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LEADERSHIP AND MANAGEMENT IN NURSING

First Semester 2013
Jacqueline G. Polancos, RN, MSN
Associate Professor, College of Nursing

Over the years, there has been one constant in the

changing health-care system, and that is that the RN is
still expected to provide leadership and management
skills to direct and ensure the high quality of the health
care given to clients. Both leadership and management
require sets of skills that can be learned. Nurses who
learn these skills will become successful managers and
the leaders of the health-care system in the future.
Successful leaders and managers understand and often
combine the best aspects of the many theories that deal
with leadership and management. Knowledge of one’s strengths and weakness provides the
basis for successful management. Developing effective leadership and management skills is a
lifelong, ongoing process. Learning from books and articles, as well as from other successful
nurse managers, presents an opportunity for professional and personal growth.

In today’s health-care system, even new graduates who have an “RN” after their name will be placed
quickly in positions of leadership and management.

MANAGEMENT VS. LEADERSHIP Leaders don’t force people to

follow – they invite them on a
The terms management and leadership are frequently journey.
interchanged but they do not have the same meaning. A leader Charles S. Lauer
selects and assumes the role; a manager is assigned or appointed to
the role. Managers have responsibility for organizational goals and the performance of organizational
tasks such as budget preparation and scheduling. Although it is desirable for managers to be good leaders
and to be effective at influencing others, there are leaders who are not managers and, more
frequently, managers who are not leaders!
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

THE TWENTY FIRST CENTURY: A DIFFERENT AGE FOR MANAGEMENT AND FOR
LEADERSHIP

“For the first time in decades, there are four separate and distinct generations potentially working
together in a stressful and competitive nursing workplace”
(Boychuck-Duchscher & Cowin, 2004,p.493).

The leadership of health care in the twenty-first century is impacted by the diverse generations in today’s
workplace: the SILENT or VETERAN Generation (born between 1925 and 1942 – account for 10% of
the current workforce); the BABY BOOMERS (born between 1943 and 1960 – account 45% of the
current workforce); Generation X (born between 1961 and 1977 – account for 30% of the current
workforce); and the newest group to the job market, Generation Y (born between 2978 and 1995 –
account for 10% of the workforce). There are major differences in these groups – in communication
styles, what motivates them, what turns them off, and their workplace ideals (Martin, 2004).
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Who are the SILENT or VETERANS?

This retiring group of nurses, as well as the oldest generation were taught to rely on tried, true and
tested ways of doing things. Their early experience with economic hardship and their witness to
the Great Depression of the 1920s and 1930s, World War II destruction and genocide, the
eradication of p[olio, and the control of other diseases (e.g TB, whooping cough) via the
development of antibiotics and immunizations, place value on loyalty, discipline, teamwork, and
respect for authority.

Who are the BABY BOOMERS ?

They make up the largest group of nurse employees working today, with the majority of
management positions filled by the Baby Boomers. This group has a multitude of family
responsibilities - they have their own children and they are caring for aging parents thus, they are
referred to as the ‘sandwich generation’. This group is very ambitious. They put long hours and
have a strong sense of idealism, both in family and in work. They value what others think, and it
is important that their achievements be recognized. They have set and maintained a grueling pace
between their family and employment responsibilities. This group has embraced technology as a
method for being more productive and to have more free time.

Who are the GENERATION X?

This group grew up in the information age. They are an energetic and innovative generation.
They are hard workers, but unlike the Baby Boomers, they Gen X employees have little loyalty
or confidence in leaders and institutions. They change jobs frequently and will stay in a position
as long as it is good for them. Their independence and reliance grew out of their childhood
experience of being alone, as both Baby Boomer parents worked. They are also called the “Latch-
key” generation. They have no aspirations for retirement. The use of technology has initiated an
expectation of instant response and satisfaction. Their learning style has been shaped by
technology – they want immediate answers from a variety of sources. They want different
employment standards – they want opportunities for self-building and responsibility for work
outcomes. They want extensive learning and precepting, and they want their questions answered
immediately. They value their free time; therefore, flexible scheduling and benefits (daycare
centers, liberal vacations, working from home) are important. They claim to be motivated by
work that agrees with their values and demands (Cordeniz, 2003).

Who is GENERATION Y?
They are also known as Generation “Net,” Nexter, or the Millenium Generation. They are the
largest group, perhaps 3x the size of Generation X. This generation represents a large number of
the children of the Baby Boomers. The impact of this generation remains to be seen, but research
has several predictions. This generation is smart and believe education is the key to success,
diversity is a given, technology is as transparent as air, and social responsibility is a business
imperative (Martin, 2004). They are optimistic, and they are interactive. Traits in this group
include individuality and uniqueness. They can multitask, think fast, as well as being extremely
creative.
Managing this group will require a totally different set of skills than what is in the market
today. They are not team players. They are in the driver’s seat, and work for them is there if they
want it. Focusing on understanding their capabilities, treating them as colleagues, and putting
them in roles to push their limits will help the manager to recognize the potential of this group to
become the highest-producing workforce in history (Martin, 2004).

Note: The challenge to nursing will be to develop a workplace as well as a profession that will be
attractive to all three generations who represent the mainstream of the workforce. Initially, there
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must be a focus on recruiting the younger generations into the health care fields, and specifically
into nursing. There must also be an emphasis on retention of experienced nurses. They are
necessary to mentor the younger generations, and their experience is invaluable.

Motivational Strategies for Generation X and Y

1. Let them know that what they do matters
When was the last time a letter from a patient that was very pleased with the care on a
unit was shared with the staff? When was the last time management sat down with all of
the unit personnel to tell them what a good job they are doing? When was the last time
the CEO complimented the staff on a job well done?
2. Tell them the truth.
When did the managers on a unit acknowledge to the staff exactly what was going on? For
example, the surgery schedule is going to be heavy this next week, there are going to be a lot
of new admissions as well as a lot of patients that will be going home. Acknowledge that
that work level is going to increase, and see if any of the staff have suggestions for
improving the coordination and workload assignments.
3. Explain why you are asking them to do it.
When a difficult time is anticipated, explain to the staff what is happening and why. Maybe a
particular area of the hospital is overloaded and additional staff are being pulled from their
regular units to help out. These patients must be accommodated and cared for – this is why
the hospital is there, and maintaining patient census is what pays the bills.
4. Learn their Language.
When was the last time the unit manager, head nurse, or other manager actually sat down
with the staff (all levels) to find out who they are and what they like to do? What are their
priorities, family situations, what they do on their off days?
5. Be on the look out for rewarding opportunities.
When did a staff member handle a particular difficult patient situation very well and the staff
member was acknowledged at that time? Give positive feedback when opportunities arise, do
not wait for a performance evaluation to do so.
6. Praise them in front of their peers and other staff.
Acknowledge a job well done at a staff meeting, or in the presence of people who are
important to that person.
7. Make the workplace fun.
Making the hospital work environment fun can sometimes be a little difficult, but there are
opportunities for humor if we just look at them. Clients share a lot of humor with the staff, is
the staff encouraged to share that with the rest of the unit personnel? When something funny
happens to staff, are they encouraged to laugh and share with others?
8. Model Behavior.
Does the behavior of the unit manager or head nurse model the behavior they are expecting
others to exhibit? What about confidentiality – it is expected of the personnel, does the
manager practice it as well?
9. Give them the tools to do the job.
What about effective communication skills, or perhaps good customer service skills – the
health care industry is in the job of providing a service for the customer – the client. Training
is offered for the technical skills – new equipment, procedures, policies, but what about
training for the skills necessary in dealing with people? How about skills to deal effectively
with the angry patient, the difficult doctor, the outraged family? (Verret, 2000).
These strategies are from Eric Chester, as presented by Carol Verret in her article, “Generation Y: Motivating and
Training a New Generation of Employees.”
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Key Points

1. Leadership: definition
Outstanding leaders go out of
their way to boost the self-
A. Leadership is defined as a process of influence. esteem of their personnel. If
B. Leadership is not limited to people in traditional positions people believe in themselves,
of authority. Similarly, leadership is no automatic when a it’s amazing what they can
nurse is in an authoritative position. accomplish.
C. A leader influences others to move in the direction of Sam Walton
achieving goals.
D. Leadership an occur in a number of dynamics and settings.
i. A leader can influence one person.
ii. A leader can influence more than one person, including small and large groups, organizations,
even entire communities or societies.
2. For leadership to be successful, the following characteristics must be present.
A. There must be positive interactions between leaders and followers.
B. The leaders and followers must have a reciprocal relationship ( communication, ideas, and
respect – must move back and forth, not just from the top-down).
3. True leadership is not based on “traditional” views of leadership as having authority, command, or
power over others.
A. Leaders can take charge of a situation, but taking charge and being responsible are not the only
characteristics of leadership.
B. Leadership and a position of authority are not equivalent.
i. A person in a position of authority is not automatically a leader.
ii. Ideally, nurses in positions of authority have highly developed leadership qualities.

4. Types of leadership
A. Formal leader: A formal leader is a person in a position of influence or authority or who has a
sanctioned role within an organization.
B. Informal leader: An informal leader is a person who demonstrates leadership and has
influence even though he or she is not in a formal leadership role in an organization.
Informal leadership is marked by two key traits:
i. Ability to influence others.
ii. Other people in the group or organization recognize that ability and are
influenced.
5. Core traits of leaders: Research on leadership does not reveal any absolute qualities that define a leader,
but most experts agree that effective leaders have the following core values:
A. A guiding vision
i. A leader is able to see a picture of the desired future.
ii. Such a picture allows the leader to set goals toward that desired future.
B. Passion
i. A leader is enthusiastic about the future possibilities.
ii. He or she has the ability to inspire people and align them in a common effort to make
those future possibilities in a reality.
C. Integrity
i. Leaders who have integrity possess a significant knowledge of the self or self-awareness,
including knowledge of their strengths and weaknesses and the ability to receive
feedback and learn from mistakes.
ii. Integrity requires honesty and maturity
iii. It is supported by the inner strength of the person’s convictions and his or her ability to
deal with conflict or obstacles that arise.
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iv. A leader’s integrity is developed through personal and professional experience and
growth.
v. Having integrity means that the person can be trusted.
D. Curiosity and / or daring
i. Leaders draw on these traits to enable them to take risks.
ii. These traits facilitate change.
iii. These traits also shorten the learning curve because leaders intuitively zero in on what
works rather than wasting time on what doesn’t work.

6. Additional traits commonly found in leaders:

A. Flexibility
i. This trait allows leaders to adapt rapidly to changes in all aspects of the environment. In
nursing, this can mean being able to manage six new admissions on the same shift ( small
scale) to merging nursing units as part of a hospital-wide redesign (large scale).
ii. Flexibility also allows leaders to deal effectively and creatively with uncertainty and even
hostility that may come their way.
B. Intelligence
i. Subject-based intelligence includes knowledge and skills associated with the person’s job
functions, and the ability to use the knowledge and skills to solve problems and improve work
processes.
ii.People-based intelligence includes “emotional intelligence” – the ability to use not only
rational but also emotional perception in learning, problem-solving, and working with people
effectively to achieve desired outcomes. Note that in nursing, this not only yields positive
patient outcomes, but also results in the ongoing professional development and job satisfaction
of the nurse.
C. Ability to support others. This trait includes the following characteristics:
i. Responsiveness to a wide range of situations and people. A person with this trait is likely to
face situations head-on rather than withdrawing or procrastinating.
ii. The leader who is able to support other practices open and effective communication
iii. The leader who is able to support others possesses key social skills – the ability to work
effectively with and respect diverse constituents, to defuse conflict, and to generate trust and
enthusiasm in others.
D. Self-confidence
i. A person who is self-confident is able to trust his or her abilities and decisions.
ii. This person is also able to receive feedback and input from others without feeling threatened.

E. Desire to lead. Accdg. to Kirkpatrick and Locke (1991), people who are effective leaders must be
interested in and have a desire to influence change in people or organizations.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

What is LEADERSHIP?
Leadership is the conception of a goal and a method of achieving it, the mobilization of
the means necessary for attainment; and the adjustment of values and
environmental factors.

Some leadership theories try to explain why some people are leaders and others are not, but as yet
none covers all the possibilities. That may be because leadership requirements differ depending on the
situation. In the Intensive Care Unit (ICU), e.g. where quick decisions are a matter of life and death, the
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leader is the nurse with highly developed critical thinking and analytical skills and the confidence to make
decisions under pressure.
In quality management, where the problems are often long term and complicated, the leader tends
to be a nurse who is well organized and can methodically sift through a mountain of information and
statistics to develop a policy that covers the widest range of possibilities.

Through the years, a number of researchers have developed theories about leadership. Be aware that older
theories were developed based on the study of white men. These may or may apply to women and people
of color.

A. Behavioral theories

Autocratic leadership/manager – based on centralized decision making. The leader makes decisions and
expects subordinates to obey. The leader uses his or her power to command others and to control
them. If this type is used consistently, a great deal of hostility may develop between the leader and
the followers. The autocratic manager may be most effective in crisis situations when structure and
control are critical to success, as, for instance, during a cardiac arrest or code situation.

Laissez-Faire leadership/manager – (French for “leave it

alone”) the leader defers decision making to her or his
followers. There is a permissive climate with little
direction or control exerted. This manager allows staff
members to make and implement decisions
independently and relinquishes most of his/her power
and responsibility to them. Workers in this situation
may wind up feeling frustrated (because the person who
is supposed to make decisions does not), and efficiency
may suffer as a result.

Democratic leadership/manager – the democratic manager

encourages participation in decision making;
and to share authority. He/she recognizes that there are
situations in which such participation may not be
appropriate and is willing to assume responsibility for a decision when it is necessary. The leader’s
power is derived from his or her expertise as well as the influence that results from close
relationships with others. The goals of the group are identified, and the manager is perceived as a
group member who is its organizer and who keeps it moving in the defined direction. The
environment is open, and communication flows both ways. This type of group tends to perform
well whether or not the leader is present, and leaders and followers tend to maintain positive
relationships.
Authoritarian Democratic Laissez-faire
Degree of freedom Little freedom Moderate freedom Much freedom
Degree of control High control Moderate control Little control
Decision making By the leader only Leader and group Group or no one
Leader activity level High High Minimal
Responsibility Leader Leader and group Abdicated
Quality of output High quality High quality / creative Variable
Efficiency Very efficient Moderately efficient Variable

Source: Tappen, RM, et al,: Essentials of Nursing Leadership and Management, ed. 2 FA Davis. Philadelphia, 2001. p.6
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Although these theories are discussed separately, they are a continuum of leadership style ranging from a
mostly passive approach to a highly controlling one.

Employee centered leadership - the focus is on the human needs of the employees. Employee-centered
leadership is considered more effective than job-focused leadership, which is more concerned with
schedules, tasks, or output than with the people who do the work.

Although most agree that every individual leans toward one of these styles, it has been found that
fluctuations from one to another can occur depending on the particular situation. In the health care
setting, good leaders carefully balance job-centered and employee-centered behaviors to meet both
staff and patient needs effectively. A good leader works toward established goals and has a sense of
purpose and direction. A good leader must also be aware of how her/his behavior impacts the
workplace.

B. Contingency Theories
Contingency approaches to leadership state that a variety of environmental factors affect the
outcome as much as do leadership style or leader characteristics . In other words, the outcomes of
leadership are determined by factors other than the leader’s behavior.

i. Fielder’s theory – a leader’s behavior depends on the interaction of the leader’s personality
and the particular needs of the situation. Leadership effectiveness depends on matching
organizational structure with the best leadership style for that organization and situation.
Effectiveness consists of the three following characteristics:
a. Leader-member relations: includes the follower’s feelings about the leader, including trust,
acceptance of the leader, and whether the leader is perceived as credible by his or her
followers.
b. Task structure: the extent to which work tasks are defined by specific procedures, directions,
and goals. Tasks are classified as high structure (routine, clearly defined) or low structure (
not predictable, creative, working “on the fly”). This concept could also be applied to a work
environment. For example, post partum is generally predictable with stable patients compared
to the emergency department’s complete lack of routine.
c. Position power. This includes the amount of influence and/or the degree of formal authority
that the leader has. In this model, high position power is considered favorable while low
position power is considered less so.

ii. Hersey and Blanchard’s situation theory. According to this theory, the effectiveness of a
person’s leadership style depends not so much on the leader but on the follower – the
follower’s maturity should be assessed in order for the most appropriate leadership style to be
implemented. With this leadership style, the effective leader also changes or adapts her or his
leadership style to match the follower’s needs and attempts to increase the follower’s level o
maturity. This leadership style can be categorized in 4 ways ( based on task and leadership
levels):
a. High task/low relationship behavior: “telling” leadership style
b. High task/high relationship behavior: “selling” leadership style ( getting people to “buy
in” to an approach, policy, or new staffing or management structure)
c. Low task/high relationship behavior: “participating” leadership style
d. Low task/low relationship behavior: “delegating” leadership style

iii. House’s path-goal theory: The effective leader makes the appropriate path easier for the
worker to follow by using the appropriate leadership style. The effective leader also matches
his or her leadership style to the situation or environment, for example, the type or
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complexity of tasks that need to be completed and the dynamics of work groups. When the
leader aligns leadership style with follower’s needs and the particular situation, he or she
enhances worker performance and satisfaction.

