations—Staff member is able to demonstrate meeting performance expectations at times.

1 Does Not Consistently Meet Expectations—In this category, remediation work is necessary.

Performance Expectations

5–Significantly Exceeds Expectations

4–Exceeds Expectations

3–Meets Expectations

2–Usually Meets Expectations

1–Does Not Consistently Meet Expectation

1. Models critical thinking and expert judgment in patient care.

2. Completes assessments, plans of care, and documentation as expected.

3. Has developed technical skills and seeks opportunity to enhance skills as appropriate.

4. Develops trusting, collaborative relationships with patients and peers.

5. Maintains confidentiality of information.

6. Demonstrates accountability for actions

7. Follows policies and protocols appropriately.

8. Completes annual education competencies and all education on new policies and procedures as expected.

9. Demonstrates care, respect, and compassion in all interactions.

TABLE 18-1 Hill Top Healthcare System


TABLE 18-1 Continued

10. Ensures patients are safe and implements all safety protocols for patients that are appropriate.

11. Brainstorms ideas of needed improvement on the unit and offers ideas to the group along with solutions.

12. Is flexible with staffing and works with peers to meet the needs of patients when planning schedule.

13. Shows commitment to learning and expanding knowledge.

14. Serves as a preceptor and charge nurse as requested.

15. Demonstrates cost awareness and uses supplies and equipment appropriately.

16. Embraces personal responsibility to the organization, patient care, and unit team.

17. Works well with multidisciplinary team, recognizing many people must work together to make great patient care.

18. Participates in a hospital or unit committee.

19. Models direct, purposeful communication.

20. Works in harmony with coworkers, being a team player and settling conflicts professionally.

Employee’s Goals for Next Year

What is the goal the employee will complete in the next 12 months? How can the manager support this goal? _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________


This verifies that this review was completed and does not necessarily signify agreement or disagreement with the contents of the review.


Employee’s Signature

Date __________

Manager’s Signature __________ Date __________ Human Resource’s Signature __________ Date __________


2. These critical incidents are stated as measurable/quantifiable behaviors. (Examples are given in Box 18-1.)

3. Critical incidents that are similar in theme are grouped together. These behavioral group- ings (performance dimensions) are labeled, for example, patient safety.

Such behavior-oriented appraisal measures can be used only for one job or a cluster of similar jobs, so these scales are time-consuming and therefore expensive to develop. For these reasons, behavior-oriented systems are generally developed when a large number of individuals are doing the same job, such as critical care nurses.

Evidence of Performance Evidence of an individual’s performance is collected in several ways, including peer review, self- evaluations, group evaluations, and the manager’s notes and evaluation.

Peer Review This is a process by which nurses assess and judge the performance of professional peers against predetermined standards (Davis, Capozzoli, & Parks, 2009). Peer review is designed to make performance appraisal more objective because multiple ratings give a more diverse appraisal. It is used frequently in clinical ladder programs, self-governance models, and evaluation of ad- vanced practice nurses.

The steps for peer review are as follows:

1. The manager and/or employee select peers to conduct the evaluation. Usually, two to four peers are identified through a predetermined process.

2. The employee submits a self-evaluation portfolio. The portfolio might describe how he or she met objectives and/or predetermined standards during the past evaluation cycle. Sup- porting materials are included.

3. The peers evaluate the employee. This may be done individually or in a group. The indi- viduals or group then submit a written evaluation to the manager.

BOX 18-1 Example of a Critical Incident

1. Name of employee: Cindy Siegler 2. Date and Time of incident: March 22, 23, 24,

at 0915 3. Description: Ms Siegler, patient care assistant, for

the third time this week had nurses complain to manager that 0800 vital signs and finger sticks were not completed at 0900. Nurses use the vital signs and finger stick results as supporting facts in safely administering their medications that are scheduled for 0900.When the nurses go to find Ms. Siegler, each time she has been in the break room on her cell phone and eating. The nurses asked Ms. Siegler why she is in the break room for long periods of time. Ms. Siegler reported to them that she’s not going to “push herself early in the day” and she likes to “ease into her shift.” The nurses also asked Ms. Siegler why she must take a break when her work isn’t done and it is a critical assessment and medication pass time for the unit. The nurses shared with Ms. Siegler that

they depend on her for vital sign and finger stick results. Ms. Siegler has told the nurses on three occasions now “I’ll get there in a bit.”

4. Comments: Ms. Siegler was counseled by man- ager. Manager told Ms. Siegler her one priority at work has to be meeting the needs of patients. Ms. Siegler was told that her role on the team is im- portant and vital sign data and finger stick results must be completed and entered into the com- puter system for nurses before 0900. Ms. Siegler was instructed to not be in the breakroom unless the charge nurse had approved the break. She was also educated on proper break length being 15 minutes. Ms. Siegler was told that failing to meet any of the expectations discussed would result in written warning counseling. Ms. Siegler acknowl- edged understanding. She said, “I’ll try harder.” Manager stated she would talk with Ms. Siegler to touch base in two weeks.


4. The manager and employee meet to discuss the evaluation. The manager’s evaluation is included, and objectives for the coming evaluation cycle are finalized.

Implementing a peer review involves several considerations. First, it is best to avoid selecting personal best friends for the review. Friends can provide poor ratings as well as in- flated ratings, resulting in a negative experience. Second, consider how often to evaluate expert practitioners—for example, those nurses who have reached the top of a clinical ladder. Third, monitor the time needed for portfolio preparation. The object is to improve professionalism and quality of patient care, not to create more paperwork.

Self-Evaluation Self-evaluations help the employee examine performance over the year and consider improve- ments to be made. It is difficult for anyone to accurately rate one’s own performance, so self- evaluations tend to be overly positive or, in some cases, excessively negative. Nonetheless, it is a valuable exercise to require employees to focus attention on how well they have met the requirements of the job regardless of whether the appraisal is behavioral-oriented (“Completes patient care plan within 24 hours of admission”) or results-oriented (“Presented one in-service on the unit”).

Group Evaluation Another technique is group evaluation. Here, several managers are asked to rank employee performance based on job descriptions and performance standards. Usually, one manager facili- tates the process. In addition to evaluating individual performance, the performance of groups of nurses can also be evaluated in this way, and group variances can be benchmarked and evalu- ated. Using group evaluation reduces personal bias, is timely, and can be effective.

Manager’s Evaluation Appraising an employee’s performance can be a difficult job. A nurse manager is required to reflect on a staff member’s performance over an extended period of time (usually 12 months) and then accurately evaluate it. Given that nurse managers have several employees to evaluate, it is not surprising that they frequently forget what an individual did several months ago or may actually confuse what one employee did with what another did.

A useful mechanism for fighting such memory problems is the use of critical incidents, which are reports of employee behaviors that are out of the ordinary, in either a positive or a negative direction. Critical incidents include four items: name of employee, date and time of incident, a brief description of what occurred, and the nurse manager’s comments on what trans- pired (Box 18-1). Electronic devices, index cards, or a small notebook are best to use because they allow notes to be taken immediately. In addition, lag time increases the likelihood of errors and the possibility that the manager will neglect to share the incident with the employee (see next section).

Recording critical incidents as they occur is bound to increase the accuracy of year-end performance appraisal ratings. Although this type of note taking may sound simple and straight- forward, a manager can still run into problems. For instance, some managers are uncomfortable about recording behaviors; they see themselves as spies lurking around the work area attempting to catch someone. What they need to remember is that this note taking will enable them to evalu- ate the employee more accurately and makes recency error (described later) much less likely.

The best time to write critical incidents is just after the behavior has occurred. The note should focus specifically on what took place, not on an interpretation of what happened. For example, instead of writing, “Ms. Hudson was rude,” write, “Ms. Hudson referred to the patient as a slob.”

Once a critical incident has been recorded, the manager should share it with the employee in private. If the behavior is positive, it is a good opportunity for the nurse manager to praise


the employee; if the behavior is considered in some way undesirable, the manager may need to coach the employee (see Chapter 19).

Because most managers are extremely busy, they sometimes question whether note taking is a good use of their time. In fact, keeping notes is not a time-consuming process. The average note takes less than two minutes to write. If one writes notes during the gaps in the day (e.g., while waiting for a meeting to start), little, if any, productive time is used. In the long run, such note taking saves time. In addition, keeping and sharing notes forces a manager to deal with problems when they are small and thus are more quickly addressed. Then completing the ap- praisal form at the end of the evaluation period takes less time with notes for reference.

A key factor in effectively using this note-taking approach is how nurse managers introduce the technique to their staff. To get maximum value out of note taking, managers need to keep in mind two important facts:

1. The primary reason for taking notes is to improve the accuracy of the performance review.

2. When something new is introduced, people tend to react negatively to it.

Managers should be open and candid about the first fact, admitting that they cannot remem- ber every event associated with every employee and telling employees that these notes will make more accurate evaluations possible. Even then, employees will still be suspicious about this pro- cedure. One way to get the procedure off to a good start is for managers to make the first note they record on an employee a positive one, even if they have to stretch a bit to find one. By doing this, each employee’s first contact with critical incidents is positive.

Three types of mistakes common with using notes are:

1. Some managers fail to make them specific and behavior oriented; rather, they record that a nurse was “careless” or “difficult to supervise.”