In nursing, for example, a manager might need very different

approaches: in a long-term care facility in which there is a
predominance of non-RN staff, with many certified nurse’s aides, a
manager may need to be more hands-on and delegate fewer tasks
and responsibilities. On the other hand, an all-RN staff in a high-
technology, high acuity critical care setting may be able to function
more independently, meaning the manager can delegate more and
the staff can be active participants in management decisions. A
mismatch in which independent nurse are given a hands-on
manager, or a situation in which less skilled workers do not get
enough direct supervision can lead to significant frustration among all nursing staff members and may
affect the quality of patient care delivered.

iv. Kerr and Jermier’s “substitutes for leadership” theory: Certain variables or factors may
influence followers’ behaviors as much as or even more than the leader’s behavior. Some of
these identified substitutes for leader behavior include:
a. amount of feedback provided by the task itself ( for example, the difference between
taking care of a patient in a coma versus a patient who communicates and actively
participates in care).
b. Significant work group cohesion ( do experienced nurses make it difficult for less
experienced nurses to be part of “the group”?)
c. Group’s rigid adherence to rules ( not only formal, but informal rules as well, such as
whether nurses are expected to take personal responsibility for continuing education
or if professional development is not valued).
d. intrinsic satisfaction provided by the work or task
For example, when critical care nurses are rotated out of critical care to a high-tech chronic care unit,
nurse’s job satisfaction may drop because the nurses experience much less feedback from their work;
patients’ conditions do not change rapidly in response to nursing interventions as they do in critical care.
Rotation out of the original work environment can dilute group cohesion, and the nurses may not feel
intrinsic satisfaction from this type of work compared to their usual fast-paced critical care work.

C. Current contemporary theories

i. Charismatic theory: leaders who have the charisma ( leadership qualities that inspire
follower’s allegiance and devotion) are able to make an emotional connection with their
followers. Generally, these leaders display enormous self-confidence and are able to get
others to have confidence in them. The positive aspect of the charismatic leader is his or her
ability to communicate vision and use unconventional strategies effectively (especially in
crisis). President John F. Kennedy used this type of leadership by showing his self-confidence
in an unconventional strategy for the time – by appearing on television. This was especially
important during the Cuban missile crisis when the US faced the threat of nuclear war after
the Soviet Union placed nuclear missiles in Cuba. On the other hand, some followers may
assign a sort of “superhuman” quality or purpose to the charismatic leader, which has allowed
some charismatic leaders such as Adolph Hitler and Charles Manson to do great harm.

ii. Transformational leadership theory: both leaders and followers act on one another to raise
their motivation and performance to higher levels. This theory depends on the concept of
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empowerment, in which all parties are allowed to work together, to the best of their ability,
to achieve a collective goal. This process transforms both the leader and the follower. The
focus of transformational leadership is allowing innovation and change.
According to this theory, there are two types of leaders:
a. Transactional leader: the person responsible for day-to-day operations
b. Transformational leader: the person responsible for maintaining the overall vision and
motivating people to incorporate that vision in their work.

C. Motivational theories: theories are sometimes called process theories because they are designed
to do more than just explain behavior. They are designed to help us understand the processes
involved in people’s behavior. The four key motivational theories are:

i. Reinforcement theory: based on the research of

Skinner (1953), views motivation as learning. Through
this process, a person becomes conditioned to
associate a behavior with a consequence (either a
positive or a negative reinforcement). According to
this theory, leaders are most effective when they can
control or even manipulate the consequences of a
follower’s behavior. This behavior modification
approach works well when enough positive
reinforcements exists and when leaders have a certain
control over follower’s access to these rewards. This
theory does not explain, however, why some
reinforcements work for some people and not for
others. In some cases, rewards can divide staff if the
same people tend to get rewards over and over again,
and some nurses are insulted by the concept of rewards, such as a free lunch coupon or other
small tokens. The efficacy of this approach may also be affected by a person’s educational
background, age, and cultural experiences.

ii. Expectancy theory: people’s expectations about a situation also help determine their
behavior. This theory emphasizes that people don’t just respond passively to reinforcement or
lack thereof; rather, they are actively and consciously interacting with their environment.
Proponents of this theory often construct a matrix that helps quantify the following three
motivational components:

a. Expectancy: the perceived probability that a certain effort will lead to a desired action or
behavior.
b. Instrumentality: the belief that a given performance level will lead to an outcome.
c. Valence: perceived value of that outcome.

In nursing, the “expectation” is often one being taken for granted, being overworked and not receiving
recognition for extra effort, or job well done. Thus, nurses may decide not to “go extra mile” if they
expect that their efforts will not be acknowledged or appreciated. A true nursing leader can change these
expectations by keeping the focus on the patient and family outcomes and the self-satisfaction that comes
from prioritizing their needs. A nursing leader can help staff nurses develop the ability to achieve
satisfaction from the intrinsic rewards of their work, altering their expectations for external rewards.

iii. Equity theory: the degree of perceive fairness in the work situation is the key to job
satisfaction and worker effort. Equity does not mean equality – it is still possible, for
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example, for workers with different skills levels,

different levels of educational preparation, or different Keys to Leadership
levels of seniority in the workplace to receive different
pay. What is important is that the workers perceive that Key Qualities
they are receiving a fair and just reward for their  Integrity
efforts, and that their efforts are being rewarded  Courage
proportionately to the efforts of the other workers.  Initiative
Workers who perceive that inequity exists will usually  Energy
modify their work ( usually in terms of amount of work
 Optimism
or difficulty of work) in order to restore equity
themselves.  Perseverance
 Well-roundedness
iv. Goal setting theory: suggests that people don’t expend  Coping skills
effort for rewards or task outcomes, but to accomplish  Self-knowledge
the goal itself. According to Locke (1968), three
assumptions from the foundation of this theory: Key Behaviors
a. Specific goals are more effective than general goals  Critical thinking
for motivating higher performance  Problem Solving
b. More difficult or challenging goals lead to higher  Acknowledgment of
performance and respect for
c. Incentives or rewards are effective only in that they individual differences
encourage people to change their goals ( that is, it’s  Active listening
not the reward in itself that promotes  Skillful
improvement). communication
 Establishment of clear
E. Wheatley’s “new leadership” concept: Margaret Wheatley goals and outcomes
(1992), the leader’s function in an organization is to:  Continued personal
i. use his or her vision to guide followers and professional
ii. help followers make choices based on values shared by development
leaders and followers
iii. provide meaning and coherence in the organization Source: Adapted from Tappen, RM,
culture et al.: Essentials of Nursing
Leadership and Management, ed. 2
This leadership concept draws strongly on the biological FA Davis, Philadelphia, 2001, p.8
concept of organisms, contending that, like an organism, the
organization is a living entity whose different parts are interdependent on each other for the entire
organization to thrive. This theory sees the organization as being able to form strong internal connections
and balances that promote the best functioning- an environment that provides optimal patient outcomes
through collaboration in the workplace and maximizes worker satisfaction.

Note: It is the responsibility of the leader to see the bigger picture and to be able to describe that
vision or picture to others. This leader is the one who can “stand on the balcony”. From this
position, the leader can monitor the ebb and flow of the organization and determine which direction
the organization is moving. Seeing the big picture and communicating this vision are needed for a
leader to be effective, because it helps to have a vision that can be put into words for others to
understand.

F. How do changes in organizations engender changes in

leadership theory and practice?
1. Organizations today are more complex, and leadership styles and methods must keep pace with
the complexities of people, the patient care they provide, and the technology they use.
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2. The most effective leadership emerges from teams that are able to direct and organize themselves.
3. Leaders must be able to lead teams that are diverse in terms of gender, race, culture, and age and
deal effectively with the different needs and motivations of these groups.

CRITICAL THINKING Question # 1

1. A sudden storm struck at about 9:30 on a Thursday night. There were multiple motor vehicle
crashes, and the community hospital emergency department was overwhelmed with injured
patients. At the same time, two people having massive heart attacks arrived by ambulance for
care. The evening shift staff was scheduled to go home at 11:30 pm. All staff, except for two
people, stayed to help the night shift, not leaving until 3:00 a.m. The 2 people who left angered
the rest of the staff because they did not pitch in to help, and offered no explanation for leaving.
The following day, the evening staff arrived to see a memo posted in the staff lounge from the
nurse manager thanking the staff for staying late, pitching in, and going the extra mile” for the
patients, their co-workers, and the department. However, the memo was addressed to the people
who were on the staffing list for the evening shift, and included the 2 people who left early. Using
one or more of the theories described, describe the positive and negative aspects of the nurse
manager’s behavior.

2. An enthusiastic, 28 year old nurse is promoted to the nurse manager’s position on a different
nursing unit within the same hospital. She worked on an oncology unit, and is now manager of a
mixed medical-surgical unit that uses critical paths extensively for its orthopedic surgical
patients. She is the third new manager in 3 years.
Every nurse who works on the day shift is this unit has been there for 10 years or more. When the
new manager spent more time on the unit observing the activities before taking the job, Mary, a
nurse with 15 years of service to the hospital, stood out from the rest of the staff members. She
told people what to do, and decided who went to break and lunch at what times. She called staff
members together for report at the end of the shift. What challenges does this “new” nurse
manager face?
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Name: _______________________________________ Section: ______ Date: ___________

Review Questions # 1: Please encircle the letter of your choice.

1. Leadership is best described as a process of

a. Coercion b. interpersonal dynamics c. influence d. passive learning

2. A person who is a leader but who does not have a sanctioned role within the organization is what kind
of a leader?
a. Formal b. informal c. situational d. traditional

3. The leadership trait defined as self-knowledge or self-awareness and the ability to receive feedback and
learn from mistakes is called:
a. passion b. vision c. curiosity d. integrity

4. The trait that allows leaders to adapt rapidly to changes in the organization’s environment is called:
a. support b. intelligence c. self-confidence d. flexibility

5. A leader who defers decision making to his or her followers is called what type of leader?
a. autocratic b. laissez-faire c. contingency d. high task

6. Which group of leadership theories states that the leader’s style has less impact on outcomes than on
certain environmental and other factors?
a. contingency theory c. charismatic theory
b. democracy theory d. goal-setting theory

7. According to House’s path theory, which of the following is true?

a. effectiveness of leadership style depends more on the follower than the leader
b. the leader’s effective leadership style helps the worker remain on the appropriate path
c. the leader’s charisma or personal appeal helps workers remain on the appropriate path
d. workers are empowered to achieve a common purpose.

8. The theory that maintains that followers and leaders influence each other to increase their motivation
and performance to higher levels is called:
a. Reinforcement theory c. Goal-setting theory
b. Equity theory d. Transformational leadership theory

9. The concept of valence is defined as

a. the perceived probability that a certain effort will lead to a desired action or behavior
b. the belief that a certain effort will lead to a desired action
c. perceived value of an outcome
d. behavior that is repeated because it is positively or negatively reinforced

10. The “new leadership” theory was proposed by

a. Skinner b. Wheatley c. Locke d. Bennis
 14

WHO NEEDS NURSING MANAGEMENT?

All types of health-care organizations, including nursing homes, hospitals, home health-care
agencies, ambulatory care centers, student infirmaries, and many others, need nursing management. Even
the nurse working with one client and family needs management knowledge and skills to help people
work together to accomplish a common goal. A primary nurse working with several clients prioritizes
their care to assist time to improve health or, sometimes, peaceful death.

Nursing administration is the application of the art and science of management to the discipline
of nursing. Nursing management is also the group of nurse managers who manage the nursing
organization or enterprise. Nursing management is the process by which nurse managers practice their
profession.

Key Points

1. What is management?

A. Management is the process of 1) coordinating actions, 2) directing actions 3) assigning resources

B. The purpose of management is to perform these tasks in order to achieve the objectives (desired
outcomes) of an organization.
C. Management is a problem-oriented process with similarities to the nursing process. It is needed
whenever two or more individuals work together toward a common goal. The manager
coordinates the activities of the group to maintain balance and direction.
D. The terms management and supervision sometimes are used interchangeably; however,
management is a broader concept that includes
The Essence of Leadership
supervising people as well as other resources to
accomplish organizational goals.
‘ A true leader has the confidence to
E. Management often focuses on issues such as costs,
stand alone, the courage to make
productivity, staffing, and effectiveness.
tough decisions, and the comparison
F. These management issues may or may not have anything
to listen to the needs of others.
to do with leadership. Management does not equal
He does not set out to be a leader,
leadership, although leadership may play a role in
but becomes one by the quality of
management.
his actions and the integrity of his
1. Management is often synonymous with constant
intent. In the end, leaders are much
activity and interaction
like eagles… they don’t flock, you
2. In the course of a typical day, managers, usually
find them one at a time.”
deal with many activities ranging from highly
prioritized and crucial to routine (for example, from a downsizing decision that will send a
nurse to a different unit, to making sure that a nurse’s employment anniversary is recognized)
3. The most common image of a manger is of a “firefighter” who responds to problems that
emerge randomly, and are addressed in order of urgency
4. Most managers spend much of their time interacting with others

Four (4) functions generally performed by a manager: planning (what is to be done), organizing
( how it is to be done), directing (who is to do it), and controlling (when and how it is done).

G. Management functions consist of:

1. Planning: determining the objectives of an institution or organization and what needs to be
done (both in the short term and long term) to achieve those objectives. Planning very often
addresses the organizational questions of what, why, where, when, how, and by whom, and it
usually consists of a four-stage process:
 15

a. Establish objectives
b. Evaluate the present and predict future trends and events
c. Formulate a planning statement
d. Convert the plan into an action statement
2. Staffing: selecting the people who are able to carry out the action plan. This selection is
usually based on:
a. The knowledge, skills, and experience of the nurse
b. The number and type(s) of patients needing care
c. Number and type of support staff available
3. Organizing: based on the plan as well as knowledge about the structure of the institution or
organization, organizing is the process of coordinating human and other resources to meet
established goals. Effective organizing consists of:
a. Knowledge of factors such as institution, environment, social structure, people, and
technology.
b. Ability to assign tasks appropriately to people who can accomplish the tasks
successfully (delegation)
c. Coordinating tasks that have been assigned and changing tasks or staff if goals are
not being met
d. Using appropriate and accepted types of authority to ensure that required tasks are
completed. Depending on the organization and the manager, authority may derive
from the manager’s position in the organization itself, or from the relationship
between supervisor and staff member. For example, in a more rigid organizational
structure such as a police or fire department, authority comes with rank.
4. Directing: motivating and leading personnel to accomplish objectives. How a person directs
others depends on that person’s authority, power, and leadership style. Effective directing is
achieved through strategies such as:
a. Setting specific, clear expectations that are realistic and measurable
b. Providing sufficient resources to accomplish the tasks
c. Fostering a work environment that balances challenges and success
d. Finding ways to recognize and reward work that meets or exceeds objectives in a
way that is meaningful to workers
5. Controlling: establishing standards of performance, comparing results with these
benchmarks, correcting performance that differs from accepted standard. Frequently used
means of control include:
a. Management by objectives (MBO) devices: determining objectives, measuring to
see if objectives are being met, and comparing objectives with standards
(benchmarks)
b. Socialization: often a key part of MBO, socialization means that nurses internalize
professional values and standard codes of behavior. For nurses, socialization is a
process of moving from the early stages of accepting perceived beliefs and values of
the profession, through formal and informal education, to the final stage of full
membership in the profession and commitment to its norms and values.
c. Managerial surveillance: the direct observation of staff behavior by the manager as
well as indirect observation, for example, through the manager’s review of records. A
key concept of this function is “span of control”, which refers to the number of
individuals for whom a supervisor is directly responsible. A narrow span of control
means fewer numbers of directly supervised staff and thus higher degrees of direct
observation and control. A wider span of control ( more than 10 supervised
employees) means less opportunity for direct observation or control. A wide span of
control can be effective as long as staff members are highly educated, tasks are
relatively routine, and managers can effectively oversee such a group.
 16

d. Continuous quality improvement (CQI): in this formal quality improvement

process, staff members participate in and lead the team. All team members are
continuously involved in peer review, so that they can identify ways to improve
processes or programs, and constantly enhance and improve the quality of care.
6. Decision making: key steps of this function include:
a. Identifying problems
b. Establishing criteria that can evaluate potential solutions to the problem(s)
c. Seeking alternative solutions, including taking no action
d. Evaluating all the alternatives that have been found
e. Selecting the best alternative, based on organizational objectives, staff, environment,
and other available resources.