2. Some managers record only undesirable behavior.

3. Some managers fail to give performance feedback to the employee at the time that a note was written.

Each of these errors can undermine the effectiveness of the note-taking process. If the notes are vague, the employee may not know specifically what he or she did wrong and therefore does not know how to improve. If only poor performance is documented, employees will resent the system and the manager. If the manager does not share notes as they are written, the employee will often react defensively when confronted with them at the end of the evaluation period. In sum, any manager who is considering using this powerful note-taking procedure needs to take the process seriously and to use it as it is designed.

By increasing the accuracy of the performance review, written notes also diminish the legal liability of lawsuits. If a lawsuit is brought, written notes are very persuasive evidence in court. Sharing the notes with employees throughout the evaluation period also improves the communi- cation flow between the manager and the employee. Having written notes also gives the manager considerable confidence when it comes time to complete the evaluation form and to carry out the appraisal interview.

The manager will feel confident that the appraisal ratings are accurate. Not only does the manager feel professional, but the staff nurse also shares that perception. In fact, it is typically found that with the use of notes, the performance appraisal interview focuses mainly on how the employee can improve next year and what developmental activities are needed rather than on how he or she was rated last year. Thus, the tone of the interview is constructive rather than argumentative.

One final issue needs to be addressed. Different employees react differently to the use of notes. Good employees react positively. Although the manager records both what is done well and what is done poorly, good employees will have many more positive than negative notes and


therefore will benefit from notes being taken. In contrast, poorer employees do not react well to notes being taken.

Whereas once they could rely on the poor memory of the nurse manager to produce inflated ratings, note taking is likely to result in more accurate (i.e., lower) ratings for poor employees. The negative reaction of poor employees, however, tends not to be a lasting one. Generally, the poor performers either leave the organization, or when they discover that they no longer can get away with mediocre performance, their performance actually improves.

In most organizations, an employee’s immediate manager is in charge of evaluating her or his performance. If the immediate supervisor does not have enough information to evaluate an employee’s performance accurately, alternatives are necessary. The manager can informally seek out performance-related information from other sources, such as the employee’s cowork- ers, patients, or other managers who are familiar with the person being evaluated. The manager weighs this additional information, integrates it with his or her own judgment, and completes the evaluation.

Evaluating Skill Competency Health care organizations are required to assess their employees’ abilities to perform the skills and tasks required for their positions (Joint Commission, 2011). Validation of competency is an ongoing process, initiated in orientation, followed up by development, and assessed on an annual basis and, possibly, remediation. Skill evaluation most commonly takes place in a skills lab, with simulation models, or by direct observation at the point of care. The manager plays a key role in determining the competences required on the job, especially for unit or department- specific competencies.

Diagnosing Performance Problems If the manager notes poor or inconsistent performance during the appraisal process, the manager must investigate and remedy the situation. Certain questions should be asked:

“Is the performance deficiency a problem?” “Will it go away if ignored?” “Is the deficiency due to a lack of skill or motivation? How do I know?”

The first step is to begin with accepted standards of performance and an accurate assessment of the current performance of the staff member. This means job descriptions must be current and performance appraisal tools must be written in behavioral terms. It also implies that employee evaluations are regularly carried out and implemented according to recognized guidelines. Also, the employee must know what behavior is expected.

Next decide whether the problem demands immediate attention and whether it is a skill- related or motivation-related problem. Skill-related problems can be solved through informal training, such as demonstration and coaching, whereas complex skills require formal training (e.g., in-service sessions or workshops). If there is a limit to the time an employee has to reach the desired level of skill, the manager must determine whether the job could be simplified or whether the better decision would be to terminate or transfer the employee.

If the performance problem is due to motivation rather than ability, the manager must ad- dress a different set of questions. Specifically, the manager must determine whether the em- ployee believes that there are obstacles to the expected behavior or that the behavior leads to punishment, reward, or inaction. For example, if the reward for conscientiously coming to work on holidays (rather than calling in sick) leads to always being scheduled for holiday work, then good performance is associated with punishment.

Only when the employee sees a strong link between valued outcomes and meeting perfor- mance expectations will motivation strategies succeed. The manager plays a role in tailoring motivational efforts to meet the individual needs of the employee (see Chapter 17). Unfortu- nately, creating a performance–reward climate does not eliminate all problem behaviors. When


the use of rewards proves ineffective, other strategies, such as coaching and discipline, are war- ranted (see Chapter 19).

To differentiate between lack of ability and lack of motivation, the manager can analyze past performance. If past performance has been acceptable and little change in standards of per- formance has taken place, then the problem results from a lack of motivation. In contrast, if the nurse has never performed at an acceptable level, then the problem may be primarily skill re- lated. Different intervention strategies should be used, depending on the source of the problem. The objective should be to enhance performance rather than to punish the employee. Figure 18-1 summarizes the steps to take.

The Performance Appraisal Interview Once the manager completes an accurate evaluation of performance, an appraisal interview can be scheduled. The appraisal interview is the first step in employee development.

Preparing for the Interview Keep in mind what needs to be accomplished during the interview. If the appraisal ratings are accurate, they are more likely to be perceived as such by the employee. This perception should, in turn, make the employee more likely to accept them as a basis for both rewards as well as developmental activities. More specifically, to motivate employees, rewards need to be seen as linked to performance.

The performance appraisal interview is the key to this linkage. In the interview, establish that performance has been carefully assessed and that, when merited, rewards will be forthcom- ing. Developmental activities also need to be derived from an accurate evaluation. If an em- ployee is rated as “needs immediate improvement” on delegation skills, for example, any effort to remedy this deficiency must stem from the employee’s acceptance of the need for improve- ment in delegation.

Even though managers try to fill out the appraisal form accurately, they should still antici- pate disagreement with their ratings. Most employees tend to see themselves as above-average performers. This tendency to exaggerate our own performance results from the fact that we tend to forget our mistakes and recall our accomplishments; we often rationalize away those instances where our performance was substandard (e.g., “I forgot, but with this heavy workload, what do you expect?”). Given this tendency to over evaluate one’s own performance and the fact that most staff previously have had poor experiences with the evaluation process, expect that staff will lack confidence in the whole appraisal process.

Assess performance

Is there a problem?

If the problem is

Provide education.


Simplify task.


Replace if time does not warrant other techniques.

Clarify expectations.

Determine obstacles and remove them.

Determine if desired performance is being punished; remove punishment.

Determine employee values regarding rewards; ensure equitable treatment.

Give feedback as appropriate.No


Motivation relatedSkill related

Figure 18-1 • Decision tree for evaluating performance.


A key step for making the appraisal interview go well is to set up the performance appraisal interview in advance, preferably giving at least two days’ notice. Schedule enough time: most interviews last 20 to 30 minutes, although the time needed will vary considerably depending on the degree to which the nurse manager and the staff nurse have talked regularly during the year.

In preparing for the appraisal interview, have specific examples of behavior to support the ratings. Such documentation is particularly important for performance areas in which an em- ployee receives low ratings. In addition, try to anticipate how the staff member will react to the appraisal. For example, will the individual challenge the manager’s ratings as being too low? Anticipating such a reaction, one can respond by saying, “Before I made my ratings, I talked with two other unit managers to make sure my standards were reasonable.”

The setting should also be considered in planning the meeting. It is critical that the inter- view take place in a setting that is private and relatively free from interruptions. This allows a frank, in-depth conversation with the employee. Although it is difficult to limit interruptions in a health care setting, choosing the meeting time carefully will help. You may be able to schedule the meeting when another manager can cover, or at a time when interruptions are least likely to occur. The most important point to remember is that a poor setting limits the usefulness of the interview. No one wants weaknesses discussed in public. Similarly, interruptions destroy the flow of the feedback session.

The Interview The appraisal interview is most likely to go well if the nurse manager has written and shared critical incidents throughout the evaluation period. If such feedback has occurred, staff members go into the interview with a good idea of how they are likely to be rated, as well as what behav- iors led to the rating. If the nurse manager has not kept notes throughout the year, it is important to recall numerous, specific examples of behavior, both positive and negative, to support the rat- ings given.

The major focus of the feedback interview should be on how the nurse manager and the staff member can work together to improve performance in the coming year. However, establish- ing such an improvement-oriented climate is easier said than done. In giving feedback, be aware that every employee has a tolerance level for criticism beyond which defensiveness sets in. Thus, in reviewing an employee’s performance, emphasize only a few areas—preferably, no more than two—that need immediate improvement.

Unfortunately, evaluators often exceed an employee’s tolerance level, particularly if perfor- mance has been mediocre. Typically, the manager will come up with an extensive list of areas needing improvement. Confronted with such a list, the staff member gradually moves from a constructive frame of mind (“I need to work on that”) after one or two criticisms are raised to a destructive perspective (“She doesn’t like me,” “He’s nitpicking,” “How can I get even?”) as the list of criticisms continues.

Following are recommendations for conducting an appraisal interview:

1. Put the employee at ease. Most individuals are nervous at the start of the appraisal inter- view, especially new employees who are facing their first evaluation or those who have not received frequent performance feedback from their manager over the course of the evaluation period. Begin the interview by giving an overview of the type of information that was used in making the performance ratings, such as, “In preparing for this review, I relied on the notes I have taken and shared with you throughout the year.” Rather than trying to reduce the tension an employee may have at the start of the interview, it is bet- ter to ignore it.

2. Clearly state the purpose of the appraisal interview. An improvement-oriented theme should be conveyed at the beginning of the interview, can lead to identifying development activities, and will help the employee do the best possible job in the coming year.