H. A variety of factors affect management roles and decisions. They include:

i. The institution’s structure ( for example, size – how it handles authority, department size
and structure, wide or narrow span of control, amount of centralization or
decentralization, how it measures and controls outcomes, and how it selects, recruits, and
rewards employees)
ii. The organization’s objectives: the service(s) it offers ( such as a hospital that specializes
in cardiology or an outpatient surgical center that specializes in cataract surgery), how
productive the organization is or how efficiently it meets objectives, the quality and
amount of its human resources, and how employees participate in goal setting.
iii. Environmental factors ( for example, the current economic, legal, technological, or
social influences that the organization must consider)
iv. Technology (for example, current state of medical or nursing science, process of
technology, computer systems, and informatics)
v. Tasks that are required or expected (for example, the nature of tasks that need to be
completed, how work tasks are designed, and the impact of the organization’s physical
layout on the nature and design of tasks)
vi. Social structure ( for example, the organization’s internal culture, how it socializes
employees, the rituals that it uses to conduct work or deal with conflict, perceptions of
authority, and language and cultural issues.

2. Current management theories

A. Scientific management
a. Established by Engr. Frederick Taylor (Principles of Scientific Management,1911) but still in
use
b. Focused on maximizing worker production levels and efficiency.
c. Relied on the view of work as systematic series of tasks that could be measured, predicted,
and manipulated to increase efficiency
d. Developed time and motion studies that resulted in “one best way’ of carrying out a specific
task or series of tasks
e. One important medical application: this method revolutionized the field of surgery
(Gilbreth,1912), as efficient surgical methods resulted in shorter operations and reduced risks
to patients.
f. This approach can also provide important feedback about workflow; where equipment,
medications, and other items essential for patient care are stored and how they can be
positioned to enhance nursing efficiency (so nurses don’t waste time walking long distances
to supply closets, for example)
B. Bureaucratic theory
a. Developed by Max Weber
 17

b. Efficiency is achieved through impersonal relations within a formal structure ( bureaucracy)

c. Focused on employee competence as the basis for hiring and promoting employees (rather
than interpersonal relationships with superiors)
d. Emphasized the orderly and rational, not the interpersonal
e. Promoted strong top-down hierarchy with clear superior-subordinate communication and
relationships. In this model, a person’s power is assigned, based on the authority of his rank
or position.

C. Administrative theory
a. Originally developed by French mining Engr. Henri Fayol (1916)
b. States that several principles are essential to the functioning of any organization: planning,
organizing, coordinating, and controlling
c. Additional component of management process is unity of command and direction (workers
get orders from only one supervisor and related work tasks are grouped under one manager)
d. Theory also recognizes the power of the informal structure in organizations (Barnard, 1939),
which identifies the role of naturally forming social groups and the recognition that they are
powerful forces in organizations.
e. Barnard believed that managers must recognize and work with these informal structures to
achieve the best outcomes for the organization
D. Human relations theory ( later called organizational behavior)
a. Focuses on the individual worker – rather than processes and procedures – as the key
to organization motivation, productivity, and control.
b. Studies in the 1930s showed that workers are motivated by other workers as much as
by environmental factors.
c. The Hawthorne effect, which was identified during these studies, says that when a
person is observed or studied, his or her behavior changes.
E. Motivational theory. This group of theories grew out of human relations theory, which
emphasized that worker output was best when workers were treated humanely. According to the
motivational theory:
a. Motivation is interpreted from people’s behavior rather than explicitly demonstrated by their
actions
b. Motivation is an integral process that directs behavior to satisfy needs
c. Understanding motivation is the key because it helps explain why people do what they do;
understanding worker’s motivation can help managers create change.
d. Most well-known motivation theories are those based on:
1. Maslow’s (1970) hierarchy of needs (physical needs must be satisfied before higher
psychological needs)
2. Herzberg’s (1968) theory (maintenance factors include adequate wages and safe workplace;
motivations include meaningful work, recognition of accomplishments, and development
opportunities)
3. McGregor’s (1960) theory ( Theory X: leaders must direct and control worker motivation and
Theory Y: workers are self-controlled and self-disciplined and the leader’s job is to remove
obstacles from their work and help them meet their personal goals)
4. Ouchi’s (1981) theory (Theory Z: the best way to motivate is through collective decision-
making, long-term job security, use of quality circles, and humanistic managements style.

3. The changing world of nursing and management

A. Management often derives from a more rigid, hierarchical structure. In traditional organizations:
 18

i. A manager is an expert in management techniques, but not necessarily an expert in

clinical realm. This can lead to
a. Managers being targets of downsizing
b. Managers becoming overseers of systems ( clinical, cost information, data) rather
than of people. This means the manager has a vested interest in maintaining these
systems even if redesign will be more efficient and will result in better patient
outcomes.
ii. The disengaged manager is not a model that works well in nursing
a. Nurses need clinical managers who have knowledge of the challenges beside
caregivers face so as to be able to support staff and advocate for staff needs to
superiors.
b. Nurses tend to be put off by managers who could not participate in patient care is
necessary during a crisis.

B. Ongoing dilemma for nursing: the combination of clinical and management skills
i. Expert clinicians are often promoted to nurse manager positions based on their clinical
expertise, and not their management skills. In many organizations, this is the only
opportunity for advancement.
ii. However, someone with great management skills may not be up-to-date clinically
C. Management without leadership: according to S. Covey ( 1989) management without leadership
is “ like straightening deck chairs on the Titanic.”

CRITICAL THINKING Question # 2

1. A nurses is working on a medical-surgical unit, and a physician has just given her an order to
insert a Foley catheter into a patient and send a urine sample to the laboratory. The nurse manager
has instructed her that it is time to go off the unit for her lunch break; if she doesn’t leave the unit
now, she will not be able to take her meal break when the cafeteria is open. Apply your
knowledge of administrative theory to describe the problem in this situation. Choose another
theory of management that could be applied in this situation, and explain how it would help the
nurse solve her dilemma.

2. A hospital is building a new medical-surgical units as an addition to the building. Describe how
scientific management theory can be used to help design the new unit to maximize nursing
efficiency.

WINNER or WHINER – Which One Are You?

A Winner Says….. A Whiner Says…
We have a real challenge here. This is a big problem.
I’ll do my best. Do I have to do this?
That’s great! That’s nice, I guess.
We can do it. It can’t be done, it’s impossible.
Yes. Maybe, when I have some time.

Source: Tappen, RM, et al: Essentials of Nursing Leadership and Management, ed. 2. FA
Davis.
 19

Name: _______________________________________ Section: ______ Date: ___________

Review Questions # 2: Please encircle the letter of your choice.

1. The purpose of management is to coordinate and direct actions and assign resources in order to:
a. Achieve the organization’s objectives c. Develop high quality staff
b. Receive a promotion d. Keep staff turnover as low as possible

2. Which of the following statements about management is true?

a. It focuses on clinical excellence
b. It tends to attract people who like quiet, routine work without interruptions
c. It focuses on issues such as cost, productivity, effectiveness, and staffing
d. It is synonymous with leadership

3. The management function that involves determining the objectives of an organization and tasks
needed to complete objectives is
a. Staffing b. directing c. planning d. controlling

4. When a person internalizes a set of standards or codes of behavior, this is called:

a. Decision making c. productivity
b. Managerial surveillance d. socialization

5. A manager with a narrow span of control will

a. Directly supervise more than 10 staff members
b. Have greater opportunities for direct observation and control of staff
c. Tend to oversee staff with high levels of training
d. Be unable to motivate staff members

6. Identify problems, establishing criteria, seeking and evaluating alternatives, and selecting the best
choice are steps in the management function of:
a. Controlling b. Decision making c. Staffing d. Directing

7. MBO stands for management by

a. Organization b. Opposition c. Objectives d. Oversight

8. The time and motion studies developed by ____ resulted in “one best way” of carrying out a
specific task.
a. Frederick Taylor c. Henri Fayol
b. Max Weber d. Abraham Maslow

9. According to bureaucratic theory, which of the following is true?

a. Efficiency is achieved through personal relations between an employee and superior
b. There is no need for hierarchy, as all workers have a key role in the organization
c. Employees should be hired based on their relationship with the owner
d. Effective organizations are rational and orderly

10. Maslow, Herzberg, McGregor, and Ouchi developed theories about worker behavior, based on
which school of thought?
a. Scientific theory c. Administrative theory
b. Motivational theory d. Socialization theory
 20

THREE BASIC SKILLS NEEDED BY ALL MANAGERS

Technical Skill is the knowledge of and ability to use the processes, practices, techniques, or tools of a
specialty responsibility area. The manager needs this skill enough to accomplish the job for which he or
she is responsible. Ex: accountants, engineers, salespersons, and quality control specialists

* Is most important for a manager at the first-line management level and becomes less important as
the manager moves up in the organization structure.

Human Skill is the ability to interact with other persons successfully. A manager must be able to
understand, work with, and relate both individuals and groups in order to build a teamwork environment.
The proper execution of one’s human skills is often called human relations

* Is important at every level in the organization. The need to be able to understand and work with
people is important at all levels, but the first-line managers’ position places a premium on human skill
requirements because of the great number of employee interactions required.

Conceptual Skill it is the mental ability to view the organization as a whole and to see how the parts of
the organization relate to and depend on one another. It is the ability to imagine the integration and
coordination of the parts of an organization - all its processes and systems. It deals with ideas and abstract
relationships.

Top
Management

Middle
Management

First Line
Management

Proportions of Management skills needed at Different levels of management

A manager needs conceptual skills to see how factors are interrelated, to understand the impact of any
action on the other aspects of the organization, and to be able to plan long range.

* Becomes increasingly important as a manager moves up the levels of management. First – level
manager focuses basically on her or his work group; therefore, the need for conceptual skill is at a
minimum. Top level management is concerned with broad-based, long range decisions that affect the
entire organization, therefore, conceptual skill is most important at that level.

Leadership today is the preferred mode of “getting things done” in health care. Successful nurse leaders
i. Respond flexibly to changes in the workplace
ii. Disseminate information rapidly and effectively through their teams
iii. Develop and maintain strong trust and interpersonal connections with staff, peers, patients,
and other health care professionals
iv. Build up and support team members’ skills and strengths, while dealing effectively with
differences
v. Do not avoid uncertainty or chaos but instead thrive on it
 21

Other characteristics of nurse leaders include:

i. Specialists and generalists: effective leaders are experts in a particular field. In nursing, for
example, this specialization could be in emergency care or community health practice. Nurse
leaders are also generalists; they know enough about a wide range of areas so that they are
able to communicate with and mediate between a variety of other specialist and specialty
practice areas.
ii. Self- reliance: effective nurse leaders understand that they must rely on themselves (to listen,
make good decisions, maintain clinical skills, etc) but they effectively balance this self-
reliance against their value to and role within the organization
iii. Connectedness: effective nurse leaders are always excellent team players, and almost always
key members of more than one team in an organization.

Roles and functions of nurse managers:

The nurse manager is accountable for:

i. Excellence in nursing clinical practice and delivery of patient care in a particular unit or area
of an organization
ii. Managing human, monetary, and other resources needed to provide excellent patient care and
achieve expected outcomes
iii. Facilitating the development of nursing and health care personnel ( both licensed and
unlicensed) in a designated unit or department
iv. Ensuring that all standards of care practiced in that area are in compliance with professional (
Nurse practice Act) regulatory, and government standards of care.
v. Developing strategic planning that supports the department’s or unit’s and organization’s
overall mission
vi. Facilitating relationships among different departments or disciplines to ensure the delivery of
the highest quality patient care

Key nurse management roles in the health care environment ( note that organizations have different
names for these functional roles):

i. First line manager. The nurse manager primarily supervises other managerial staff and
monitors the quality of care that staff provide to patients. This manager is also responsible for
motivating staff to meet organization goals. The remainder of the nurse manager’s time is
usually spent in planning and coordination and staff evaluation. Key tasks that a first-line
nurse manager may perform include:
a. Preparing orientation schedule in collaboration with nurse educators
b. Submitting time schedules for nursing shifts
c. Making budget recommendations to nursing administration based on unit needs and
patient acuity
d. Calculating amount of staff needed and meeting challenges when staff members call
out sick, or other situations disrupt the staffing schedule
e. Making daily patient rounds
f. Conducting meetings with staff
g. Conducting employment reviews, including counseling reports and termination
h. Setting goals for individual patient care areas
i. Participating in quality assurance activities
j. Maintaining clinical knowledge through reading journals, participating in continuing
education activities, and other opportunities for learning
 22

ii. Middle-level manager. The nurse director supervises first-level managers, usually within a
geographic or specialty area and is responsible for all people and activities in this area. The
mid-level manager spends more time planning, coordinating, negotiating, and evaluating, and
less time directly supervising staff. Increasingly, this level of responsibility requires graduate
level education. Key tasks that a middle-level manager may perform include:
a. Assessment: observe whether policies and objectives are meeting the needs of
patients and the staff that provide care
b. Planning: set short-term and long-term goals of patient care, revise policies if needed
so that patient care objectives can be met and outcomes can be achieved most
efficiently.
c. Organization: put plans in action ( via delegation and committee work) by
developing appropriate teaching strategies, organizing budget to meet planning
needs, engaging in customer relations and communication to improves outcomes and
manage risk effectively.
d. Control. Analyze results of implementation, consider changes that need to be made,
facilitate nurse managers in research and development, and communicate changes
and opportunities to managers and staff

iii. Executive-level manager. The chief nurse executive or vice presidents of patient care
services spends the lowest amount of time in supervision; most of the time is spent in
planning and making policies. This person is less responsible for direct supervisory activities
and more responsible for establishing overall organizational goals and strategic plans for a
department, division, or entire organization – oversight often includes non nursing areas. As
with the middle-level manager, the responsibilities for this position usually require significant
managerial experience and graduate level education. Key tasks that nursing executive might
perform include:
a. assessment: understand the organization’s internal environment or culture and the
external environment (bioethics, legislation, regulation, technology, community) in which
it must function.
b. planning: Forecast trends in health care, costs, reimbursement, and regulation, and
developing responsive strategic plans
c. organization: based on assessment and strategic planning, bring together the appropriate
mix of staff, other resources, ongoing research, and education
d. control: evaluate nursing policies, programs, and services, to ensure they are consistent
with the organization’s mission and objectives and the needs of the patients and of the
staff.

Other managerial roles that have evolved:

i. charge nurse ( also called resource nurse)

a. expanded staff nurse role with some managerial responsibility on a given shift in a
frontline role
b. may be a permanent or rotating assignment
c. usually functions as a liaison to the nurse manager, particularly on off-shifts
d. tasks include assisting in shift coordination, promoting quality care, using resources
efficiently, troubleshooting problems that occur, and helping staff members with
making decisions and prioritizing care
e. differs from first-level manager in that a charge nurse has more limited authority and
limited scope of responsibility; depending on the organization, the charge nurse may
or may not be involved in the staff evaluations (may be more involved in off-shifts in
which the manager has less direct observation of staff members)
 23

ii. staff nurse

a. this position may not have formal managerial rank but the nurse uses managerial and
leadership skills to work with other nurses and assistive personnel.
b. Management responsibilities include supervising to ensure quality patient care,
delegating tasks appropriately, and motivating staff.

Mintzber’s (1994) contemporary model of managerial work says that managerial functions occur at
three levels – information, people, and action.

i. Information processing: the most abstract level – including communicating ( sharing)

information with others as well as controlling (using information to manage other’s work)
ii. People: at this level, the manager leads ( encourages and enables) people and links people (
establishes networks) to help them be effective
iii. Action: at this level, the manager is very involved in “doing” – this includes supervisory
actions such as directing change, handling disturbances, and negotiating.