3. Go through the ratings one by one with the employee. Provide a number of specific examples of behavior that led to each rating. Be careful not to rush. By systematically going through the ratings and providing behavioral examples, nurse managers project an image of being prepared and of being a professional. This is important for getting the staff nurse to accept the ratings and act on them.

4. Draw out the employee’s reactions to the ratings. Ask for the employee’s reaction to the ratings and then listen, accept, and respond to them. Of the seven key behaviors for do- ing performance reviews, nurse managers have the most difficulty with this one. To carry out this phase of the interview effectively, you must have confidence in the accuracy of the ratings.

When asked to express their reactions, individuals who have received low ratings will frequently question the rater’s judgment (“Don’t you think your standards are a little high?”). Not surprisingly, the manager whose judgment has been questioned tends to get defensive, cutting off the employee’s remarks and arguing for the rating in question. Being cut off sends a contradictory message to the employee. The individual was asked for reactions, but when given, the supervisor did not want to hear them. You should an- ticipate that the ratings will be challenged and must truly want to hear the staff nurse’s reaction to them.

After having listened to the employee’s reactions, accept and respond to them in a man- ner that conveys that you have heard what the employee said (e.g., paraphrase some of the comments) and accept the individual’s opinion (“I understand your view”). In addition, you may want to clarify what has been said (“I do not understand why you feel your initiative rating is too low. Could you cite specific behavior to justify a higher rating?”). Strive for a candid, two-way conversation to find out exactly how the employee feels.

5. Decide on specific ways in which performance areas can be strengthened. The focus of the interview should now shift to the future. If a thorough review of an employee’s perfor- mance reveals deficiencies, you and the employee may jointly develop action plans to help the individual improve. An action plan describes mutually agreed-on activities for improv- ing performance. Such developmental activities may include formal training, academic course work, or on-the-job coaching. Together, you and the staff nurse should write down the resulting plans.

Because of the possibility of defensiveness, address only one or two performance areas needing improvement. Choose only the areas that are most troublesome and focus attention on these. In arriving at plans for improving performance, begin by asking the staff member for ideas on how to enhance personal performance. After the individual has offered sugges- tions, you can offer additional suggestions.

It is critical that such performance plans refer to specific behavior. In some cases, not only will the staff member be expected to do things in a different manner (“I will refer to a patient as Mr., Mrs., or Ms. unless specifically told otherwise”), but you may also be expected to change your behavior (“I will post changes in hospital policy before enforcing them”).

6. Set a follow-up date. After having agreed on specific ways to strengthen performance in problem areas, schedule a subsequent meeting, usually four to six weeks after the ap- praisal interview. At this later meeting, provide specific feedback on the nurse’s recent performance.

This meeting also gives you and the nurse an opportunity to discuss any problems they have encountered in attempting to carry out their agreed-on performance/improvement plans. In most cases, this follow-up session is quite positive. With only one or two areas to work on and a specific date on which feedback will be given, the nurse’s performance usually improves dramatically. Thus, the follow-up meeting is one in which you have the opportunity to praise the employee.


7. Express confidence in the employee. The final key behavior is simple but often over- looked. It is nevertheless important that a manager indicate confidence that improvement will be forthcoming.

Since no more than two problem areas should be addressed in the appraisal interview, other problem areas may be considered later in the year. If the targeted performance areas continue to improve significantly, then meet again with the staff member one or two weeks after this follow- up session to raise another area that needs attention. As before, develop and write down specific ways to improve the performance deficiency and schedule another follow-up meeting. In short, performance deficiencies are not ignored, they are merely temporarily overlooked.

Potential Appraisal Problems No matter what type of appraisal system is used, problems that lessen the accuracy of the performance rating can arise, such as leniency, recency, and halo errors; ambiguous evalu- ation standards; and written comments problems. These, in turn, limit the usefulness of the performance review.

Leniency Error Managers tend to overrate their staff’s performance. This is called leniency error. For example, a manager may rate everyone on her or his staff as “above average.” Although numerous reasons are given for inflated ratings (e.g., “I want my nurses to like me,” “It’s difficult to justify giving someone a low rating”), these reasons do not lessen the problems that leniency error can create for both the manager and the organization. If you give a mediocre nurse lenient ratings, it is dif- ficult to turn around and take corrective action, such as discipline.

Leniency error can also be demoralizing to the best performers, because they would have received high ratings without leniency. However, with leniency error, these outstanding nurses look less superior compared to their coworkers. Thus, leniency error tends to be welcomed by poorer performers and disliked by better ones.

Recency Error Another difficulty with most appraisal systems is the length of time over which behavior is eval- uated. In most organizations, employees are formally evaluated every 12 months. Evaluating employee performance over such an extended period of time, particularly if one supervises more than two or three individuals, is a difficult task. Typically, the evaluator recalls recent perfor- mance and tends to forget more distant events. Thus, the performance rating reflects what the employee has contributed lately rather than over the entire evaluation period. This tendency is called recency error; it too can create both legal and motivational problems.

Shelby Miller, RN, transferred from a medical unit to the telemetry unit nine months ago. Overall, her performance has been good and she is an excellent team member. On two occasions, other nursing staff told the nurse manager, Lucinda Amos, about Shelby’s quick and accurate assessment of critical changes in patient status. Last week, Shelby mis- read a physician’s order and didn’t administer pre-procedure medications as directed. The procedure had to be rescheduled, resulting in surgical delays as well. The physician was angry and complained to both Lucinda and the cardiology nursing director. On her annual performance appraisal, Lucinda rated Shelby “below average” on patient care delivery.

Legally, if a disgruntled employee can demonstrate that an evaluation that supposedly re- flects 12 months actually reflects performance over the last 2 or 3 months, an organization will have difficulty defending the validity of its appraisal system. In terms of motivation, recency error demonstrates to all employees that they only need to perform at a high level near the time


of their performance review. In such situations, an employee is highly motivated (e.g., asking the supervisor for more work) just prior to appraisal but considerably less motivated as soon as it is completed.

As with leniency error, recency error benefits the poorly performing individual. Nurses who perform well year-round may receive ratings similar to those mediocre nurses who noticeably improve as their evaluation time approaches. Fortunately, recording critical incidents during the year lessens the impact of recency error.

Halo Error Sometimes an appraiser fails to differentiate among the various performance dimensions (e.g., nursing process, communication skills) when evaluating an employee and assigns ratings on the basis of an overall impression, positive or negative, of the employee. Thus, some employees are rated above average across dimensions, others are rated average, and a few are rated below aver- age on all dimensions. This is referred to as halo error.

If a nurse is excellent, average, or poor on all performance dimensions, she or he deserves to be rated accordingly, but in most instances, employees have uneven strengths and weaknesses. Thus, it should be relatively uncommon for an employee to receive the same rating on all per- formance dimensions. Although halo error is less common and troublesome than leniency and recency error, it still is not an accurate assessment of performance.

Ambiguous Evaluation Standards Most appraisal forms use rating scales that include words such as “outstanding,” “above average,” “satisfactory,” or “needs improvement.” However, different managers attach different meanings to these words, giving rise to what has been labeled the ambiguous evaluation standards problem.

One organization dealt with the problem by identifying core competencies and skill level descriptors and tagging them with evaluation criteria, such as “exceeds expectation,” “meets ex- pectation,” or “requires improvement” (Schoessler et al., 2008). Senior leadership validated that competency statements met accepted standards. Another approach is to develop rating forms that have each gradation along the performance continuum (e.g., excellent, satisfactory) anchored by examples of behavior that is representative of that level of performance.

Written Comments Problem Almost all performance appraisal forms provide space for written comments by the appraiser. The wise manager uses this space to justify in detail the basis for the ratings, to discuss develop- mental activities for the employee in the coming year, to put the ratings in context (e.g., although the evaluation period is 12 months, the appraiser notes on the form that he or she has only been the nurse’s manager for the past 3 months), or to discuss the employee’s promotion potential. Unfortunately, few nurse managers use this valuable space appropriately; in fact, the spaces for written comments are often left blank. When there are comments, they tend to be few and gen- eral (e.g., “Joan is conscientious”), focus totally on what the individual did wrong, or reflect only recent performance.

Dawn Stanley, RN, is director of nursing for an assisted living center. Two certified nurse aides transferred to her center from other facilities in the health care system. Both CNAs have struggled to meet performance expectations in the first 90 days of their new posi- tions. In preparing performance appraisals for both employees, Dawn reviewed previous appraisals to see if other managers had indicated areas for improvement or performance trends. Both employees were rated as “marginal performers” but no written comments were provided, making the appraisal process more difficult for Dawn.

The existence of the written comments problem should not be surprising. Most managers wait until the end of the evaluation period to make written comments; thus, the manager is faced


with a difficult, time-consuming task. Small wonder, then, that the few comments tend to be vague, negative in tone, and reflect recent events. Fortunately, regular note taking can lessen the problems associated with written comments.

Improving Appraisal Accuracy For the manager and employee to get maximum benefit from an appraisal, it needs to encom- pass all facets of job performance and be free from rater error. Although attempting to get com- pletely accurate evaluations is often impossible, there are ways to greatly improve the accuracy of appraisals.

Appraiser Ability Accurately evaluating an employee’s performance involves using the job description, skill level descriptors, or core competency statements to identify behaviors required, then observing the employee’s performance over the course of the evaluation period and recalling it, and knowing how to use the appraisal form accurately. To the extent that any of these things are lacking, a manager’s ability to rate accurately is limited.

Fortunately, a manager’s ability to rate employees can be improved. An organization can de- velop detailed job descriptions, skill level descriptors, and competency statements. The rater can be given more opportunities to directly or indirectly observe an employee’s behavior. For example, other supervisors can provide information on an employee’s performance when the immediate su- pervisor is not present. Managers can be taught to take notes on an employee’s behavior to facili- tate recall. In addition, managers can learn to use the appraisal form better through formal training.

Formal training programs help to increase appraiser ability by making raters aware of the various types of rating errors (the assumption being that awareness may reduce the error ten- dency), by improving raters’ observational skills, and by improving raters’ skill in carrying out the performance appraisal interview.

Simone Hurtado is team manager for the pediatric home services team. In previous years, Simone has struggled to adequately evaluate her employees. Since all of the patient care is delivered in client’s homes, Simone relied on sporadic client feedback and review of patient care documentation to complete employee appraisals. Recently Simone attended an appraisal workshop. Using some of the suggested strategies, Simone and the other team managers have set up an observation schedule for their employees. Each employee will be randomly observed by a team manager in a client’s home every six to eight weeks. Additionally, employees will be asked to complete self-evaluations as well as evaluations of other team members they work with on a regular basis. Simone has also established a system for compiling ongoing employee performance documentation.

Appraiser Motivation Managers have a multitude of tasks to perform, often immediately. Not surprisingly, then, they often view performance appraisals as a task that can be done later. Furthermore, many managers do not see doing appraisals as particularly important, and some question the need for doing them at all. This is especially true if all employees receive the same percentage salary increase. Thus, if nurse managers are to be motivated to do appraisals well, they need to be rewarded for their efforts.

A nurse manager may spend little time on appraisals for several reasons:

● The organization does not reward the person for doing a good job. ● The manager’s supervisor spends little time on the manager’s own appraisal (thus sending

the message that doing appraisals is not important). ● If a manager gives low ratings to a poor employee, a superior may overrule and raise the



In short, in many health care organizations, the environment may actually dampen appraiser motivation rather than stimulate it. Given these reasons for not spending time on appraisals, it is fairly obvious how an organization can enhance appraiser motivation:

● The manager needs to be rewarded for conscientiously doing performance reviews. ● The manager’s supervisor needs to present a good model of how an appraisal should be

carried out. ● As far as possible, the manager should be able to reward the highly rated staff.

This becomes more likely as outcomes are used as the basis for reimbursement to the orga- nization and, subsequently, the organization bases rewards on productivity. For the organization and its employees to benefit from the performance appraisal system, pay increases should not be across the board, layoffs should not be based on seniority, and promotions should be tied to superior performance.

Learn how one manager used a performance evaluation to help a staff member and benefit the organization at the same time (see Case Study 18-1).

EVALUATING STAFF Brenda Tice has been nurse manager for the medical in- tensive care unit (MICU) in a large urban hospital for six months. The MICU rarely has staff openings and the average nurse has 12 years of experience on the unit. Brenda herself was a nurse on the unit for 10 years prior to her promotion to nurse manager.

Lori Cook has been an RN on the MICU day shift for the past 18 months. Lori is pleasant and tries hard to please her patients and coworkers. However, she consis- tently stays late to complete her charting, relies heavily on coworkers to help her throughout the shift, and has little confidence in her own ability to handle complex patients. Often Lori will break down and cry during a patient code and is seemingly overwhelmed by the code process. Although the other nurses are supportive of Lori, they are aware of her limitations. Several nurses have complained when they have been assigned two high acuity patients and Lori is assigned one lower acu- ity patient.

Brenda discussed the issues with Lori. Brenda told Lori that she would help her attempt remediation as part of an action plan for performance improvement in order to meet minimum expectations for her position. Brenda arranged for Lori to attend several training programs designed specifically for ICU nurses, provided opportu- nities for experienced nurses to mentor Lori on more complex patients, and provided her with reference ma- terials to reinforce Lori’s skill set. Brenda also reviewed Lori’s personnel records for the past 18 months. While Lori is rated high for attendance and her interpersonal skills, her clinical skills are rated as fair. Brenda notices three separate performance counseling documents dat- ed within the past 12 months, with little improvement noted in her clinical performance.

Following another code incident in which Lori started crying and was asked to leave by a physician, Brenda determines that while Lori has many positive qualities, she does not have the clinical skills necessary to func- tion independently in the MICU. Brenda had provided Lori with an action plan and fair warning and conversa- tion about her not meeting expectation in the ICU and shared that Lori may not be a fit in the ICU environment. After contacting the human resources department to discuss the transfer process because of Lori’s continued lack of ability to meet ICU performance expectations, she schedules a meeting with Lori to discuss her perfor- mance issues. Brenda reviews the performance concerns with Lori and informs her that due to her continued lack of ability to meet expectations she has 30 days to accept reassignment within the hospital to a unit that more closely matches her clinical abilities. Lori decides to in- terview for positions in the geriatric psychiatric unit and the psychiatric day treatment program.

Manager’s Checklist The nurse manager is responsible for:

● Understanding the performance appraisal process and appraisal tools used by the organization

● Providing honest and timely feedback to all employees

● Communicating as needed with the human resources department when performance issues arise

● Accurately and thoroughly documenting all performance-related issues

● Identifying the impact of poor performers on the morale and productivity of staff

● Making staffing decisions in a timely manner



Rules of Thumb For approximately five percent of employees, the prescriptions given in this chapter will not work, for reasons yet unknown. Additional suggestions or “rules of thumb” derived from practi- cal experience include the following:

● Go beyond the form. Too often, people doing evaluations cite an inadequate form as an excuse for doing a poor job of evaluating their employees. No matter how inadequate an appraisal form is, managers can go beyond it. They can focus on behavior even if the form does not require it. They can set goals even if other supervisors do not. They can use criti- cal incidents. In short, managers should do the best job of managing they can and not let the form handicap them.

● Postpone the appraisal interview if necessary. Once the appraisal interview begins, there is often the belief that the session must be completed in the time allotted, whether the ses- sion is going well or not. Managers forget the goal of the appraisal interview is not merely to get an employee’s signature on the form but also to get the employee to improve perfor- mance in the coming year. Therefore, if the interview is not going well, a manager should discontinue it until a later time. Such a postponement allows both the manager and the em- ployee some time to reflect on what has transpired as well as some time to calm down.

In postponing the meeting, the manager should not assign blame (“If you’re going to act like a child, let’s postpone the meeting”), but should adopt a more positive approach (“This meeting isn’t going as I hoped it would; I’d like to postpone it to give us some time to collect our thoughts”). Most managers who have used this technique find that the sec- ond session, which generally takes place one to two days later, goes much better.

● Don’t be afraid to change an inaccurate rating. New managers often ask whether they should change a rating if an employee challenges it. They fear that by changing a rating, they will be admitting an error. They also fear that changing a rating will lead to other ratings be- ing challenged. A practical rule of thumb for this situation is if the rating is inaccurate, change it, but never change it during the appraisal interview. Rather, if an employee challenges a rat- ing and the manager believes the employee has a case, the manager should tell the person that some time is needed to think about the rating before getting back to the employee.

The logic behind this rule of thumb is as follows: If a manager does a careful job of evaluating performance, few inaccurate ratings will be made. But no one is perfect, and on occasion, managers will err. When such an error occurs, the manager should correct it. Most employees respect a manager who admits a mistake and corrects it. By allowing for time to reflect on the ratings, a manager eliminates the pressure to make a snap judgment.

An effective performance evaluation contributes to the employee’s development, improves job satisfaction, and enhances employee morale. Learning how to evaluate employees is one of the nurse manager’s useful activities.

What You Know Now • Doing performance appraisals is one of the most difficult and most important management activities. • Accurate appraisals provide a sound basis for both administrative decisions (e.g., salary increases, promo-

tions) and employee development. • The evaluations system may be results oriented or based on behavioral criteria. • Evaluation standards must be based on identified criteria, such as job descriptions, skill level descriptors,

or core competencies, and based on performance as evaluated over the course of a year. • To enhance the accuracy of the performance appraisal, the manager should record critical incidents

throughout the evaluation period. • Self-evaluation, peer review, group evaluations, and the manager’s evaluation are examples of ways to col-

lect evidence of performance.


• To improve the value of the appraisal interview, the manager should follow the key behaviors for conduct- ing an appraisal interview.

• Problems with employee appraisal include leniency error, recency error, halo error, ambiguous standards, and the inadequate use of written comments.

• The manager’s ability to accurately evaluate staff can be improved through formal training and a posi- tive example from the manager’s supervisor.

Tools for Evaluating Staff Performance 1. Become familiar with the evaluation process adopted by your organization. 2. Familiarize yourself with the appraisal instrument used for staff evaluation. 3. Learn to use critical incidents and include positive behaviors as well as those needing improvement. 4. Be alert to the chances for error in the appraisal process. 5. Prepare for an appraisal interview using the strategies suggested in the chapter. 6. Follow the key behaviors for conducting an appraisal interview.

Questions to Challenge You 1. What evaluation method is used at your workplace or clinical site? If you do not know, find out and

share it with a colleague or class. 2. If you have been evaluated in the skills lab, on a simulator, or at the point of care, which assessment

best evaluated your skills? 3. What components of your job (or clinical placement) are evaluated? Are they the appropriate ones? 4. What types of assessment methods have been used to evaluate you? Were they the best ones to eval-

uate your performance? What would you suggest? 5. If you have been evaluated as an employee, did your evaluator follow the key behaviors in this chap-

ter? What improvements would you suggest? 6. Have you ever evaluated someone else’s performance at work? How closely did your actions follow

the suggestions in the chapter?