Characteristics that distinguishes leaders and managers include:

i. Facilitator vs. director: leaders provide their staff resources that enable them to learn and
solve problems, rather than giving directions on how tasks ‘should be” done
ii. Coordinating vs. controlling: effective leaders excel at stepping back and allowing people to
use their initiative to solve problems with some support, but minimal guidance. Leaders then
are free to work at higher level, coordinating a variety of able employees, rather than
controlling or directing employees’ every move.
iii. Pull vs. push: effective leaders encourage and motivate people to act rather than ordering
them to act
iv. Macromanagement vs. micromanagement: effective leaders tend to look at the big picture
on a series of tasks. Micromanagement is often perceived by staff as indicating that they are
incompetent or not to be trusted to act appropriately when independent.
v. Peers/followers vs. subordinates: leaders tend to follow a less hierarchical approach to
working with others, thus seeing staff members as part of a team rather than as located at
higher or lower levels of an organization. This more open structure facilitates feedback and
communication.
vi. Coaching/ challenging vs. blaming: effective leaders use mistakes or problems as learning
opportunities that provide a chance for coaching in proper procedure or challenging them to
increase their level of competence or performance rather than blaming, chastising, or
punishing.
vii. Solving problems vs. just identifying them: effective leaders are active problem solvers,
balancing the various needs of staff and the organization, matching resources appropriately
with problems, and promoting both efficiency and care in an environment that is focused on
patient care. These leaders may see problem solving as so effortless that they are not aware
they are doing it; a problem-solving approach simply seems natural to them.

In many organizations, leaders and managers have very different roles:

A. Leadership
i. Key role is prioritizing and optimizing patient care
ii. Focus is first on patient outcomes and then on “bottom line” outcomes

B. Management
i. Priority is the function of the organization
ii. Particular focus on meeting financial or business goals
 24

Name: _______________________________________ Section: ______ Date: ___________

Review Questions # 3: Please write the letter of your choice in the space before the number.

___1. Which of the following is a characteristic of an effective nurse leader?

a. Following rules precisely c. Withholding strategic information for long periods of time
b. Developing strong and trusting relationships with staff d. Focusing on the business of health care

___2. A nurse manager who spends 90% of his or her time submitting time schedules for nursing shifts
and assigning teams and patients is at what level of management?
a. First-line nurse manager c. chief nurse executive
b. middle-level manager d. vice president of patient care services

___3. The advantage of a nurse leader being both a generalist and a specialist is that the nurse can:
a. Delegate all tasks to others
b. Operate effectively without input from other staff members
c. Choose not to be part of a management team
d. Be an expert on a topic as well as communicate with a variety of other specialists

___4. Which of the following is true about the nurse leader’s trait of self-reliance?
a. It prevents the nurse leader from working effectively in a team
b. It is a characteristic only of nurse managers, not of nurse leaders.
c. It balances the nurse’s personal abilities with the needs of the organization.
d. It allows the nurse leader to accomplish multiple tasks without any assistance

___5. A focus on meeting an organization’s financial or business goals is a function of:

a. Management b. leadership c. problem-solving d. coaching

___6. The level of nursing manager that spends the least time directly supervising certified and non-
certified nursing staff is:
a. Nurse executive c. first-level manager
b. Middle -level manager d. charge nurse

___7. A staff nurse with some increased managerial responsibilities is usually called a (n)
a. Nurse executive c. nurse assistant
b. Charge nurse d. associate director of nursing

___8. According to Mintzberg’s model of managerial work, effective managers:

a. Act first and then communicate
b. Are seldom involved in leading people or forming networks
c. Manage action by doing, for example, directing change or negotiating
d. Lead at the first level, act at the second level, and communicate in summary form

___9. The ability to interact with other persons successfully. A manager must be able to understand,
work with, and relate both individuals and groups in order to build a teamwork environment
a. Human skill b. Conceptual skill c. Technical skill d. Human relations

___10. The effective nurse leaders understand that they must rely on themselves but they effectively
balance against their value to and role within the organization
a. Specialist b. connectedness c. Self- reliance d. generalist
 25

POWER AND AUTHORITY IN NURSING

Power is having the ability to effect change and influence others to meet identified goals or the ability or
capacity to act. In the minds of many people, this word elicits images of control and coercion –
the concept of “power over”.

To empower nurses is to provide them with greater influence and decision making in their roles. The
realization of greater power in the profession depends on the willingness of administrators to
allocate this power and of nurses to accept it, along with the accompanying responsibility.
 Remember, power and responsibility go hand in hand.

Key Points

A. Having power means being able to make change, or to prevent change from happening.
According to Miller (2003), for nurses, a positive definition of power means the ability to:
i. Take resources by either creating them or acquiring them and
ii. Use them to meet goals such as providing safe and competent care as well as meeting
organizational goals

B. Stephen Covey ( 1990) says that power is the vital energy to make choices and decisions. It is
also the ability to overcome deeply embedded habits and to cultivate higher, more effective and
productive habits.

C. ‘ Leadership cannot exist without power’ according to Costello-Nickitas ( 1997)

D. Power does not depend on the level at which a person sits in the hierarchy, but rather on “how an
individual perceives power, how others perceive the individual, and the extent to which an
individual can influence events” ( Miller, 2003, p. 348).

E. People achieve power through influence:

i. Influence is “a skill used to gain power in interpersonal situations
ii. A person who can influence (help change) another person’s feelings, attitudes, or behavior
is powerful

Positive sources of power:

The key sources of power are factors that help a person influence others to do what that person
wishes ( Fisher and Koch ( 1996) More specifically, according to Wells (1998), most nurses are able to
exert influence through using one or more of the following:

A. Expertise
i. skills and abilities the nurse possesses (can be clinical skills, communications skills, and
problem-solving skills
ii. knowledge the nurse possesses. This generally focuses more on clinical knowledge but can
also include knowledge about information systems, political structures, sources of data,
available opportunities, and other knowledge.
For instance, the enterostomal therapist has expertise in the care of individuals who have had
ostomies. Therefore, staff nurses seek out the therapist as a resource and use the expert’s
knowledge to guide the care of these patients.

C. Legitimacy, or power derived from the position a nurse holds in a group. Legitimacy equates
with degree of authority.
 26

i. Focuses on personal authority that the nurse holds rather than authority designated by an
organization
ii. The group recognized legitimate leaders and generally follows those with whom the
group members agree. Leaders with whom the group significantly disagrees often lose
their legitimacy.
iii. Legitimacy as the sole source of a person’s power may not be sufficient in some settings,
and may not be recognized in others.
For example, a nursing administrator without an educational background equal or higher
than her contemporaries in other departments may not be perceived as having legitimate
power. A nurse who is seen as legitimate in one setting or culture may not be seen in the
same way in another setting; for example, a nurse who is an administrator in a small
long-term care facility may not make an automatic transition to the same administrative
position in a medium-sized community hospital. Men in nursing have struggled to
achieve legitimacy in a predominantly female profession.

C. Admiration and trust, sometimes called referent power or charismatic power. This type of power is
characterized by:
i. a high level of respect for and trust in the charismatic individual
ii. a significant amount of loyalty to the person who possesses referent power
This can explain the fact that followers sometimes rationalizes or try to “explain away” any of the
leader’s behavior that is inconsistent.
iii. a high level of confidence in followers, which depends on the trust in the charismatic leader. A
leader with charismatic or referent power can be extremely influential, especially in difficult or
stressful times ( Miller, 2003). This power can be easily abused. Franklin D. Roosevelt and John
F. Kennedy are considered charismatic leaders, as were Charles Manson and David Koresh.
iv. Among the most important characteristics of ethical charismatic leaders is the ability to
develop creative, critical thinking in their followers and to stimulate followers to think
independently and to question the leader’s view to reduce the risk of blind loyalty that may
ultimately be harmful to followers.

D. Information power. This type of leader has characteristically

i. has significantly knowledge or understanding that is useful, accurate, or timely
ii. readily shares this knowledge with others
iii. does not rely on the organization to bestow power; the power comes from the person’s own internal
know-how and his or her willingness to share that power with others

E. Connection power. The nurse who exercises this power is aware that:
i. all people are connected in some way to all other people. This is especially true in health care
organizations and nursing communities in which people are connected through schools,
professional organizations, and community affiliations.
ii. people are attracted to making connections to people with power or their associates. No one, in
nursing or elsewhere, likes to feel detached from sources of influence. For nurse leaders, this
can be as simple as a verbal recognition of, staff excellence or as complex as an award
banquet.
iii. people at all levels of an organization are connected, and those connections must be
acknowledged and respected. As Miller (2003) notes, effective leaders recognize, for example,
that workers at all levels of organization have a complex web of relationships with more and
less powerful people. If you are disrespectful of the hospital vice president’s clerical staff,
you can easily damage any relationship with the vice president as well.

F. Honesty, integrity, and ethical practice – also called principled-centered power – have these
 27

characteristics:
i. Based on principles of honor, respect, loyalty, honesty, and integrity
ii. How leaders choose what to do in any situation is based on these principles; all decisions
made are measured against these principles. According to Sullivan and Decker (2001), nurses
must understand and select behaviors that are in accord with principle-centered leadership,
including:
a. Getting to know people and learning what they want and need
b. Being open: to keeping others informed, and to use trust and respect instead of fear and
suspicion
c. Knowing one’s own values and visions
d. Increasing interpersonal skills such as listening and expressing ideas clearly
e. Using personal power to enable others
f. Increasing connections between people and enlarging one’s own sphere of influence.
g. Understanding that in order to “win” one does not have to “lose” and that a win-win
outcome can be the key to building ongoing, successful relationships.

Note: Leaders and managers need to understand the concept of power and how it can be used and
abused in working with others. Graduate nurses need to be aware of and willing to implement
methods and resources to increase their personal power. As they gain experience in the staff
nurse role, they can develop expert power by increasing competency in their roles and
clinical skills.

Guidelines for using power positively in organizations. Effective ways for using the different types of
power:

1. Expert power
a. Preserve credibility ( for example, by avoiding speculation or careless discussions)
b. Stay up-to-date with technology and other changes that affect people’s work
c. Act with confidence and decisiveness in crises
d. Show respect and avoid arrogance; avoid damaging people’s self-esteem
e. Show concern for the perspectives of all people at all organizational levels; attempt to show
how changes minimize risk to people.
2. Authority/legitimacy power
a. Ask, don’t demand
b. Make sure staff understands directions or questions
c. Explain why you are asking for something to be done
d. Follow up to ensure compliance
3. Referent/charismatic power
a. Be considerate, show concern for people, treat people fairly, and defend their interests to
supervisors or outsiders
b. Avoid expressing (verbally or in action) hostility, rejection, distrust, or indifference toward
people
c. Make requests that are reasonable
d. Be a positive role model
4. Connection power
a. Use relationships correctly and appropriately
b. Avoid name dropping
c. Be ready to reciprocate – if someone does a favor for you, offer to return the favor in a spirit
of give and take, not keeping score
d. Recognize that all connections have limits, and abide by them
 28

Power influences choices, and choices affect behaviors and feelings. A clear vision unites power and
choices by:
a. Building consensus
b. Identifying capabilities
c. Determining factors needed for success
d. Identifying resources: people, time, and money

Other (less positive) sources of power

A. Punishment or coercive. Most experts recognize that the power to punish or give negative incentives
(dock someone’s pay, issue a reprimand, termination) is sometimes necessary, as these penalties can
discourage certain behaviors. However, as Miller ( 2003) notes, this type of power is perceived as
i. humiliating by the person on the receiving end of the coercive power and thus
ii. much less desirable for use by people in authority positions
iii. however, some people who enjoy holding power over others may actually enjoy using
punishment or coercive power, just to show they can.

B. Reward power. This can encourage certain behaviors, and people may be motivated by monetary and
other reward systems. However, Miller (2003) states:
i. Rewards that assigned and distributed unfairly can have the opposite effect
ii. Rewards do not provide long-term changes in behavior or attitudes
iii. withholding rewards can produce resentments
iv. rewards don’t motivate as effectively or as consistently as a clear, unifying vision
v. If reward is used, the leader should remember to
a. Avoid overdoing incentives, emphasize the intrinsic reward of teamwork and loyalty
instead
b. Reinforce actual behavior rather than future performance
c. Ensure rewards reflect total, not partial, performance
d. Recognize that monetary awards may be the least effective
e. Carefully match the reward to the person; a reward for a unit secretary that is valued and
appreciated may not have value for a registered nurse on the same unit.

Empowerment –the process by which we facilitate the participation of others in decision making and
take action within an environment where there is equitable distribution of power.

Empowerment is built:
a. Through a commitment to the well-being of all concerned, from the lowest to the highest levels of
an organization
b. By providing an atmosphere in which risk taking is valued and encouraged to lead to or provide
insights
c. With flexibility to adapt to changing priorities, needs, and situations
d. From diversity
i. In styles of thinking, communication, and problem solving
ii. In accepting and encouraging culturally different points of view
e. With cooperation rather than competition
f. Though the ability to compromise (finding as many win-win solutions as possible)
g. With empathy for patients, other staff, management, and people in the community
Empowerment is demonstrated through:
1. An increased ability to solve problems creatively and effectively
2. Improved communication
a. Between nurses and patients
 29

b. Between nursing team members ( RN, LPN, nurse’s aides, unit secretaries, and other assistive
personnel)
c. Between nurses and other health team members (respiratory, physical and occupational
therapists; pharmacists; and physicians, for example)
d. Between nurses and management
e. Throughout the organization
f. Between the organization and the community through community outreach programs
3. Increased satisfaction with work, including less stress and lower levels of burnout
4. Improvements in people’s
a. Levels of self-esteem
b. Ability to function with autonomy
c. Levels of accountability and responsibility

Critical thinking Questions # 3

1. Using your knowledge of the entities of power, describe the powers that interact between an
organization and a collective bargaining unit that represents workers in the organization.

2. When patients are empowered, are they more independent? Does that threaten established lines of
power between the patient and the nurse or between the patient and the physician? What are the
benefits and downsides of patient empowerment?
 30

Name: _______________________________________ Section: ______ Date: ___________

Review Questions # 4: Please write the letter of your choice in the space before the number.

___1. A nurse who has power is able to

a. Make staff do anything the nurse wants c. Avoid engaging in organizing politics
b. Make or prevent change d. Avoid decision making

___2. According to this author, power includes the capacity to culture more effective habits.
a. Nicolo Machiavelli c. Stephen Covey
b. Warren Bennis d. Eleanor Sullivan

___3. A characteristic of “power over” strategy is that it makes the receiver feel
a. Empowered b. Collaborative c. Incompetent d. Secure

___4. A nurse’s clinical abilities, education, and knowledge of systems are part of the power source
known as: a. legitimacy b. charismas c. connection d. expertise

___5. The source of power known as “connection power” is the best described as
a. Power that equates with the degree of the nurse’s personal or organizational authority
b. Power that is based on people’s respect for or trust in a particular person
c. Power based on honor, respect, loyalty, and integrity
d. Power that derives from an awareness of the networks that exist between people in an
organization

___6. Leaders who make all their decisions based on their own ethical values (honesty, integrity, respect,
etc) are engaged in what kind of power?
a. Expertise b. principle-centered c. legitimacy d. charisma

___7. An effective use of reward power would include

a. Giving bonuses for future performance
b. Using money as the primary reward system
c. Rewarding total performance
d. Giving incentives every day

____ 8. Preserving credibility, staying current with technology, and acting decisively in crises are positive
ways of using what type of power?
a. Expert b. Reward c. Authoritative d. Charismatic

____9. A person who effectively uses connection power would:

a. Do a lot of name dropping to emphasize connections
b. Continually return to the same people for favors to build a network
c. Build a group of networks based on different affiliations
d. Understand that reciprocity is unimportant

___10. Which of the following is true about punishment or coercive power?

a. Penalties do not change people’s behaviors
b. People appreciate being the recipient of this type of power
c. This type of power can include docking a person’s pay, reprimands, or termination
d. This type of power should never be used in an organization
 31

FUNCTIONS OF NURSING MANAGEMENT

A nurse manager performs these management functions to deliver health care to patients. Nurse
managers or administrators work at all levels to put into practice the concepts, principles and theories of
nursing management. They manage the organizational environment to provide a climate optimal to
provision of nursing care by the clinical nurses.

PLANNING
o is pre-determining a course of action in order to arrive at a desired result.
o the continuous process of assessing, establishing goals and objectives and implementing
and evaluating them, which is subject to change as new facts are known.
o primary to all other activities or functions of management

o a thinking or conceptual act that is frequently committed to writing – if plan is not written
down, they probably won’t be implemented.

o the forecasting of events – the building of an operational plan

o an important management function that helps reduce the risks of decision making
problem solving, and effecting planned change.

While planning is largely conceptual, its results are clearly visible.

Note: nursing managers who learns to plan will aim for maximum utilization of all resources –
money, supplies, equipment, and personnel.

Importance of Planning : It
1. leads to the achievement of goals & objectives Without good
2. gives meaning to work advice everything
3. provides for effective use of available resources & facilities goes wrong---
4. helps in coping with crises it takes careful
5. is cost-effective planning for things
6. is based on the past & future activities to go right.
7. discovers the need for change
8. necessary for effective control Proverbs 15:22
9. orients people to action, instead of reaction
10. increases the chances of success by focusing on results, not on
activities
11. increases employee involvement & improves communication

Scope of Planning

Top Management ( Nursing Directors, Chief Nurses, Directors of Nursing & their assistants)
Set the over-all goals and policies of the organization.
- Scope of responsibility is the over-all management of the organization.