References Davis, K. K., Capozzoli, J., &

Parks, J. (2009). Imple- menting peer review: Guidelines for managers and staff. Nursing Admin- istration Quarterly, 33(3), 251–257.

Joint Commission. (2011). Com- prehensive accreditation manual for hospitals: The

official handbook. Retrieved July 28, 2011 from http://www.jcrinc.com/ Accreditation-Manuals/ PCAH11/2130/

Schoessler, M. T., Aneshansley, P., Baffaro, C., Castellan, T., Goins, L., Largaespada, E., Payne, R., & Stinson, D. (2008). The performance

appraisal as a developmen- tal tool. Journal for Nurses in Staff Development, 24(3), E12–E18.

Topjian, D. F., Buck, T., & Kozlowski, R. (2009). Em- ployee performance? For the good of all. Nursing Management, 40(4), 24–29.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!


Day-to-Day Coaching

Positive Coaching

Dealing with a Policy Violation

Disciplining Staff

Terminating Employees

Coaching, Disciplining, and Terminating Staff 19

Key Terms Coaching Discipline

Progressive discipline Terminate

1. Describe how to coach an employee. 2. Discuss positive coaching. 3. Explain how to confront an employee

about a policy violation.

4. Discuss how to discipline an employee. 5. Describe how to terminate an employee.

Learning Outcomes After completing this chapter, you will be able to:


O ne of the most challenging problems for managers is knowing what to do when employees fail to perform to expectations. Managers often want to ignore the prob-lems, hoping they’ll disappear, but that seldom happens. Instead, the manager can learn how to handle these problems.

Day-to-Day Coaching Coaching, the day-to-day process of helping employees improve their performance, is an impor- tant tool for effective nurse managers. Yet coaching is probably the most difficult task in man- agement and is often neglected. In one short interaction, it encompasses needs analysis, staff development, interviewing, decision making, problem solving, analytical thinking, active listening, motivation, mentoring, and communication skills. Intervening immediately in performance prob- lems on a day-to-day basis usually eliminates small problems before they become larger ones and the subject of discussion in performance appraisal interviews or disciplinary actions. Coaching should also be used when performance meets the standard but improvement can still be obtained.

The goal of coaching is to eliminate or improve performance problems, but few nurses are prepared to coach and are often hesitant to confront employee problems. Coaching employees when the problem initially surfaces can potentially save time, prevent poor morale from occur- ring, and avoid more difficult action later, such as discipline or termination (Palermo, 2007). Additionally, appropriate and timely coaching can help retain employees and reduce turnover (Stedman & Nolan, 2007). (See Chapter 20 for more on reducing turnover and retaining staff.)

Examples of problems that coaching can improve or eliminate are incorrect flow sheet doc- umentation, excessive absenteeism, or frequent personal phone calls or excessive texting. Before entering into a coaching session, the nurse manager (coach) should prepare for the interaction and try to anticipate how the employee will react (“Everybody gets personal phone calls”) in or- der to formulate an appropriate response (“I am here to talk about the number of personal phone calls you receive”). In general, coaching sessions should last no more than 5 to 10 minutes. The steps in successful coaching are:

1. State the targeted performance in behavioral terms. “For the past two days, the physical assessment portions of your flow sheets have not been filled out.”

2. Tie the problem to consequences for patient care, the functioning of the organization, or the person’s self-interest. “It’s difficult for other nurses and physicians to know whether the patient’s status is changing, and therefore it’s hard to know how to treat the patient. Physical assessments are a standard of practice in our unit. Failure to document assessments could lead to legal problems should the patient’s record go before a court of law.” This is an important but often overlooked step because it cannot be taken for granted that the employee knows why the behavior is a problem. If employees are expected to act in a certain way, they need to under- stand why the behavior is important and be rewarded when it has improved. Avoid threatening language, such as “If you want to stay in this unit, you had better complete your documenta- tion.” This puts the employee on the defensive and makes the person less receptive to change.

3. Having stated the problem behavior, avoid jumping to conclusions but instead explore reasons for the problem with the employee. Listen openly as the employee describes the problem and the reasons for it. If the problem was caused by ignorance—for instance, lack of familiarity with the standard of care on performing and documenting assessments—sim- ply inform the nurse of the appropriate behavior and end the coaching session.

4. Ask the employee for his or her suggestions and discuss ideas for how to solve the problem. In many cases, the employee knows best how to solve the problem and is more likely to be committed to the solution if it is his or her own. It is better to encourage employees to solve their own problems; however, this does not mean that managers cannot add suggestions for improvement. It is essential to listen openly to understand the employee’s perspectives.


5. How formal should the coaching session be? If the problem is minor and a first-time oc- currence, you may simply state what actions will be taken to solve the problem and end the meeting. In most cases, however, you and the employee should agree on specific behavioral steps each will take to solve the problem; write down these steps for later reference.

6. Arrange for a follow-up meeting, at which time the employee will receive performance feedback. It is possible that an employee may bring up personal problems as a cause for the work problems. The coaching session then verges on becoming a counseling session. When the employee brings up personal problems, nurse managers should convey their concern and willingness to work with the employee to get help for the problems. In most cases, nurse managers will not be the direct source of the help but rather will help the employee seek out other, more appropriate, sources, such as the organization’s employee assistance program. Do not delve into potential personal problems (“Are there problems at home that I should know about?”) unless staff raise them. The employee’s personal life is not the manager’s business.

Positive Coaching Coaching as a strategy to improve problem performance has been discussed, but coaching can also be used as tool to reinforce positive behaviors (Karsten et al., 2010). In fact, negativity is a far more common experience than a positive experience (Huseman, 2009). Coaching can be a leadership development tool as well.

Coaching has been shown to help leaders become more confident and competent and to improve their team’s functioning as well (McDermott & Levenson, 2007; McNally & Lukens, 2007). Coaching leaders is especially useful during times of transition, but historically, asking a leader to use a coach has been seen as punitive (Karsten et al., 2010). Often a senior executive uses a coach to model the importance to administrative staff. Coaching administrators is also a strategy for succession planning (McNally & Lukens, 2006).

Leadership coaching can be undertaken as one-on-one interactions with a coach, a group with similar needs participating in coaching sessions together, or individual and group sessions. Such coaching is results oriented, and its purpose is to help the participant become more self- aware, ensure accountability, and attain professional goals (McNally & Lukens, 2006).

Dealing with a Policy Violation As with day-to-day coaching, the manager must prepare to confront an employee about a policy violation. The leadership style of the manager is important in determining whether the employee perceives that he or she is being told what to do versus being sold on the idea that she or he is an important contributor to the staff. The steps involved in confrontation are similar to coaching. These steps are outlined in Box 19-1.

The first key behavior is to determine whether the employee is aware of the policy. The employee should have received policy information at orientation, and an updated policy manual should be readily accessible to all employees. It is also important to know whether the policy has been enforced consistently. If policies regarding tardiness are not applied to everyone on a daily basis, efforts to change this behavior in one individual predictably will be unsuccessful. It is bet- ter to identify policies and procedures that the majority of staff accept and to determine which employees need direction in compliance.

Second, describe the behavior that violated the policy in a manner that conveys concern to the employee regarding the outcome. By focusing on the employee’s behavior, you avoid mak- ing the interaction a personal issue.

After stating that the policy has been violated, obtain a document that states the policy so that in- terpretation issues can be clarified. For example, if the policy being violated is the requirement that nurses report to a peer about their patients when leaving the unit, have a copy of the policy in hand.


The next step is to solicit the employee’s reason for the behavior (e.g., what is preventing the person from informing a peer about patients when leaving the unit). Allow sufficient time for the employee to respond while at the same time guarding against the pursuit of extraneous, unrelated issues. In the latter event, redirect the employee’s attention to the policy violation and suggest dealing with other issues at another time.

Convey to the employee that she or he cannot continue breaking an established policy. In the previous example, you could discuss the effects of the behavior, such as medications not given, IVs running dry, and patients being left unattended, as reasons for having the policy.

Next, explore alternative solutions so that negative outcomes will be avoided. Ask the em- ployee for suggestions for solving the problem, and discuss each of the suggestions. Offer help if it is appropriate. Decide and agree on a course of action. The last step in the process is to set up a reasonable date to follow up with the employee on adherence to the established policy.

Although dealing with policy violations in a distinct step-by-step sequence is not always possible, proceed in an orderly manner. Many policy violations require early and decisive inter- ventions, and these must be handled in an immediate, forthright manner.

Disciplining Staff Most managers dread having to discipline an employee. Nevertheless, there will be occasions where discipline is necessary (e.g., when a regulation has been violated that jeopardizes patient safety). Managers may hesitate to discipline for many reasons, including:

● Lack of management support or training ● Letting past inappropriate behavior go by without mention ● Rationalizing to avoid disciplining ● Previous poor experience with attempting to discipline employees ● Fear that the employee will respond negatively (White, 2006)

Learning how to discipline effectively can reduce your concerns and improve morale for all em- ployees. Keep in mind, though, that the primary function of discipline is not to punish the guilty party, but to teach new skills and encourage that person and others to behave appropriately in the future.

BOX 19-1 Steps in Confrontation

1. Prepare before the meeting.

2. Without attacking the person, describe the un- desired behavior. Tie that behavior to its con- sequences for the patients, organization, or employee.