Middle Management ( Nursing Supervisors)

-Direct the activities that actually implement the broad operating policies such as staffing
and delivery of services to the units headed by the Senior or head Nurses.
 32

- Formulation of policies, rules and regulations, methods and procedures for personnel for
intermediate level planning for ongoing activities and projects are done in coordination
with top management and those in the lower level.

Lower or first level management (Head Nurses or Senior Nurses (including Charge Nurses or team
leaders)
- do the daily schedules, or weekly plans for the administration of direct patient care in
their respective units

Major Aspects of Planning

1. Plans should contribute to objectives (actions without plans often result to chaos)
2. Planning precedes all other processes of management (organizing, directing, controlling)
(Planning and control are as inseparable as Siamese twins)
3. It pervades all levels. ( from higher to lower echelons and vice versa, horizontally or across….)
4. It should be efficient (it should contribute to the attainment of objectives not only in terms of
pesos, man-hours, units or products but also include values as individuals and group satisfaction)

Elements of Planning

1. Forecasting
2. Setting the Vision, Mission, Philosophy, Goals and Objectives
3. Developing & Scheduling Program
4. Preparing the Budget
5. Establishing Nursing Standards, Policies and Procedures

1. Forecasting - estimates the future, including the environment in which the plan will operate. It
includes who the patients are – their customs, beliefs, language/dialect barriers,
public attitude and behavior, the acuity of their conditions/illnesses, the kind of
care they will receive; the number and kind of personnel (professional and non-
professional); and the resources-equipment, facilities, supplies needed.

2. Setting the Vision, Mission, Philosophy, Goals & Objectives

Vision – outlines the organization’s future role and function that gives the agency something to
strive for.
Mission – outlines the purposes the agency is in (whether hospital or health care), who clients are
(the poor, the needy, the middle or upper class), what services are provided (in-patient,
out-patient, emergency) and why it exists.

Philosophy – describes vision. It is a statement of beliefs and values that direct one’s life or one’s
practice. In an organization, it is the sense of purpose of the organization & the reason
behind its structure and goals.

A written statement of philosophy explains the beliefs that determine how the mission or
purpose is achieved, it gives direction to achieving the goals and objectives set.

Goals (general) and Objectives (more specific) - they are action commitments through which its
mission and purpose will be achieved and the philosophy or belief sustained.
 33

They are stated in terms of results to be achieved and should focus on the production of health care
services to the patients

* Philosophy states beliefs and values while objectives state specific and measurable goals to be
accomplished.

3. Development & Scheduling Program

- programs are determined, developed and targeted within a time frame to reach the goals
and objectives set.

4. Preparing the Budget

Components of Budget
Cash Budget – estimating the amount of money received form patients and allocating it
to cash disbursement required to meet obligations promptly as they come.
Operating Budget – salaries, supplies, drugs & pharmaceuticals, etc…
Capital Expenditure Budget – consists of accumulated data for fixed assets that are expected to
be acquired during the budgeted period

5. Establishing Nursing Standards, Policies and Procedures

Proverbs 28:2
1. Nursing Standards – this can supply professionally desirable
norms against which the department’s performance can be measured. In time of civil
Areas for improvement are identified, and a plan of action to correct war there are this
be made and implemented. many leaders, but
Ex: Structure, Criteria, and Standards a sensible leader
restores law and
2. Nursing Service Policies – are broad guidelines for the order.
managerial decisions that are necessary in organizational and
departmental planning.
- they govern the action of workers and supervisors at all levels and are intended to achieve pre-
determined goals.
- they serve as basis for future actions and decisions, help coordinate plans, control performance,
and increase consistency of action by increasing the probability that different managers will make
similar decisions when independently facing similar situations.

Three General Areas in Nursing that requires policy formulation

1. Areas in which confusion about the locus of responsibility might result in neglect or
malperformance of an act necessary to a patient’s welfare,
2. areas pertaining to the protection of patients and families’ rights e.g right to privacy, property
rights,
3) areas involving personnel management and welfare

Characteristics of Good Policies

1. written and understandable and known by those who will be affected by them.
2. comprehensive in scope, stable, flexible so they can be applied to different conditions that are not so
diverse that they require different set of policies.
3. consistent to prevent uncertainty, feelings of bias, preferential treatment and unfairness.
4. realistic and prescribe limits
5. should allow for discretion and interpretation by those responsible for it.
 34

Example of Nursing Service Policies

1. Admissions – Receiving, consent, notifying doctor, care of patients
2. Doctor’s Orders – written, verbal, telephone
3. Reporting On or Off-Duty – Information given in leaving unit

3. Nursing Procedures – are specific directions for implementing written policies

2 Areas procedures are needed:
a) related to job situations such as reporting complaints or disciplinaryinstances,
b) involves patient care

II ORGANIZING
- the grouping of activities for the purpose of achieving objectives.
- it shows the part each person will play in the general social pattern as well as the
responsibilities, relationships and standards of performance.

Elements of Organizing
1. Setting –up the Organizational Structure
2. Staffing
3. Scheduling
4. Developing a Job Description

1. Setting up the ORGANIZATIONAL STRUCTURE

- process or way a group is formed, its channels of authority, span of control and lines of
communication mechanism through which work is arranged & distributed among the
members of the organization so that the goals can be logically achieved.

Organizational Chart – a line drawing that shows how the parts of an organization are linked.

Characteristics of Organizational Chart

1. Division of Work – each box represents an individual or sub-unit responsible for a
given task of the organization’s workload
2. Chain of Command – lines indicate who reports to whom & by what
authority
3. Type of work to be Performed – indicated labels or descriptions for the boxes
4. Grouping of Work Segment – shown by the clusters of work groups
5. The level of Management, which indicate individual & entire management hierarchy,
regardless of where an individual appears on the chart.

Organizing Principles
1. Unity of Command – responsible to only one Superior
2. Scalar principle – authority & responsibility should flow in clear unbroken lines from the
highest to the lowest executive.

3. Homogenous Assignment or Departmentation - workers performing similar assignment are

grouped together for a common purpose
4. Span of Control – the # of workers that a supervisor can effectively manage should be
limited depending upon the pace & pattern of the working area
5. Exception Principle – recurring decisions should be handled in a routine manner by a lower-
level manager. Unusual matters/problem should be referred to higher levels.
 35

Forms of Organizational Structure

1. Hierarchical / line organization - oldest and simplest form
- associated with the principle of chain of command, bureaucracy, vertical control and
coordination, levels differentiated by function & authority & downward communications
- has authority for direct supervision of employees
2. Staff organization
- assists the line in accomplishing the primary objectives of the unit
- provides advice and counsel
- includes clerical, personnel, budgeting & finance, staff development, research & specialized
clinical consulting
3. Free –Form/ Matrix
- super imposes a horizontal program over the traditional vertical hierarchy. personnel from
functional depts. are assigned to a specific program or project & become responsible to 2
bosses – a program manager & the functional dept. head.
- actually an interdisciplinary team of core & extended members
- e.g. “task force”, “ad hoc committee”
- the expert is the authority that leads the team
________________________________________________________________________________

To identify staffing and scheduling in nursing management a patient has to be classified accordingly:

Patient Classification System (PCS)

- method of grouping patients according to the amount and complexity of their nursing
care requirements, of nursing time & skill they require. This assessment can serve in determining the
amount of nursing care required, generally within 24 hours, as well as the category of nursing
personnel who should provide that care.

Purposes for classifying patients: For/ to

1. staffing. Perceived patient needs can be matched with available nursing resources
2. program costing & formulation of the nursing budget
3. tracking changes in patient care needs
4. determine values for the productivity equation: output divided by input.
5. determine quality

Classification Categories
Level I – Self Care or Minimal Care – Patient can bathe, feed and perform ADL.
Level II – Moderate Care or Intermediate Care – Patient needs some assistance in ADL,
ambulating up and about for short periods of time,
Level III – Total, Complete or Intensive Care – Patients are completely dependent upon the nursing
personnel.
Level IV – Highly Specialized Critical Care - Patients maximum nursing care, they need
continuous treatment, observation, many medications, IV piggy backs, vital signs q 15-30 mins.
hourly output; significant changes in doctor’s orders more than care hours/patient/day may range
from 6-9 or more.
The number of categories in a patient classification may range from 3 to 4, which is the
most popular, to 5 or 6. These classes relate to the acuity of illness and care requirements, such as
minimal, moderate, or intensive care. Other factors affecting the classification system would relate
to the patient’s capability to meet his physical needs to ambulate, bathe, feed himself, instructional
needs including emotional support. Patient care classifications have been developed primarily for
medical, surgical, pediatrics, and obstetrical patients in acute care facilities.
 36

Levels of Care NCH Needed Ratio of Prof. to Non-Prof

Per Patient/ Day
Level I
Self Care or Minimal Care 1.5 55:45

Level II
Moderate or Intermediate 3 60:40

Level III
Total or Intensive Care
4.5 65:35
Level IV
Highly Specialized or 6 70:30
Critical Care 7 or higher 80:20

Percentage of Nursing Care Hours

The percentage of nursing care hours at each level of care also depends on the setting in which the care is
being given.

Percentage of Patients in Various Levels of Care

Types of Hospital Minimal Moderate Intensive Highly
Care Care Care Specialize Care

Primary Hospital 70 25 5 -

Secondary 65 30 5 -
Hospital
30 45 15 10
Tertiary Hospital
10 25 45 20
Special Tertiary
Hospital

* The Forty-Hour Week Law, Republic Act 5901, provides that employees working in 100 bed
capacity and up will work only 40 hours a week.

* This also applies to employees working in agencies with at least one million population.

* Employees working in agencies located in communities with less than one million population,
will work 48 hours/week and therefore will get only one off-duty a week

Personnel Policies that have to be enjoyed by each personnel regardless of the

working hours / week.

3 day special privilege to government employees by the Civil Service Commission as per
Memorandum Circular No. 6 series of 1996 which may be spent for birthdays, weddings,
anniversaries, funerals (mourning), paternity leave, relocation and enrollment or graduation leave,
hospitalization and accident leaves.
 37

CLASSIFICATION OF HOSPITALS AND OTHER HEALTH FACILITIES

1. Government or Private
1.1. Government – operated and maintained partially or wholly by the national,
provincial, city or municipal government, or other political unit; or by any
department, division, board or agency thereof.
1.2. Private – privately owned, established and operated with funds through donation,
principal, investment, or other means, by any individual, corporation, association,
or organization.
2. General or Special
2.1. General – provides services for all types of deformity, disease, illness or injury.
2.2. Special – primarily engaged in the provision of specific clinical care and
management. A primary care hospital, secondary care hospital, tertiary care
hospital, or infirmary, may provide special clinical service(s).
3. Service Capability
3.1. Primary Care Hospital –
3.1.1. Non-departmentalized hospital that provides clinical care and
management on the prevalent diseases in the locality
3.1.2. Clinical services include general medicine, pediatrics, obstetrics and
gynecology, surgery and anesthesia
3.1.3. Provides appropriate administrative and ancillary services (clinical
laboratory, radiology, pharmacy)
3.1.4. Provides nursing care for patients who require intermediate, moderate
and partial category of supervised care for 24 hours or longer
3.2. Secondary Care Hospital –
3.2.1. Departmentalized hospital that provides clinical care and management
on the prevalent diseases in the locality, as well as particular forms of
treatment, surgical procedure and intensive care
3.2.2. Clinical services provided in the Primary Care Hospital, as well as
specialty clinical care
3.2.3. Provides appropriate administrative and ancillary services (clinical
laboratory, radiology, pharmacy)
3.2.4. Nursing care provided in the Primary Care Hospital, as well as total
and intensive skilled care
3.3. Tertiary Care Hospital –
3.3.1. Teaching and training hospital that provides clinical care and
management on the prevalent diseases in the locality, as well as
specialized and sub-specialized forms of treatment, surgical procedure
and intensive care
3.3.2. Clinical services provided in the Secondary Care Hospital, as well as
sub-specialty clinical care
3.3.3. Provides appropriate administrative and ancillary services (clinical
laboratory, radiology, pharmacy)
3.3.4. Nursing care provided in the Secondary Care Hospital, as well as
continuous and highly specialized critical care
3.4. Infirmary – a health facility that provides emergency treatment and care to the
sick and injured, as well as clinical care and management to mothers and
newborn babies.
3.5. Birthing Home – a health facility that provides maternity service on pre-natal and
post-natal care, normal spontaneous delivery, and care of newborn babies.
 38

3.6. Acute-Chronic Psychiatric Care Facility – a health facility that provides medical
service, nursing care, pharmacological treatment and psychosocial intervention
for mentally ill patients.
3.7. Custodial Psychiatric Care Facility – a health facility that provides long-term
care, including basic human services such as food and shelter, to chronic
mentally ill patients.
http://www2.doh.gov.ph/BHFS/classification.pdf

2. STAFFING – the process of determining & providing the acceptable # & mix or personnel to
produce a desired level of care to meet patient’s demand for care.

Methods of Staffing Pattern

1. Conventional – centralized- decentralized combination; oldest and most common

2. Cyclical – staffing pattern repeats itself every 4 – 6 wks or 7 -12 wks, etc.

2.a 40 hrs/4 days – 40 hrs a wk is worked in 4 days, followed by a block of off duty time

2.b Seven days off, 7 on – a 10 hr day is worked for 7 days, followed by 7 days off

Criteria for staffing patterns depends on:

1. Existing organizational structure & Standards
2. Availability of job descriptions or performance responsibilities which spell out precise
job content, including duties, activities to be performed, responsibilities & results
expected from the various roles by the organization.

3. SCHEDULING – a timetable showing planned work days and shift for nursing personnel

Types of Scheduling:

1. Centralized – Chief Nurse or designate do assigns the personnel to the hospital units

2. Decentralized – Chief Nurse or designate assigns personnel but supervising Nurse/ Head or Senior
arranged the shift and off duties

3. Cyclical – Covers designated number of wks. (cycle length)

it assigns required number of nursing personnel to each nursing unit consistent with the unit’s
patient care requirements, the staff preference, then, education, training and experience.

The following scheduling variables should be considered:

a. Length of scheduling period whether 2 or 4 weeks
b. Shift rotation
c. Week-ends off
d. Holiday offs
e. Vacation leaves
f. Special days ( birthdays, wedding anniversaries, etc.)
g. Scheduled events in the hospital training programs, meetings, etc.
h. Job categories
i. Continuing Professional Education (CPE) programs
 39

Advantages of Cyclical Schedule

1. It is fair to all
2. It saves time as the schedule does not have to be redone every week or two
3. It enables the employees to plan ahead for their personal needs preventing
frequent changes in the schedule.
4.Scheduled leave coverage such as vacation, holidays and sick leaves are more stable
5. Productivity is improved

Factors Considered in Making Schedules

a. the different levels of the nursing staff - adequate mix of nurses and nursing attendants should be
observed so that they only assume duties they are legally responsible for, according to their positions,
education, training and experiences.
b. adequate coverage for 24 hours, seven days a week
c. staggered vacations and holidays - not everybody can enjoy the holiday off on exactly the same day
that these occur; schedules for holidays are staggered at least once a month.
Vacations (whether forced or requested) are likewise staggered to ensure adequate coverage at all
times.
d. weekends – Weekends are scheduled in such a way that everyone gets a fair share of at least one
week-end off a month.

 Saturdays and Sundays tend to have lower requirements since there are lesser medical rounds,
fewer medical orders and lower patient census.

e. long stretches of consecutive working days are to be avoided as much as possible because it might
affect the health of the nursing personnel.
 Afternoon and night shifts are more difficult than the day shifts.
 Nursing personnel should get their fair share of these things including the ‘relief ’ duty for the
three shifts periods.

f. evening and night shifts requirements for staff are usually lower than in the morning shift

g. floating

Some problems that occur in the schedules:

* busy units may require additional help
* unscheduled absences may occur and suddenly a staff may be pulled out from her regular area
of assignment to cover for another unit.
- in order to minimize problems as a result of emergency assignments cross training and/ or
orientation to complementary units is advised.

4. Developing JOB DESCRIPTION – a statement that sets the duties and responsibilities of a specific
job.
 40

Name: _______________________________________ Section: ______ Date: ___________

Review Questions # 5: Please write the letter of your choice in the space before the number.