3. Solicit and openly listen with empathy to the em- ployee’s reasons for the behavior.

4. Explain why the behavior cannot continue, and ask for suggestions in solving the problem. If none are offered, suggest solutions. Agree on steps each will take to solve the problem.

5. Set and record a specific follow-up date.

Is the employee aware of the policy and procedure? Desired behavior?

Has the policy/procedure been consistently enforced?

How will the employee react?

Jane, were you aware that it is clinic policy to notify both the clinic manager and the hospital supervisor when you will be absent from work? Not only were we worried about you, but we had to reschedule patient procedures because we did not have the staff to attend to both clinic appointments and special procedures.

Why didn’t you notify someone about your absence?

In the future, you will need to notify both the clinic manager and the hospital supervisor if you cannot come in. How do you suppose you might do this, since you do not have a phone?

Can we meet again in one month to review this plan?


BOX 19-2 Guidelines for Effective Discipline

1. Get the facts before acting. 2. Do not act while you are angry. 3. Do not suddenly tighten your enforcement of rules. 4. Do not apply penalties inconsistently. 5. Discipline in private. 6. Make the offense clear. Specify what is appropri-

ate behavior.

7. Get the other side of the story. 8. Do not let the disciplining become personal. 9. Do not back down when you are right. 10. Inform the human resources department and

administration of the outcome and other pertinent details.

BOX 19-3 Verbal Warning Form

Employee’s name: Date of verbal warning: Specific offense or rule violation: Specific statement of the expected performance:

Any explanation given by the employee or other significant information:


Supervisor Date _____________________

When faced with a disciplinary situation, maintain close contact with the organization’s human resources department and administration. Before taking any disciplinary action, discuss the action you intend to take and seek approval for it. This close coordination with administration is essential to guarantee that any disciplinary action is administered in a fair and legally defensible manner.

To further ensure fairness, rules and regulations must be clearly communicated, a system of progressive penalties must be established, and an appeals process must be available. To enforce rules or regulations, managers must inform employees of them ahead of time, preferably in writ- ing. Guidelines for effective discipline can be found in Box 19-2.

Penalties should be progressive. Progressive discipline is the process of increasingly severe warnings for repeated violations that can result in termination. Questions to ask include:

● How many different offenses are involved? ● What is the seriousness of the offense? ● What were the time interval and employee responses to prior disciplinary action? ● What is the previous work history of the employee?

Penalties are also progressive, beginning with a verbal warning (Box 19-3), and followed by a written warning (Box 19-4), suspension, and discharge.

For minor violations (e.g., smoking outside in an unauthorized area), penalties may progress from an oral warning, to a written warning placed in the employee’s person- nel folder, to a suspension, and ultimately to discharge. For major rule violations (e.g., theft of property), however, initial penalties should be more severe (e.g., immediate suspension).


At each stage of the disciplinary process, documentation is essential. In addition, an appeals process should be built into an organization’s disciplinary procedures to ensure that discipline is carried out in a fair, consistent manner.

Case Study 19-1 shows how one nurse manager handled a disciplinary problem.

Terminating Employees Unfortunately, some employees do not respond to either coaching or discipline, and nurse man- agers will face the day when they must terminate, or fire, an employee (Bing, 2007). The steps in terminating an employee are similar to those for disciplining, except there are no plans to cor- rect the behavior and no follow-up. As with a disciplinary action, nurse managers must maintain close contact with the organization’s human resource department and nursing administration. They must discuss the termination and seek approval for it.

Preparation before terminating an employee is essential (Cohen, 2006). To prepare, answer the following questions:

1. Did you set your expectations clearly from the beginning? Did you review the job descrip- tion, performance appraisal criteria, and pertinent policies and procedures with the em- ployee? These expectations should have been in writing.

2. Did you document the employee’s performance on a continuing basis, using the critical in- cident or a similar method?

BOX 19-4 Written Warning Form

Employee’s name: Date of conversation: Specific rule violation or performance problem:

Previous conversations about the rule violation or performance problem:

Specific change in the employee’s performance or behavior expected:

Employee’s comments:

Supervisor’s comments:

Employee’s signature: -or- Employee was asked to sign this written warning on _____________ but declined to sign.

_____________________ Supervisor Date _____________________


PROGRESSIVE DISCIPLINE Katie Connors is nurse manager of the birthing center in a metropolitan hospital. The hospital has several different nursing programs that utilize various patient care units for clinical instruction. A student nurse, Amber Schroeder, was assigned to work with Natalie Cole, RN, for the day shift. Natalie and Amber’s patient arrives at the birth- ing center for induction of labor. During the admission process, the patient confides to Natalie and Amber that she is terrified that she might need a caesarean section. Amber tells the patient that a young woman and her baby recently died at the hospital during an emergency C-section. The patient begins to hyperventilate, refuses to let Natalie continue with the admission, and threatens to leave the birthing center. Natalie is so angry at Amber for scaring the patient that she grabs her by the arm and pulls her out of the room. Natalie loudly berates Amber in the hallway to the point that Amber is crying.

Katie hears the commotion in the hallway and in- structs Amber to sit in the staff lounge until her instruc- tor can return to the unit. Katie and Natalie reassure the patient, who allows Natalie to complete the admission process. Throughout the shift, Natalie tells every staff member and physician about Amber’s “stupid com- ment.” Katie speaks with the nursing instructor and Amber about the incident. She also checks back with the patient and gently gathers facts about the incident.

Katie is concerned about Natalie’s response to the situation. While Natalie has excellent nursing skills, she has often been abrupt or rude to other staff members. Katie has coached Natalie on her communication skills in three other specific incidents and verbally warned Nata- lie about her lack of professional communication. After discussing the incident with the human resources man- ager, Katie agrees that a written warning will be placed in Natalie’s personnel file.

At the end of the shift, Katie requests that Natalie come to her office to discuss what happened with the

student nurse. Katie informs Natalie she is disappointed in how she reacted to the inappropriate comment made by the student nurse. Specifically, physically grabbing the student and verbally attacking her in front of patients and staff was unacceptable and violates hospital policy. Further, Natalie continued to disparage the student to other staff and physicians, which is also unacceptable. Natalie expresses her frustration at the thoughtlessness of Amber’s comment. Katie tells Natalie that while Am- ber’s comment was inappropriate, Natalie’s response was also inappropriate. Katie reinforces to Natalie the im- portance of professional communication at all times and reviews the communication points she had provided to Natalie in the past. She also informs Natalie that she will have a written warning placed in her personnel file. Nat- alie apologizes for her actions and assures Katie she will work on her communication skills. Katie documents the incident and follow-up action in Natalie’s personnel file.

Manager’s Checklist The nurse manager is responsible for:

● Collecting all necessary facts related to the disciplin- ary situation

● Communicating with the human resources depart- ment and nursing administration about the offense and appropriate penalty

● Disciplining the employee in a timely manner ● Providing strategies to the disciplined employee to

improve his or her behavior ● Clearly and firmly communicating expectations for

appropriate behavior ● Documenting the outcome of the discipline as

appropriate ● Following up with the human resources department

and nursing administration regarding the outcome of the discipline


3. Did you keep the employee informed about his or her performance on a regular basis?

4. Did you conduct coaching sessions or deal with policy or procedure violations in a timely manner? Were the sessions and the agreed-on actions in these meetings documented?

5. Were you honest with the employee about the poor performance or the policy that was vio- lated? Were you specific about behaviors that failed to meet expected standards? Was the expected performance stated in behavioral terms?

6. Were you consistent among employees in how you dealt with performance issues and policy or procedure violations?

7. Did you follow up? Did you deliver the actions you agreed to in the coaching sessions?

8. Did you document everything in writing? The importance of this cannot be overstated.

9. Have you notified security so that the terminated employee may be escorted out?


This checklist applies to almost every instance of termination. The few exceptions might be theft or physical abuse of a patient or assault on others. Even in the latter instances, observation and documentation are crucial to avoid legal challenges.

A sample script for a termination conversation is shown in Box 19-5. See how one manager handled terminating an employee in Case Study 19-2. Terminating an employee affects the morale of the entire unit. Coworkers may take sides,

and the manager may need to share pertinent facts if they relate to patient safety or acceptable behavioral standards. Not terminating poor performing staff, conversely, can hurt the manager’s credibility and decrease performance on the unit (Hader, 2006).

Employees cannot be fired simply for being a member of a protected class, including their race, sex, national origin, or religion, or their disability as long as their disability does not pre- vent them from doing their job. In addition, a nurse, for example, cannot be fired for refusing to follow medical orders that he or she believes might harm a patient.

Even with careful documentation and the most conscientious adherence to organizational poli- cies regarding termination, firing an employee may be followed by legal action, grievance proce- dures, and stressful and time-consuming hearings. A preferable alternative is that the employee voluntarily resign. Careful documentation may allow the manager to suggest that the employee vol- untarily leave the organization. This allows the employee to leave without a record of termination.

Being a nurse manager is a challenging, ever-changing job and seldom more difficult than when employees must be disciplined or terminated. Even coaching employees can be a stressful experience. Developing the skills to intervene early with employee problems and follow-up as necessary should the problem continue or escalate will help reduce incidents and improve per- formance and morale.