___1.A function of management that helps reduce the risks of decision making, problem solving, and
effecting planned change.
a. Controlling b. Planning c. Directing d. Organizing

___2. The level of management where the Nurse Director is, that sets the over-all goals and policies of the
organization.
a. Middle Mgt. b. Lower/first level mgt. c. Top level mgt. d. Operating level

___3. It describes the vision. It is the organization’s sense of purpose:

a. Vision b. Mission c. Goals d. Philosophy

___4. Programs are determined, developed and targeted within the time frame to reach goals/objectives.
a. Development and scheduling b. Staffing c. Budgeting d. Planning

___5. Broad guidelines for the managerial decisions that necessary in organizational and departmental
planning.
a. Nursing Standards b. Nursing Service Policies c. Nursing law d. Rules

___6. This can supply professionally desirable norms against which the department’s performance can be
measured.
a. Nursing Standards b. Nursing Service Policies c. Nursing law d. Rules

___7. They are specific directions for implementing written policies.

a. Nursing Standards b. Nursing Policies c. Nursing Procedures d. Nursing law

___8. The number of workers that a supervisor can effectively handle should be limited depending upon
the pace & pattern of the working area.
a. Unity of command b. Exception Principle c. Span of Control d. Scalar Principle

___9. The method of grouping patients according to the amount of care requirements, nursing time & skill
they require.
a. Modalities of nursing care b. Patient Classification System c. Patient’s level of acuity

___10. The process of determining & providing the acceptable #& mix of personnel to produce a desired
level of care to meet patient’s demand for care.
a. Scheduling b. Planning c. Staffing d. Development

___11. A timetable showing planned work days and shift for nursing personnel.
a. Scheduling b. Planning c. Staffing d. Budgeting

___12. A statement that sets the duties and responsibilities of a specific job.
a. Nursing Service Policies b. Job description c. Guidelines
 41

III DIRECTING
- the issuance of orders, assignments and instructions that enables the nursing personnel to
understand what are expected of them.

Elements of Directing
1. Delegating /Delegation
2. Utilizing / Revising / Updating Nursing Service Policies
& Procedures
3. Supervision
4. Communication
5. Coordination
6. Staff Development
7. Decision Making
8. Motivating / Motivation
Delegate!
1. DELEGATING - getting the work done through subordinates
– assigning specific tasks/duties to workers with commensurate authority to perform the job

With the increased use of less-educated and unlicensed personnel in today’s health-care system, it is
essential that the nurse develop effective delegation, and supervision skills. The nurse needs to be mindful
that the tasks that can be delegated can change on the basis of working setting, client needs, position
descriptions, institutional training of personnel, and the ever changing requirements of nurse practice acts
and professional standards. Nurses also need to know when delegation is inappropriate.

DELEGATION and SUPERVISION IN NURSING

In today’s health-care system, delegation has become an essential component of client care and
management of nursing units. It allows health-care managers to maximize the use of caregivers who are
educated at multiple levels in a variety of programs. Delegation, if performed properly, permits nurses to
meet the requirements of quality care for all client and has become a basic skill that registered nurses
(RN) must learn. The goal of delegation is to meet the cost restraints of limited health-care budgets by
using less-expensive personnel that maximize the use of time by RNs and to promote team building.

Although delegation and supervision are closely related concepts, they are different.

Delegation is recognized as assigning or designating a competent individual the responsibility

of carrying out a specific group of nursing tasks in the provision of care for certain clients.
Delegation includes the understanding that the authorized person is acting in the place of the RN
and may be carrying out tasks that generally fall under the RN’s scope of practice.

This includes more than asking someone to do something. Delegation has been defined by the
American Nurses Association (ANA) as “ the transfer of responsibility for the performance of an
activity from one individual to another, with the
former retaining accountability for the outcome” Let whoever is in charge keep this simple
(ANA, 1995). This definition emphasizes that delegation question in her head (NOT how can I
increases the responsibility and accountability of the always do the right thing myself but) how
RN. Be sure you know the delegation rules and can I provide for this right thing always to
regulations of your state’s nursing practice act. be done? - Florence Nightingale
Additionally, you will also need to know that delegation
policies and job descriptions of nursing team members in your employing agency.
 42

Supervision is the initial direction and periodic evaluation of a person performing an assigned task to
ensure that he or she is meeting the standards of care. Although delegation almost always requires
supervision, it is possible to have supervision without delegation.

Supervision: “the provision of guidance or direction, evaluation and follow-up by the licenses nurse for
accomplishment of a nursing task delegated to unlicensed
assistive personnel.”
Nurses need to recognize when to delegate.
Nurses are often confused regarding supervision.
This responsibility does not belong to only the one with the title
of manager or house supervisor; rather, the expectation by law
is that any time you delegate a task to someone else, you will be
held accountable for the initial direction you give and the timely
follow-up (periodic inspection) to evaluate the performance of
that task.

When nurses delegate nursing tasks to non-nurses, the

RNs are always legally responsible for supervising those people
to ensure that the care given meets the standards of care. Legally, the power to delegate is restricted to
professionals who are licensed and governed by a statutory practice act. RNs are considered
professionals with state-sanctioned licenses governed by a nurse practice act and therefore are
authorized to delegate independent nursing functions to other personnel.

The stresses the belief that even though the leader or manager delegates a task to another employee, he or
she remains responsible and accountable for the care that is provided.

“When nurses delegate nursing tasks to non-nurses, the RNs are always legally responsible for
supervising those people to ensure that the care given meets the standards of care.”

Delegation and supervision are integrated processes: Once you delegate, you must
supervise.

To increase delegation skills, it is sometimes necessary to overcome the myth of perfection. In

teaching or training someone else to do a delegated task, initially they may or may not be able to perform
the activity as well as you can; however, it is not important that they do this perfectly, in the way you do
it, or even as well as you do. What is important is that they meet the standards required to complete the
task adequately. As long as safety is not compromised, it is more effective time
management to delegate to others. With experience, most people will improve
(and may even surpass you).

The Nurse’s Responsibilities

Assess the Client. Prior to delegating any task, RN should give careful consideration to the condition of
the client’s health care needs. Assessing clients is a designated responsibility of RNs. Without a
thorough assessment, it is likely that critical needs will remain unidentified by less trained
personnel, leading to potential errors in care. Clients who are relatively stable and not likely to
experience drastic changes in health-care status are the most suitable for delegation. Also, the tasks
being delegated must be relatively uncomplicated, routine, performed without varying from policy
or procedure, and should nor require the use of nursing judgment while being performed.
 43

Know Staff Availability. The delegating nurse needs to know the availability the availability of staff, the
education, and competency levels of the personnel to be assigned. These factors must be matched
with the level of care required by the client. Key information to obtain in relation delegation is
how often the delegates has performed the required tasks o cared for this type of client, what units
the delegate has worked on and feels comfortable in, and his or her organizational abilities.

Know the Job Description. The RN needs to know both the institution’s official position description for
the unlicensed assistive personnel (UAP) (nursing aide) as well as the individual UAP’s abilities.
For example, the position description may state that the UAO can care for postoperative clients
who have multiple wound drains. However, when the RN assigns a specific UAP to such a
postoperative client, the nurse discovers that UAP has has worked only in the newborn nursery for
the pas 5 years and has no knowledge of how to care for adult postoperative clients. If the RN
assigns this UAP anyway and a major complication develops as a result of the UAP’s lack of
competence (even though the position description states that this is an appropriate function for the
UAP), the RN will be held legally responsible for the poor outcome. When the RN determines that
the client’s need match the skills and abilities of the UAP or the licensed practical nurse (LPN),
only then should that person be assigned.

Educate the Staff Member. RNs who delegate are also responsible for educating the UAP (nursing aide)
about the task to be done. If the UAP is unfamiliar with the task, the RN is required to demonstrate
how the task or procedure is performed and then document the training. Education also includes
telling the UAP what is expected in the completion of the tasks and what complications to watch
for and report to the RN. The ANA suggests that the RN watch the UAP perform the designated
task at least initially, and then make periodic observation throughout the shift to ensure safe and
competent care for the client. Furthermore, the RN must always be available to answer questions
and help the UAP whenever assistance is required. Consider the following situations:

Elsie Humber, RN, is the evening charge nurse on a busy oncology unit of the country hospital. On one
particularly busy evening, she discovered during shift report that one of the scheduled LPNs has called in
sick and no other LPNs are available to take her place. Ms. Humber assigns the LPN’s duties and clients,
including a heat lamp treatment for a decubitus ulcer, to a UAP who has worked in the unit for several
months. The UAP protests the assignment, but Ms. Humber rebukes him by saying “I have no one else. If
you don’t care for these clients, they won’t get any care this shift”. In setting up the heat lamp treatment,
the UAP knocks the lamp over and burns the client. Because of his suppressed immune system
chemotherapy and generally debilitated condition, the burn doesn’t heal and develops into infection. The
client later sues the hospital for malpractice. The hospital in turn attempts to shift the legal responsibility
for the burn to Ms. Humber. Who is legally responsible for the incident? Does the client have grounds for
a successful case?

Predictable and Uncomplicated

When a nurse delegates a task, the outcomes of task should be expected and predictable. For
example, when a UAP (or nursing aide) is assigned the task of feeding a client who has suffered a stroke
and has hemiplegia, the predicted outcome will be that the client will eat and not choke on the food. The
task should not require excessive supervision, complex decision making, or detailed assessment during its
performance. If any of these elements are required, then it needs to be re assigned to an RN.

“It is important to remember that when nurses delegate nursing tasks, they are not delegating
nursing”.
 44

It is important to remember that when nurses delegate nursing tasks, they are not delegating
nursing. Professional nursing practice are both a science, on a unique body of knowledge, and an art
guided by the nursing process. It is not merely a collection of task. Of all health-care workers,
professional workers are the most qualified to provide holistic care of the client by promoting health and
treating disease. Nurses’ education and experience provide them with the skills and knowledge to
coordinate and supervise nursing care and to delegate specific tasks to others.

How Do I Know What And When I Can Delegate?

Knowing the nurse practice act of your state or country, in addition to the policies for each
institution, is critical in delegating appropriately and safely. Once that has been established, consider
some general guidelines regarding what and when to delegate.

You should not delegate to anyone other than another RN the task of assessment to determine
changes in a patient’s condition. Licensed practical nurses or vocational nurses perform patient
assessment (gathering data), but it is the RN who must confirm and
interpret these findings. Assessment should not be delegated when a
decision needs to be made regarding patient care, the patient’s
condition is changing, or there is a new patient the RN has not
previously assessed.
According to the nursing process, after assessment and
analyzing comes planning. This is another role of the RN. Data can be
gathered from a number of sources including input from a nursing
assistant, etc. Ultimately it is the responsibility of the RN to determine
the immediate plan of care and the comprehensive plan of care for the
patient.
Many nurses suffer from “ supernurse syndrome”
Another area of the nursing process that is
reserved for the RN is the area of evaluations. It is the RN’s responsibility to determine the patient’s
response to procedures, medications, nursing care, and so forth. Nursing judgment based on the
assessment and evaluation of the patient must also remain the responsibility of the RN. It all comes down
to the RN’s responsibility in implementing the nursing process. Time management with delegation can
help the RN more effectively implement the nursing process.

Determine which patients are the most stable and whose positive progress can be anticipated. The
stable patients with predictable progress should be the first to be delegated. The unstable, unpredictable
patient should only be delegated to an RN. An RN should be assigned to any patient who is undergoing a
procedure or treatment that may cause them to become unstable.
When you are dealing with unlicensed assistive personnel, you can delegate them those activities
that are standard with specific guidelines that are unchanging. For example, feeding, dressing, bathing,
obtaining equipment for the nursing staff, picking up meal trays, refilling water containers, straightening
up cluttered rooms – all of these activities should have guidelines according to the institution policies, fit
within the job description, and be followed by the unlicensed assistive personnel.
Patient teaching and discharge planning are also the responsibility of the RN. It is the RN’s
responsibility to determine the patient’s learning needs and to establish a teaching plan. It is also the RN’s
responsibility to coordinate and implement the discharge planning. The RN should request input from all
nursing personnel who have assisted to provide care for this patient or who are involved (.eg. dietary,
physical therapy) in the care of the patient. It is important that once the RN implements the teaching plan,
the other RNs, licensed practical nurses, vocational nurses, and unlicensed assistive personnel are aware
of what the patient has been taught so they may follow-up and report any pertinent observations to the
RN. >
 45

Nursing care makes a difference in patient outcomes. This care is more than providing tasks. It
incorporates assessment, care planning, initiation of interventions, interdisciplinary collaboration, and
outcome evaluations. It includes patient and family teaching, therapeutic communication, counseling,
discharge planning, and teaching. To maximize the impact nursing care can have on patient
outcomes, nurses must develop and integrate multiple strategies to promote effective time
management.

Critical Thinking: Determine how and to whom patients are delegated on your current clinical unit.
What guidelines are implemented?
Critical Thinking : In Your Organization, Can You Delegate The Following Tasks?
NO YES
Bladder retention catheter insertion
Taking vital signs
Feeding a patient
Hygienic care
Medication administration
Discontinuing an IV line
Teaching insulin administration

Nursing is a knowledge-based process discipline and cannot be reduced solely to list of tasks.
The licensed nurse’s specialized education, professional judgment and discretion are essential for quality
nursing care… while nursing tasks may be delegated, the licensed nurse’s generalist knowledge of patient
care indicates that the practice-pervasive functions of assessment, evaluation and nursing judgment must
not be delegated.

According to nurse-attorney Joanne P. Sheehan, nurses cannot delegate the following:

Assessments that identify needs and problems and diagnose human responses.
o Any aspect of planning, including the development of comprehensive approaches to the total care
plan.
o Any provision of health counseling, teaching, or referrals to other health care providers.
o Therapeutic nursing techniques and comprehensive care planning.

DEVELOPING DELEGATION SKILLS

Clear Communication. In the process of developing delegation skills, students should try to emulate the
good delegators. Develop good communication and interpersonal relationship skills. Make eye
contact with the other person, be pleasant, and asks for suggestions. However avoid allowing the
person to whom the tasks are being delegated to control the exchange by intimidation or resistance.

Careful Monitoring. Effective delegation includes monitoring the delegates while they are giving care.
Are they doing what they should be doing? Do they understand the responsibilities involved in the
client’s care? Help them if they need help. Effective delegation also presumes that the delegator
will teach the delegates who demonstrate a lack of knowledge. Most important, at the end of the
shift, say “Thank you. I appreciate the hard work (good job) you’ve done today.”
Certain delegation situations may place the RN at an increased risk for liability. Try to
avoid the following when delegating:
* Assigning tasks that are highly invasive or have the potential to cause significant
physical harm to clients.
* Assigning tasks that are designated under the scope of practice or standards of care as
belonging exclusively to RN (admission assessments, care plan development)
 46

* Assigning tasks that the person is not trained for or lacks the knowledge to safely complete
* Assigning tasks when there is inadequate time to safely monitor or evaluate the practice of
the person performing the tasks.

Client Care Needs

RN
Admission Assessment
IV Meds
Blood Products
Care Plan
Client Teaching
Unstable Clients
Acute Diseases

LPN
UAP
Vital Signs
Feeding
Uncomplicated Skills
Basic Hygiene
Stable Clients
Basic Skills
Chronic Diseases
Stable Clients
Oral and IM
Chronic Diseases
Medications
Ambulation
WHO IS ACCOUNTABLE HERE?
One of the biggest questions concerning teamwork and delegation is the issue of personal
accountability. The definition of delegation already notes that the nurse is accountable for the total
nursing care of the individuals. What does this really mean?

Accountability: “being answerable for what one has done, and standing behind that
decision and/or action”.

Accountability has gotten a lot of “ bad press,” and many nurses feel that being accountable
means “I am the one to blame.” With that kind of attitude, no wonder there is reluctance to delegate!
What is the point if someone else is going to make a mistake and you are going to be taking the blame?
(Notice how e focus on the negative and forget that accountability also means taking the credit for the
 47

positive results we achieve through the actions and decisions we make, and our freedom to act because of
our licensure.) Here is an important reminder about accountability before you take the weight of the world
on your shoulders:

“ The delegate is accountable for accepting the delegation and for his/her own actions in
carrying out the task”

It is important to focus on what you are accountable for in this process and to let the delegate also
assume his or her own level of accountability. Remember, you are accountable for the following:
 Making the decision to delegate in the first place
 Assessing the patient’s needs
 Planning the desired outcome
 Assessing the competency of the delegate
 Giving clear directions and obtaining acceptance from the delegate
 Following up on the completion of the task, providing feedback to the
delegate.

What if the delegate makes a mistake doing the task? What are you accountable for? Let us consider the
following example:

It is 7 AM on your busy medical-surgical unit. You scan your assignment quickly, reviewing the high
points with your nursing assistant before going into report. With trays coming at 7:30, you remind your
assistant that your patient in room 210 will be going to surgery this morning and is to have nothing to eat
or drink. Coming out of report, you make brief rounds, only to find that ( you guessed it) your patient in
room 210 is happily drinking her morning coffee and eating a bagel.
What are you accountable for?
Did you delegate correctly?
What do you do now?