BOX 19-5 Script for a Termination Conversation

Manager: Lucy, we are here today to have the conversation I told you we would be having about your attendance. On March 13, you received a written warn- ing counseling for your attendance. Since then, you have accumulated the following unscheduled absences:

On March 17, you missed work because of car problems. Then on May 2, you didn’t report to work be- cause you said you forgot you were working, and then refused to come in. You have now accumulated eight incidents of unscheduled absence this year. Our hospi- tal attendance policy states that the hospital relies on employees being dependable to take excellent care of patients and that when employee attendance interrupts the ability to provide excellent care, we must advance the corrective action process. At our hospital, eight ab- sences in a 12-month period is considered an unaccept- able, very serious violation of our hospital’s policy.

Prior to today, you received a verbal counseling and a written warning for your attendance. At the time of your verbal counseling, you had accumulated the following unscheduled absences:

August 23, last year, you missed your shift at work, stating you had a family issue.

September 8, you missed work, stating you were ill. September 24, you called in reporting GI illness

and did not come to work.

November 20, you called in to work reporting you had overslept and wouldn’t be reporting to work.

On November 25, you were given verbal counsel- ing concerning your attendance. A copy of the policy was given to you at that time, your absences were reviewed, and you acknowledged that you understood you should not miss more work unplanned.

You continued to accumulate unscheduled absences and were given a written warning on February 1. These absences included the following:

On December, 16 you called in to work reporting a scheduling conflict.

On January 27, you called in and said you had a cold and weren’t coming to work.

In addition to your verbal and written warnings, I, as your manager, spoke with you on other occasions as well to remind you about the attendance policy and the seriousness of your current attendance situation. You have continued to accumulate absences and have seri- ously violated the attendance policy despite multiple attempts at coaching. Therefore today, May 3, your employment is terminated. Human Resources is here with us to provide you all information on your benefits, retirement fund, and to answer any questions you have.


What You Know Now • Coaching is the day-to-day process of helping employees improve their performance or eliminate a per-

formance problem. • Coaching can reinforce positive behaviors, serve as a leadership development tool, and assist with succes-

sion planning. • To confront an employee, make the employee aware of the policy violation and its consequences, elicit

reasons for the behavior, and agree on steps to prevent future recurrence. • When rule violations occur, disciplinary action is needed. Penalties should be progressive. • When staff members do not respond to discipline, managers must terminate their employment. • If an employee must be terminated, the manager must stay in close contact with the human resources

department and administration when planning and carrying out the termination.

TERMINATING STAFF Carrie Lyle is nurse manager of a 20-bed medical–surgi- cal unit in a suburban hospital. Six months ago, Mar- garet Johnson, LPN, transferred to the unit from the skilled nursing unit. Carrie noted that although Marga- ret had been an employee of the hospital for 12 years, her personnel record included several entries regarding substandard performance. Carrie also found gaps in her performance appraisals from other units. Carrie dis- cussed these issues with Margaret prior to her transfer and clearly indicated performance expectations. Howev- er, Margaret often arrives late to work and leaves before report is finished for the day shift.

Claire Kindred, RN and night shift charge nurse, has worked with Margaret for the past six months. Claire requested a meeting with Carrie to discuss patient care concerns. Claire indicated that during most shifts, Mar- garet takes extended meal and break times. She has been found sleeping during her shift in empty patient rooms. Recently, Claire helped one of Margaret’s pa- tients to the bathroom. When recording the patient’s output, she noted that Margaret had charted the pa- tient’s IV intake for the entire shift even though it was only three hours into the night shift. When confronted, Margaret laughed and told Claire she was “just saving time.” Claire had documented the dates of the incidents and provided them to Carrie.

Carrie met that evening with Margaret to discuss her performance and informed her that she will be on pro- bation for the next 30 days. During the probation time, Margaret’s performance would be reviewed each shift to ensure she is completely meeting all expectations for patient care and performance. The next morning, Rob- ert Adams, RN, brought one of his patient’s charts to Carrie’s office. The patient had been assigned to Mar- garet on the night shift. In addition to diabetes, the patient has bilateral below-the-knee amputations. On the patient’s physical assessment, Margaret had charted

positive pedal pulses. She also charted she had changed the patient’s IV tubing and IV dressing. On closer in- spection, Robert found that the date stickers had been covered over by new stickers and no IV tubing changes were noted on the patient’s chart. Carrie immediately contacted the human resources department. She tells them that Margaret has falsified patient documentation in direct violation of her probation and hospital policy. The human resources department reviews Margaret’s file and concurs that immediate termination is appropri- ate. Exit paperwork is initiated by the human resources department and forwarded to Carrie.

Carrie meets Margaret as she arrives for her sched- uled shift. She asks Margaret to come into her office to discuss her immediate termination of employment. Margaret is visibly shaken and says “I’ll do better,” then “You can’t do this to me.” Carrie calmly outlines the per- formance problems and compliance issues that support Margaret’s termination. She has a security officer escort Margaret to her locker to gather her personal items. Carrie documents the meeting outcome in Margaret’s personnel file.

Manager’s Checklist

The nurse manager is responsible for: ● Understanding the organization’s discipline and

termination policies and procedures ● Reviewing personnel files and identifying past per-

formance problems that may affect current or future performance

● Addressing employee performance issues in a timely manner

● Verifying performance problems rather than person- ality problems

● Working with the human resources department when employee termination is indicated



Tools for Coaching, Disciplining, and Terminating Staff 1. To prepare and conduct a coaching session a. Note the behavior and why it is unacceptable b. Explore reasons for the behavior with the employee c. Ask the employee for suggestions to solve the problem d. Arrange for follow-up 2. To conduct a discipline session a. Be certain you are calm before beginning b. Assure privacy before beginning c. Apply rules consistently d. Get both sides of a story e. Keep the focus on the problem, not the person f. Arrange for follow-up g. Inform the human resources department and administration 3. To prepare to terminate a staff member a. Inform the human resources department and administration beforehand b. State the offending behavior and the reason for termination c. Explain the termination process d. Remain calm e. Arrange for employee to be escorted out f. Report back to the human resources department and administration

Questions to Challenge You 1. Have you ever been coached, confronted, or disciplined in your workplace or clinical site? How well

did the intervenor handle the situation? How well did you handle it? Did you learn from it? 2. Have you ever had to coach, confront, or discipline someone? How did the person respond? How

well did you do? What did you learn? 3. Do you think you could terminate a staff member? If not, how would you prepare yourself? 4. Select a colleague or classmate and role-play four situations: a. A coaching session b. A confrontation c. A discipline session d. A termination After you have completed these sessions, reverse positions and play the opposite role. 5. Critique each other’s performance.

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!


References Bing, S. (2007). A tale of three

firings. Fortune, 156(2), 210. Cohen, S. (2006). How to termi-

nate a staff nurse. Nursing Management, 37(10), 16.

Hader, R. (2006). Put employee termination etiquette to practice. Nursing Manage- ment, 37(12), 6.

Huseman, R. C. (2009). The importance of positive cul- ture in hospitals. Journal of Nursing Administration, 39(2), 60–63.

Karsten, M., Baggon, D., Brown, A., & Cahill, M.

(2010). Professional coach- ing as an effective strategy to retaining frontline managers. Journal of Nursing Adminis- tration, 40(3), 140–144.

McDermott, M., & Levenson, A. (2007). What coaching can and cannot do for your orga- nization. Human Resources Planning, 30(2), 30–37.

McNally, K., & Lukens, R. (2006). Leadership develop- ment: An external-internal coaching partnership. Jour- nal of Nursing Administra- tion, 36(3), 155–161.

Palermo, J. C. (2007). Well-crafted worker discipline program diminishes risk. Business Insurance, 41(8), 9.

Stedman, M. E., & Nolan, T. L. (2007). Coaching: A dif- ferent approach to the nursing dilemma. Nursing Administration Quarterly, 31(1), 43–49.

White, K. M. (2006). Better manage your human capi- tal. Nursing Management, 37(1), 16–19.

20 CHAPTER Managing Absenteeism,

Reducing Turnover, Retaining Staff














Key Terms Absence culture Absence frequency Attendance barriers Engagement Family and Medical Leave Act

1. Explain absenteeism. 2. Discuss ways to manage absenteeism. 3. Describe how nursing turnover affects the

organization. 4. Explain voluntary turnover.

5. Discuss what organizations can do to improve retention of nurses.

6. Discuss what managers can do to help retain nurses.

Learning Outcomes After completing this chapter, you will be able to:

Involuntary absenteeism Involuntary turnover Presenteeism Salary compression Total time lost

Turnover Voluntary

absenteeism Voluntary turnover


K eeping higher-performing nurses is a priority in health care. Appropriate hiring deci-sions begin the process, but once employment begins organizations can do much to ensure that they retain their best performers. It is appropriate to mention several sug- gestions here from Chapter 17, Motivating and Developing Staff. Mentoring, coaching, nurse residency programs, and clinical ladder advancement programs all help retain nurses. In order to understand why nurses are absent or leave the organization and develop ways to retain them, it is necessary to consider absenteeism, turnover, and retention.

Absenteeism Although the extent or the cost of nurse absenteeism is difficult to determine, it is well estab- lished that absenteeism in health care organizations is both pervasive and expensive. The costs of absenteeism, however, can also have a detrimental effect on the work lives of the other staff. Working shorthanded, especially for an extended period of time, can create both physical and mental strain. Even if temporary replacements are called in, the work flow of the unit will still be disrupted as hurried staff must take time to explain standard organizational procedures to replacement nurses.