In your review of the previous guidelines, you identified that you did indeed delegate appropriately. Your
communication may or may not have been as complete as it needed to be.

You are accountable for correcting the clinical effects of this error:

Did the patient eat or drink too much, requiring that surgery be canceled or delayed? You will call the
operating room and make the appropriate adjustments in this patient’s care on the basis of the decision
regarding her surgery time. What about the nursing assistant? You are also accountable for following up
with her regarding her performance, giving the appropriate feedback so that the understands her level of
personal accountability as well.

THE FIVE RIGHTS OF CLINICAL DELEGATION

Right Task Right Communication
Right Person Right Feedback
Right Circumstance

The RIGHT TASK

The first part of any decision regarding delegation is the determination of what needs to be done
and then the assessment of whether this is a task that can be delegated to someone else. Many nurses,
unfortunately, suffer from “super nurse syndrome” and believe that no task should be delegated because
no one can do it better, faster, or easier than they can. In comparison, other nurses may be all too eager to
delegate the least desirable tasks to someone else. A word of caution is necessary here: If we focus only
 48

on making task lists for people to do, we eliminate the very core of our purpose. Remember, your role as
RN on the team involves the coordination and planning of care, with your primary focus on identifying
with the patient and the physician the desired outcomes for your patients. Once determined, interventions
will be readily apparent, and the decision regarding possible delegation of these tasks must be made.

What Can I Delegate?

Fortunately, there are several references to assist you in making this determination. The first place
is looking into the nurse practice act of your state. The scope of practice for each level of care provider
usually includes a description of the tasks that may be performed at that level. The next place to look is in
your organization, getting a copy of the job description and the skills checklist for each care provider.
This will give you a very specific lists of tasks to work from, but remember, there are other
considerations. Simply because the skills checklist includes ambulation of patients, it may not be
advisable to delegate the first ambulation of a postoperative total hip replacement patient to the new
patient care assistant.

Is There Anything I Cannot Delegate?

Again, your first resource is the law. Many states are very specific in their description of what
cannot be delegated and therefore belongs only to the RN’s scope of practice. The National council of
State Boards of Nursing ( CSBN) reminds us that nursing is a knowledge-based process discipline and
cannot be reduced solely to list of tasks. The licensed nurse’s specialized education, professional
judgment and discretion are essential for quality nursing care… while nursing tasks may be delegated, the
licensed nurse’s generalist knowledge of patient care indicates that the practice-pervasive functions of
assessment, evaluation and nursing judgment must not be delegated.
According to nurse-attorney Joanne P. Sheehan, nurses cannot delegate the following:
 Assessments that identify needs and problems and diagnose human responses.
 Any aspect of planning, including the development of comprehensive approaches to the total care
plan.
 Any provision of health counseling, teaching, or referrals to other health care providers.
 Therapeutic nursing techniques and comprehensive care planning.

Beyond the law, your employer will have job descriptions and skills checklists that should clearly define
the role of the caregiver. As many organizations develop creative assistant roles to leverage the
professional judgment of scarce registered nursing personnel, the scope of practice of each role is defined
first by the law. If the organization extends the role of a patient care technician to include preoperative
teaching, you want to be aware that this is clearly an RN function and not allowed by law to be delegated
to the technician. A job description and a policy would not override the legal limits of the scope of
practice.
Where To Look For Determination of the Right Task
Nurse practice act
Employee job description
Skills checklist
Demonstrated competency

With the right task selected according to the scope of practice, the policies in your agency, and your
assessment of the situation, there is still work to be done. Who will do the task?

The RIGHT PERSON

Matching a task that can be delegated to the right person involves that definition of delegation
once again. Nurses must select the right task for a competent person in a selected situation. How do we
select the right person in the right situation?
 49

How Can I Use Outcomes In Delegating?

USING OUTCOMES IN DELEGATING

Patient Outcome Task/Process Who will perform it?

Mr. Peterson Patient will be clean Bath Nursing assistant or

Patient & caregivers will
Ms. Ibutu know how to perform skin
assessment and range of
motion
other care associate
Bath with education RN: teaching plan; OT,
regarding home care PT, or rehabilitation
aide may also assist

1.Patient will maintain Initial baseline vital RN: assessment and

Mr. Handelsky cardiorespiratory homeostasis signs and assessment, interpretation of data
and continue on care path day close monitoring
1 LPN: data-gathering and
reporting RN: initial
2.Patient will be free of pain Pain assessment and plan for comfort
and comfortable for this shift. treatment, comfort measures and pain
Long-term outcome, pain free measures assessment
death ( repositioning skin
care) Assistant: comfort
measures, report of
progress
LPN, Licensed practical nurse; OT, occupational therapist; PT, physical therapist; RN, Registered Nurse.

TALKING ABOUT OUTCOMES: WHAT’S IN IT FOR ME?

 Provides a method to decide appropriate assignments: who should be doing what task
 Gives you a sense of purpose for the shift ( short term) and long term
 Enhances your ability to motivate co-workers along a track to achieving the outcomes
 Clarifies your role as leader of the team
 Verifies and clarifies patient/ family expectations when outcomes are discussed and
planned with them
 Promotes job satisfaction for the whole team

In planning for the right person to do a task, focusing on outcomes is essential . For example, two
patients can be admitted to a hospital. Each of these individuals will need a bath today ( task), but who
will do the bath is related to the outcome you are trying to achieve. For Mr. Peterson who has been
homeless and is in dire need of hygienic care so that you can perform a complete and accurate skin
assessment, the priority outcome you and your patient desire is that Mr. Peterson will be clean. With Ms.
Ibutu, who is a paraplegic, today is the day that her caregivers and she will demonstrate how they will
assess the skin for areas of breakdown and how to perform range of motion to her lower extremities. The
RN’s decision about who will do the task is dependent on the plan of care and the goals that the team has
established in the discussion with the patient or family.

This same logic applies when you have heard in report that a patient is unstable. In your current
care-delivery system on your unit, the LPN may carry out the initial vital sign data-gathering in your
postoperative ICU. Suppose, for example, that the report you received stated that there had been
increasing cherry red drainage in the chest tube and that the patients cardiac monitor showed
 50

supraventricular tachycardia, with increasing respiratory rate. On the basis of the outcome for the shift,
Mr. Handelsky will maintain cardiorespiratory homeostasis and continue on critical path for first day
post-thoracotomy. Using your insight that his condition may be deteriorating, you may make a different
decision regarding who will be there for initial patient contact. If the assistant working with you today is
an experienced team member, you may choose to send him in to see the patient immediately while you
check on another critical patient. Or if the assistant is a float from an agency, known to you only by initial
questioning, you may immediately make a visit to see Mr. Handelsky and begin to set up the plan for the
data-gathering and schedule for reporting that you will expect from your assistant. This would be a very
different process if the outcome you wanted to achieve was pain relief and comfort for a terminal patient.
Focusing on outcomes takes time. But, as many have often said, “If you fail to plan, you plan to fail.”
Why should an RN focus on outcomes? Discussion of goals not only establishes who should be doing
what task, but also allows RN to motivate others. How many of us jump on a train if we do not know
where it is going?
A purpose and destination allow all the team members to function more effectively. When
assistive personnel are given the same assignment daily, without variation, without any understanding of
why they are doing what they are doing, it is similar to being an assembly line worker putting widgets in a
machine. Satisfaction and motivation of co-workers generally come from the feeling that they are making
a difference in the lives of their patients.
In a similar manner, you as the leader of the team would feel much better at the end of your shift
or assignment if you could feel comfortable with the outcomes you have assisted the patient In achieving.
You could actually verify the outcomes and plan with the patients, much as you were always told to do by
the teachers in your nursing program! Much time is saved by streamlining the care to the patient’s
expectations.
Again, the RN is accountable for the patient, for determining the situation in which delegation
will be used, and for the selection of the right person to do the right task, in addition to the periodic
inspection and follow-up of those they supervise.

The RIGHT CIRCUMSTANCES

The National Council of State Boards of Nursing discussed the “right circumstance” as an additional
consideration for the nurse. “Right Circumstances - appropriate client setting, available resources, and
consideration of other relevant factors,” suggests that the staffing mix, community needs, teaching
obligations, and the type of patients being cared for should be considered. (NCSBN, 1995). Different
rules for delegation may apply regarding what and how an RN must delegate in home care, long-term
care, or in community homes for the developmentally disabled or group boarding homes for assisted
living.

How Can I Determine The Strengths And Weakness Of Team Members?

Often motivated by the fear that a delegate may make a mistake in an assigned task, nurses focus
on the potential weakness of their team members. As nurse, we are educated to anticipate the worst so that
we can prevent accidents, adverse drug reactions, and negative sequelae to disease processes and
treatments alike. Prudent as this approach may be for the safety of all concerned, it is worthwhile to
discuss the need to be clear on the strengths of the team members as well.
Assigning tasks on the basis of the strengths of the person will allow the individual and the
patient to experience the very best care. Now, as a supervising RN, you are in a new position with respect
to the long-term performance of delegates. If assistive personnel are assigned only those tasks they are
good at, they may not grow in their abilities and skills. This mistake is exemplified by a hospital that had
created a new multiskilled patient care assistant (PCA) role with certified nursing assistants (CNAs).
These CNAs had been trained to do phlebotomies as well, as authorized by the state board. Phlebotomists
had been eliminated but were given the option of training for the new PCA role. When all of the PCAs
worked together, the lab tests were drawn by those who had been phlebotomists were off on vacation and
 51

maternity leave. None of the PCAs who were formerly CNAs had become proficient at this skill!
Recognize strengths, and encourage the best patient care possible by using them, but challenge delegates
to grow too.

The dreaded weaknesses in performance of team members can often be prevented by asking the
right questions before delegation. Nurses can be reserved about asking personnel such as float or agency
replacement staff about whether they feel comfortable in completing the assignment they have received.
Float and temporary personnel tell us that they would prefer being asked about their competency at the
beginning of a shift or assignment, with the offer of help and clarification, rather than having to locate an
RN to request information. The American Nurses Association (ANA) Code of Ethics states, “ The nurse
is responsible and accountable for individual nursing practice and determines the appropriate delegation
of tasks consistent with the nurse’s obligation to provide optimum patient care” (ANA, 2001). Be assured
that although it is the responsibility of the RN to assess the competency of those they supervise, the
delegate must be “accountable for accepting the delegation and for his/her own actions in carrying out the
task (NCSBN, 1995). The RN who is familiar with the situation, however, must ask the correct
questions to determine whether the person is competent.
For example, if an RN were planning to ask a nursing assistant to feed a baby with respiratory
difficulties, based on the outcome that the baby would be able to ingest 12 ounces of formula this shift,
what questions might the RN ask to determine the potential strengths and weaknesses? If the individual
has not had experience in this procedure, how could the nurse ensure future competency? In this
situation, an RN would certainly ask questions about past experiences with feeding babies with difficulty
swallowing. If the delegate assures the RN that she is competent, the RN may go further in asking what
the CNA would do if coughing or choking occurred. Depending on the situation, the RN would probably
want to demonstrate feeding techniques and observe skills to ensure the competency of the delegate.

What Are The Causes Of Performance Weaknesses?

Let us take a look at an example of a performance weakness and try to determine what the potential
causes may be.
In this scenario, you are an RN working as night shift on a hematology-oncology unit, and an agency
nursing assistant, Pam, comes to work with you this shift. Pam is excited about the possibilities of
interviewing for a regular night shift position and would love to work extra on holidays and weekends. As
you begin to discuss her assignment for the night, she states, “ Oh, I forgot to tell you, I do not ever take
patients who are HIV-positive! Ever!”

There are some potential costs and benefits to your response to this statement. As the charge
nurse, you could ignore this statement and continue with your work. You may decide this person has
problems, and you may elect to deny her request for an interview. Or you may determine there is
something behind her refusal. How you respond may cost you a potentially valuable staff member and
could upset the other members of your staff and the patients. Avoiding the problem or accommodating
her refusal could become a terrible headache for making assignments and would be contrary to the
mission of your organization.

Experience has shown that there are several potential causes of performance inadequacies.
POTENTIAL SOURCES OF PERFORMANCE WEAKNESSES
 Unclear expectations
 Lack of performance feedback
 Educational needs
 Need for additional supervision and direction
 Individual characteristics: past experiences, motivational or personal issues
 52

One of the most common causes is that the employee is not aware of what is expected of him
or her. Does Pam know that at this facility it is part of your policy that everyone takes care of all patients,
whether or not they are known to be HIV-positive? Perhaps being aware of this expectation would assist
Pam in making her decision about whether to apply for work on this unit.
Often being clear about expectations is not enough. Each of us has some blind spots in his or her
own performance. Perhaps we think we are doing just fine, meeting performance competencies and
beyond, but colleagues have noted that we are not performing procedure according to policy. If these
observations are not shared, we will blithely believe we are doing great. Another common cause of
performance difficulties is that no one has shared their perceptions of our performance with us. Pam
may have adopted this attitude regarding other patients in other work settings, and because of the
desperation for help, no one had shared the fact that this behavior falls short of competencies in her job
description.
Another common origin of performance weakness is an educational need. Does Pam need more
education about how HIV infection is transmitted and how it is prevented? Surely she had to complete
some content regarding this in her CAN certificate course, but it seems she did not internalize this
content. Or is there a personal problem? She may have just witnessed the death of a loved one from AIDS
and feel unable to cope with seeing others with this disease for the short term.
The amount of supervision needed can be another source of performance problems. As an RN,
you must determine the degree of “periodic inspection” needed by the delegate. Some people require
additional direction but are still able to do the job competently. In the absence of that direction, they will
be unable to create positive patient outcomes. Nurses tell us they wish that the assistive personnel on their
staff would be “self-directed and take initiative without being told.” We question whether an RN’s hope
that all will do their jobs without interaction or supervision on his or her part fits with the definition of
supervision! Again, as a leader, the RN must determine how much supervision is needed for the
individual delegate, just as we determine the degree of observation needed for each patient on the basis of
our assessment of their needs. In Pam’s case, her reluctance to work with patients with HIV may have
nothing to do with supervision but may reflect a need for guidance, education, or a frank discussion of
expectations.
As the RN who is supervising Pam, what steps would you take to determine the cause of Pam’s
performance weakness, the assertion she refused to care for patients with HIV? What question would you
ask? How would you respond so that you could continue to use Pam’s services this shift, maintain the
integrity of your mission, and preserve to use Pam’s services for hiring a new employee?
Matching the right person with the right task is the second step in the circular process of delegation. This
process includes planning and articulating priority patient outcomes, assessing the competency of the
delegate to perform the task, determining the potential strengths and weakness of the assistive personnel,
and planning how much supervision is needed. To ensure that the right task will be done by the right
person, additional clarification of expectations, performance feedback, and planning for education needs
may be necessary; these steps will promote the long-term success of the team. The right communication
will begin that clarification process, bringing us to the next step in the four rights of delegation.

The RIGHT COMMUNICATION

How Can I Get The Delegate To Understand And What I Want?

No matter what, it always comes back to communication. How clear you make your initial
direction will be the cornerstone in determining the success of your delegated task and, ultimately, the
performance of your team. The bottom line, whether the patient outcome was achieved, hinges on your
ability to give initial direction that clearly defines your expectations of the delegate in performing the
assigned task. It is not surprising that this is a step that is often done poorly or left out entirely because the
assumption is made that the individual “ knows what the job is and should just do it.”
 53

The first component of supervision, according to its definition, is the provision of initial direction.
Achieving a balance in which we provide enough information for the person to understand the request
without overstating the case and risking confusion or condescension requires that we tread a fine line.

The use of the “four Cs” of initial direction will help you to plan your communication

The FOUR Cs of INITIAL DIRECTION

CLEAR: Does the team members understand what I am saying?
CONCISE: Have I confused the direction by giving too much unnecessary information?
CORRECT: Is the direction according to policy, procedure, job description, and the law?
COMPLETE: Does the delegate have all the information necessary to complete the task?

Situation:
Let us assume that you are working in a home health agency and you are planning the care for a
patient with congestive heart failure. You have made your initial visit, assessing the patient and planning
the outcomes you and the team will work toward in the next 3 weeks. Your patient is taking diuretics and
antihypertensives, in addition to potassium supplements and being on a restricted diet. She is frequently
short of breath and requires an assistant three times/week for hygienic care. In addition to providing
hygienic care, you would like that assistant to monitor BP on the days you are not making a visit and to
notify you if the BP is outside of the range of 120 to 170 systolic and 50 and 90 diastolic. Using the four
Cs listed, you can evaluate your communication.