A Model of Employee Attendance To understand employee absenteeism, it is important to distinguish voluntary from involuntary absenteeism. For example, not coming to work in order to finish one’s income taxes would be seen as voluntary absenteeism (i.e., absenteeism under the employee’s control). In contrast, taking a sick day because of food poisoning would be considered involuntary absenteeism (i.e., largely outside of the employee’s control). Although this distinction seems reasonable in theory, in practice it is often difficult to distinguish these two categories because of a lack of accurate information (few employees will admit to abusing sick leave). In fact, 65 percent of employees call in sick for reasons other than illness (CCH Survey, 2007).

Some organizations try to distinguish voluntary from involuntary absenteeism by the way they measure absenteeism. Traditionally, health care organizations have measured absenteeism in terms of total time lost (i.e., the number of scheduled days an employee misses). Given that one long illness can drastically affect this absenteeism index, total time lost is clearly not a perfect measure of voluntary absenteeism. In contrast, absence frequency (i.e., the total number of distinct absence periods, regardless of their duration) is somewhat insensitive to one long illness.

This distinction between absence frequency and total time lost should make sense to man- agers. For example, an employee who missed nine Mondays in a row would have nine absence frequency periods as well as nine total days absent. In contrast, a person who missed nine con- secutive days of work would have nine total days lost but only one absence frequency period. Intuitively, it seems likely that the first individual was much more prone to being absent volun- tarily than the second.

An employee’s attendance at work is largely a function of two variables: the individual’s ability to attend and motivation to attend as shown in Figure 20-1.

As seen in Figure 20-1, an employee’s ability to attend can be affected by such attendance barriers as:

● Personal illness or injury ● Family responsibilities (e.g., a sick child) ● Transportation problems (e.g., an unreliable automobile)

Although it is natural to view such barriers as resulting in involuntary absenteeism, some- times this is too simplistic a judgment. For example, an employee whose car was not running may consciously have not made alternative arrangements to get to work the next day because he or she was not motivated to attend. This example illustrates that some of the distinctions


portrayed in Figure 20-1 are not always clear-cut. In trying to understand employee absenteeism, a manager will have to make assumptions about why the behavior is occurring (e.g., a manager cannot be certain that a person was actually ill).

According to the attendance model, an employee’s motivation to attend is affected by several factors: the job itself, organizational practices, the absence culture, generational differ- ences, management, the labor market, and the employee’s personal characteristics.

The Job Itself In assessing the job itself, employees holding more enriched jobs are less likely to be absent than those with more mundane jobs. Enriched jobs may increase attendance motivation because employees believe that what they are doing is important and because they know that other em- ployees are depending on the job holder (i.e., if the job holder doesn’t do his or her job, other employees can’t do theirs).

The nature of a job influences attendance through its effect on attendance motivation as well as on illness and injuries (i.e., attendance barriers). For example, a job that requires heavy lifting (e.g., moving patients from beds to stretchers) may increase the likelihood that a staff nurse will be injured. Similarly, a job that exposes a nurse to patients with highly contagious conditions, such as in an outpatient clinic, may increase the likelihood of illness.

Organizational Practices As portrayed in Figure 20-1, organizational practices can also influence attendance motiva- tion. Some health care organizations have absence control policies that reward employees for good attendance and/or punish them for excessive absenteeism. An organization may also be able to increase attendance motivation by carefully recruiting and selecting employees (see Chapter 15). In addition to affecting attendance motivation, organizational practices may influ- ence an employee’s ability to attend. Organizational activities, such as offering wellness pro- grams, employee assistance programs, van pools, on-site child care, or coordinating car pools could influence an employee’s ability to attend work.

Absence Culture The absence culture of a work unit (or an organization) can also influence employee attendance motivation. Some work units have an absence culture that reflects a tolerance for absenteeism. Other units have a culture in which being absent is frowned upon. Although an organization’s

Attendance barriers lllness and injuries Family responsibilities Transportation problems Past experiences

Job itself

Organizational practices


Labor market

Absence culture Employee attitudes, values, and goals

Attendance Attendance motivation

Perceived ability to attend

Figure 20-1 • A diagnostic model of employee attendance.


absence culture can be affected by organizational practices (e.g., attendance policies) and the nature of the jobs involved (e.g., people in higher-level jobs tend to be less accepting of cowork- ers calling in sick), it is also affected by informal norms that develop among work-group mem- bers. For example, people in a cohesive work group may develop an understanding that missing work, except for an emergency or a serious illness, is unacceptable. Such an attendance culture is likely to emerge if the employees work in jobs that they see as important (e.g., providing di- rect patient care) and if an employee being absent causes a hardship for coworkers (e.g., forced overtime, being called in on a day off).

Generational Differences Today’s workforce includes nurses from four generations, and each cohort (traditionals, baby boomers, Generation X, and Generation Y) has different expectations in the workplace (Dols, Landrum, & Wieck, 2010). Younger nurses expect to have flexible scheduling and may use absenteeism to achieve it.

Older nurses may resent the younger ones, especially their technology skills and their lower need for social interaction. Here is an example:

Kirsten McNamara is 24 years old. She spends her lunch break relaxing and returning text and e-mail messages on her phone while she eats; she uses the quiet time to rejuve- nate. Her coworkers, traditionals and baby boomers, are offended, and complain that she was “on her phone and rude” the whole lunch hour.

Generational differences affect retention as well. Generation X and Y nurses want challeng- ing careers that offer opportunities for growth and advancement as well as time for lives outside of work. Flexible schedules and time off are valued by these cohorts, and organizations can ex- pect high turnover if these expectations are not met.

Expectations of the younger generational cohorts affect supervision as well. They expect independence and to be involved in decision making (Farag, Tullai-McGuinness, & Anthony, 2009). Thus, shared governance is an appropriate structure, and consultation is an effective man- agement strategy.

Management Management influences attendance motivation of all staff as well. A nurse manager can influ- ence the nature of a staff nurse’s job (e.g., the degree of responsibility given and participation in decision making), decisions about personnel, the consistency with which organizational prac- tices are applied (e.g., whether sanctions are enforced for abuse of sick leave), and a work unit’s absence culture by stressing the importance of good attendance.

A shared governance organizational model encourages attendance because of the emphasis on cooperative decision making. The manager who consults frequently with staff supports this model. Knowing that their input is valuable to the unit’s functioning promotes participation and, thus, attendance.

Cost-cutting is here to stay (Ferenc, 2009), and managers must be flexible in the work environment. Recognize staff performance, make any enhancement or flexibility necessary in order to keep staff. Evaluate work flow and consider creative ways to use staff to get all the work done. Be open to potentially having to work in a different way or change a work flow.

Labor Market Another factor that influences attendance is the labor market. If the nurse believes that plenty of equivalent jobs are available locally, he or she might be less motivated to attend than if fewer jobs were available.


To the extent that the local employment market for nurses leads an employee to perceive it would be easy to find an equivalent job if she or he lost or disliked the current one, one would expect a lower level of attendance motivation than if market conditions were less favorable. This might happen during a nursing shortage.

Personal Characteristics Although features of the job itself, organizational practices, absence culture, generational dif- ferences, supervision, and the labor market can all have a direct effect on employee attendance motivation, these factors can also interact with an employee’s attitudes (e.g., job satisfaction), values (e.g., personal work ethic), or goals (e.g., desire to get promoted). If a person who seeks variety works in a job that does not provide it, the employee may become dissatisfied and thus more likely to abuse sick leave.

The reverse is also true. Employees’ attitudes, values, and goals can also have a direct effect on attendance motivation. For example, a staff nurse with a high personal work ethic or a goal of getting promoted should be more highly motivated to attend work than a nurse who lacks such a work ethic.

An employee’s attendance behavior is also influenced by past experiences. For example, if an employee’s perfect attendance in the previous year was not recognized, we might expect the employee’s attendance motivation to decrease in the coming year. Conversely, if a coworker with an outstanding attendance record received a promotion, peers who value a promotion and who witnessed this link between performance and reward would be more motivated to attend work in the upcoming year.

Managing Employee Absenteeism The attendance model in Figure 20-1 is useful not only for understanding why absenteeism occurs, but also for developing strategies to control it. Some causes of absenteeism, such as transportation difficulties or child care problems, may be beyond the direct control of nurse managers. A manager, however, should try to do what is possible, either in interactions with staff or by attempting to influence the organization to change policies that may be interfering with a nurse’s ability or motivation to attend work. On the other hand, the manager must be careful that the steps taken do not go so far as to discourage the legitimate use of sick leave. Clearly, one does not want sick nurses coming to work and exposing patients and coworkers to their illnesses.

To diagnose the key factors leading to absenteeism, the manager needs information from several sources, including staff, the human resources department, other nurse managers, and administration. Absence patterns can answer such questions as:

● Is absenteeism equally distributed across all nurses? ● In comparison to other units, does your area of responsibility have a high

absenteeism rate? ● Are most absences of short or long duration? ● Does the absenteeism have a consistent pattern (e.g., occur predominantly on weekends or

shortly before a person quits)?

Although a manager may not be able to do much to affect the staff’s ability to attend, the organization can take several actions. For example, to lessen child care problems, the organiza- tion could set up or sponsor a child care center. To reduce transportation problems, an orga- nization could provide shuttle buses or coordinate car pools. Health fairs, exercise programs, and stress-reduction classes could be offered to promote health. Given that alcoholism and drug abuse are widely recognized as important causes of absenteeism, an employee assistance pro- gram may be cost-effective. In addition to these organizational actions, a nurse manager, through coaching, may be able to influence a staff nurse’s attendance. (See Chapter 19 for information on how to coach staff.)


Clearly, the best way for nurse managers to control absenteeism is by encouraging their staff’s