“Mrs. Jones has a heart condition and high BP that requires medication and constant monitoring. One of
our goals is to help Mrs. Jones have a stable BP, in a range that isnormal for her. On the days that you
are visiting and giving the patient her bath, I would also like you to take her BP. If it is outside the range
of 120 to 170 systolic and 50 to 90 diastolic, I would like you to let me know. We may need to adjust her
medication, change her diet, or call her physician for different orders.”

Clear: Does the home health aide understand what is being asked of her? This direction is fairly
straightforward: an easily understood instruction of taking the blood pressure.

Concise: Have you confused the assistant by giving too much information? Or is it enough for her to
complete the task? Only the assistant can help you with this determination. You will need to ask
directly, “ Am I confusing you, or do you have enough information to do the job?” Every individual
has different needs. However, you will want to make certain to check this out; some people will not
be honest or accurate in their assessments of their understanding or abilities, leading to trouble later.
Many of us are reluctant to ask questions, being afraid to admit our need for additional information.
(We do not want to look like we do not know what we are doing!) This reluctance can ultimately
result in harm to the patient because assumptions are made that the direction was understood when,
in fact, it was not.

Correct: Can a home health aide monitor BP? Where would you look for additional information if you
were not sure?

Complete: Does the assistant have enough information to fulfill your expectations? Once again, you will
need to ask the delegate for clarification of his or her understanding of what you are asking. If you
expect this assistant to also note the respirations and alert you to increased effort of breathing, have
you shared that in your initial direction? Or did you assume she would naturally observe all vital
signs because you alerted her to the patient’s condition ( and besides, she is a good assistant)? In our
attempts not to appear condescending ( I do not want to insult this assistant by reminding her to note
 54

the respirations – she might think I do not trust her to think!), we may often choose not to be as
complete as we should be in giving initial direction.

Another common pitfall is the rationale that comes from working with someone over a period of time. A
working relationship develops, and a routine or pattern of performance is established. When this happens,
we start talking less and less to the other individual, believing that “ she knows what I expect her to do.”
Consider the following situation:

You are working on a surgical unit in a partnership with Sam, an LPN you have been working
with for the past year. Your easygoing style had led to a comfortable reliance on each other and
the feeling that each knows what other expects. On this particular evening shift, you are traveling
down the hall, intent on medicating one of your patients. You also see a post anesthesia care unit
(PACU) nurse bring one of your patients back to surgery. Seeing Sam coming your way, you
state,” Sam, the post-op is back in room 103.” Evaluate your initial direction.

Did you believe that Sam just knew you wanted him to check on the patient, get the first set of vital signs,
position the patient, check the dressing and the drains, and note the status of the intravenous tube?

Thirty minutes later, you are standing at the nurse’s station, noting an order. Sam is
charting. You ask him, “ Sam, how’s the patient in room 103 doing? Expecting a brief report,
you are surprised when Sam says, “I don’t know. I thought you were going to take him.” What
went wrong?

No matter how long you have been working with someone, the right communication is essential to
ensure the success teamwork. Sam did not accept the delegated task ( remember what the delegate is
accountable for?) because he did not understand what you meant. Be sure that you check the delegate’s
understanding of what you are saying. Failing to do this may result in unmet expectations, which lead
to anger and frustration. More importantly, the patient will not receive the optimal care that both of you
want to provide.

You have carefully assessed the patient, determined your plan on the basis of outcomes, and selected the
right task to delegate to the right person. You have even given clear initial direction as part of the right
communication. Now what? The final right of delegation is also a part of supervision: the periodic
inspection of the actual act. Read on as we continue with a discussion of the right feedback.

THE RIGHT FEEDBACK

How Can I Effectively Give And Receive Feedback?

Many nurses have shared their discomfort with giving and receiving feedback from co-workers.
Few of us enjoy telling co-workers how they are doing or hearing about how we may have missed the
mark! When supervising others, it is absolutely necessary to give feedback during your “periodic
inspection.” By following a formula for giving and receiving feedback and practicing it daily, RNs are
assisted in the difficult job of correcting the performance of others. The reciprocal feedback process also
permits you, as supervising RN, to hear how your own supervisory performance and communication
affected the outcomes of the team.
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FEEDBACK FORMULA
 Ask for the other individual’s input first!
 Give credit for effort.
 Share your perceptions with each other.
 Explore differing points of view, focusing on shared outcomes.
 Ask for the other individual’s input to determine what steps may be necessary to make
certain desired outcomes are achieved.
 Agree on a plan for the future, including timeline for follow up.
 Revisit the plan and results achieved.
Modified from Hansen R, Jackson M: Clinical delegation skills: a handbook for nurses, ed 3, Sudbury, Mass
2004, Jones & Bartlett.

Let’s look at how this process can be used in a situation in which positive feedback is intended.

An RN (Pat) is working with a float RN ( Julia) for the first time. Julia is new in the pool but is
an experience nurse. Pat is so pleased with Julia’s experience and performance that she has
gone off to have a nice break and lunch with an old friend from the third floor. She has also
taken time to meet with a colleague from the evening shift regarding a unit problem.
Unfortunately, she has not been present on the unit much today. When Pat is having lunch with
her friend, she exclaims, “That new float Julia is just excellent! If it weren’t for her, I couldn’t
be here having lunch with you. I hope that she knows how organized and valuable she is!” Her
friend, Alex, states, “ Well, you know you should tell her, not just me, about this.” When Pat
returns to the floor, flushed with good intentions of making Julia’s day with effusive praise, she
tells Julia about how lucky she has been to work with her today.

Because all of us crave positive feedback, and Julia is new to your organization, will Julia tell Pat that
she’s been trying to find her for hours? Probably not. But she may tell others that “ Pat is one of those
‘dump and run’ nurses. I don’t want to work on that floor again!” What if Pat asked first, “ How have
things been going for you today, Julia? I know this is your first day on the unit.” Julia may have
determined it was possible ( and expected) to give reciprocal feedback: “ I’ve have been trying to find
you! I have completed everything, but it hasn’t been easy. Where have you been?” The best intentions
can be destroyed by not asking the other individual for input first.

If you plan to give some negative feedback to an individual, you will also need to ask for her/his input
first. For example:
You have just noted that the night shift CAN did not chart the intakes and outputs (I & O’s)
on three patients on your telemetry unit. You have called him and are thinking about how o
discuss this with him in a positive manner, yet you know that he is not going to want to chat
because it is about time for him to get some rest.

If you said, “Why didn’t you put the I & O’s on the charts!?” the CAN would react defensively. If you
state, “How was your night? I noted that the I & O’s are not on the charts,” you have allowed the person
to respond with what happened. If this CAN went home early with the flu or the unit experienced three
codes, it would not be an effective or popular action to pounce on the team member for missing data.
This brings us to the next step in the process – giving credit for what has been accomplished. Let
us turn to Pat and Julia. At this point, Julia’s input has been received. Pat can state, “Well, I can see I did
not help you as much as I should have and I forgot to give you my beeper number. But I do want you to
know that I’ve checked on all of our patients, and they are very happy with their care today.”
 56

After hearing input and giving credit where it is due, exploration of the gaps in the relationships
and their communication and initial direction at the beginning of the shift can now be undertaken
with open and frank discussion.
The discussion of differences will progress most smoothly if each party recognizes that they share
common objectives: safe, effective care of the patients on their unit, as reflected in the fulfillment of
shared, planned outcomes or goals determined by collaborative discussion among patients and care team
members. When difficulties or conflicts occur, remember the reason you are both there: the
patients.
Julia and Pat may clarify what happened and what actions each may take to ensure that the missed
communication does not happen again in the future. Do not try to “fix” the situation for the other
individual or prescribe what you will do for them. The other individual will know what he or she
needs to do to achieve your shared outcomes. For example, Pat may have decided that what would fix
it for Julia would be to convene an hour before shift tomorrow and go through the unit manuals and read
procedures. However, the most Julia may need is a beeper number and some more discussion and
planning about assignments at the beginning of the shift.
Why wait for the other individual to come up with ideas when we can solve it for them? RNs who
lead teams throughout the nation tell us that their work lives would be much better if everyone were
behaving in an accountable manner. When we ask others for their step-by-step plan to prevent the
problem in the future, it helps them determine that they are accountable for their own performance. In our
scene with the missing I & O data, the RN will ask, “ How can you make sure those I & O’s are charted
before you leave in the future? What will work for you?” This type of statement confess the necessary
respect for the delegate’s ability to determine how to adapt his work performance.
Do not miss the final steps in the formula. The individuals must agree on how they will proceed in
the future and when they will revisit the problem or issue again. Julia may determine that she’ll remind
Pat in the future when she gets to the unit that she will need her beeper number and a plan for the day.
When the next shift is completed, they will want to compare notes about how the shift has proceeded and
whether patient outcomes have been achieved. The CAN may decide to ask the RN next week whether
she has noted any missing I & O’s. The pair will be able to evaluate whether the CNA’s charting plan has
been effective and can proceed to celebrate the success of the plan or to try other interventions.
ASSESSING YOUR DELEGATION SKILLS
Assemble these documents:
 Your state nurse practice act
 Your job description and those co-workers and delegates
 Skills checklists
 The patient list or assignment form from your unit
 A list of the usual staffing complement for your shift
1. Using the above, determine the short-term outcomes for an average patient assignment
based on the information you have been given in a report. What tasks could be delegated
to the individuals you have on staff? When will you complete further assessment of the
patient situations?
2. Based on the outcomes and job descriptions, how will you determine the competency of
individuals to complete the tasks you have determined could be delegated?
3. How will you communicate the team’s plan using outcomes in your discussion?
4. How often will you communicate with the delegates, based on their need for supervision
and patient complexity and dynamics? Have you used the four Cs?
5. How will you evaluate the effectiveness of your plan? How will you give positive
feedback to the team?
6. A mistake was made by a delegate. You determined the person was competent, but the
procedure was done improperly. For what are your accountable? How will you give
feedback to the individual, encouraging his or her growth and accountability?
7. Have you implemented the Four Rights of Delegation?
 57

Practice using the feedback formula. Remember the following three most important points:
 Ask for the other person’s input first.
 Give credit for the accomplishments and efforts.
 Ask the other individuals to come up with steps for resolving the issue.
How would you use this formula to tell a supervisor that you are concerned about how long it has been
since you have heard about your intershift transfer and you are getting worried about whether it will take
place? How would you give positive feedback to an individual on your team who has been improving his
ability to get out on time? What about a delegate who is “ missing in action,” the person you cannot seem
to locate when you need her?

Barriers to Effective Delegation

A. Internal Barriers (person delegating):
1.Lack of experience delegating
2.Lack of confidence in others
3.Personal insecurity
4.Demanding perfectionism
5.Poor organizational skills
6.Indecision
7.Poor communication skills
8.Lack of confidence in self
9.Fear of not being liked by everyone
10.Micromanaging management style
B. External barriers ( circumstances or person being delegated to):
1.Unclear policies about delegation
2.Policies that do not tolerate mistakes
3.Management-by-crisis model for facility
4.Unclear delineation of authority and responsibilities
5.Poor staffing
6.Lack of competence
7.Overdependence on the person delegating
8.Unwillingness to accept responsibility for one’s own practice
9.Immersion in trivia and gossip
10.Work overload
Sources: Fisher, M: do you have delegation savvy? Nursing 2000 (9): 58-59, 2000 Tappen, RM: Nursing Leadership and Management, ed. 4.
FA Davis, Philadelphia, 2001heeler, J: How to delegate your way to a better working life. Nursing Times 97 (36):34-35, 2001

As a leader: What Cannot Be Delegated?

o Overall responsibility, authority, accountability
o Authority to sign one’s name is never delegated
o Evaluating the Staff/or taking necessary corrective/ disciplinary action
o Responsibility for maintaining morale/encouragement of staff
o Too technical jobs and those that involves trust and confidence

Conclusion
We often hope for an exact prescription for what to delegate, when and how. Because nursing
assessment and professional judgment are necessary for clinical delegation, each situation will be
different. Whether you work in an intensive care unit in a large tertiary hospital or a rural long-term care
facility, the template of the delegation process – matching the right task with the right delegate,
communicating effectively, and offering and receiving feedback – will be similar.
 58

Name: _______________________________________ Section: ______ Date: ___________

Review Questions # 6: Please write the letter of your choice in the space before the number.

___1. It is getting the work done through subordinates.

a. Supervision b. Delegating c. Coordination d. Motivating

___2. It is designating a competent individual the responsibility of carrying out a specific group of
nursing tasks in the provision of care for certain clients.
a. Supervision b. Delegating c. Coordination d. Delegation

___3. They are considered professionals with state-sanctioned licenses governed by a nurse practice act.
a. BSN b. RN c. Staff Nurses d. Graduate Nurses

___4. This means, being answerable for what one has done, & standing behind that decision &/or action:.
a. Responsibility b. Liability c. Accountability d. Answerable

___5. The determination of what needs to be done & then the assessment if the task can be delegated to
someone.
a. Right Feedback c. Right Task
b. Right Circumstance d. Right Assignment

___ 6. The first source of information to know of what can and what cannot be delegated to someone.
a. Policies b. Law c. Job description d. Operating Guidelines

___7. This refers to appropriate client setting, available resources, and consideration of other relevant
factors.
a. Right Feedback c. Right Task
b. Right Circumstance d. Right Assignment

___8. The RN who is familiar with the situation must ask the correct questions to determine whether the
person is____________.
a. Committed b. Excellent c. Efficient d. Competent
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PATTERNS OF NURSING CARE DELIVERY

(Modalities of Nursing Care, Systems of Nursing Care, Care Delivery Models)
Every patient needs a nurse.
American Nurses Association
What Are The Effects Of Various Patterns Of Nursing Care Delivery?
Over the years, nursing care has been delivered in many ways, including total patient (private
duty model), functional, team, primary, and relationship-
based care.

TOTAL PATIENT CARE OR

PRIVATE DUTY MODEL
Originally nursing was organized around the total
patient care or private duty model. Registered nurses were
hired by the patient and provided care to one patient,
typically in their home. This approach was used in which
one nurse assumes responsibilities for the complete are of
the a group of patients on a 1:1 basis, providing total patient
care during the shift.
The quality of care in the total patient care model is
considered to be high, because all activities are carried out by Evolving patterns of nursing care delivery.
RNs, who can focus their complete attention on one patient.
This model is efficient because it (1) decreases communication time between staff caring for a patient, (2)
reduces the need for supervision, and (3) allows one person to perform more than one task
simultaneously. Patient satisfaction tends to be high with this model if continuity of care and
communication are maintained among nurses.

FUNCTIONAL NURSING
The movement to use RN as employees of hospitals came with the outbreak of World War II.
RNs took over the work in the hospital and that, coupled with the war effort, stimulated the nursing
shortage of that period. This forced hospitals to develop alternative models of nursing. The positions of
aides and licensed vocational/practical nurses came into being, and in some states, they allowed to
perform functions such as administration of medications and treatments.
This functional kind of nursing, which broke nursing into a series of tasks performed by many
people, resulted in a fragmented, impersonal kind of care.

Lines of Authority: Functional nursing

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Fragmentation of care caused patient problems to be overlooked, because they did not fit into a
defined assignment. This assembly- line approach provided little time for the nurse to address
psychosocial or spiritual needs. They cite a number of studies, which found that errors and omissions
increased when functional nursing was used. This approach would seem to be cost efficient, because it
can be implemented with fewer RNs. However, there are studies that suggest that the functional method
in fact, costs more than primary nursing care. In addition, patients, nurses, and physicians have been
critical of this approach because of the fragmentation and the lack of accountability for the total patient.

TEAM NURSING
In the 1950s, team nursing evolved as a way to address the problems with the functional
approach. In this type of nursing, groups of patients were assigned to a tram headed by a tram leader,
usually an RN, who coordinated the care for a designated group of patients. ( see figure below). The team
leader determines work assignments for the team on the basis of the acuity level of the group of patients
and the ability of the individual team members. The following is an example of the components of a team:
 An RN who is the team leader
 Two licensed vocational nurses/practical nurses assigned to patient care
 Two unlicensed assistive personnel (UAP)

Lines of authority: team nursing

The success of team nursing centers on good communication among the team members. It is
imperative that the team leader continuously evaluates and communicates changes in the patient’s
condition to the team members. The team conference is a vital part of this approach, allowing the tram to
assess the needs of their patients and revise their individual plans of care on an ongoing basis.

The team model allows the nurse to know patients well enough to make assignments that best
match patient needs with staff strengths. Patient needs are coordinated, and continuity of care may
improve, depending on the length of time and each member stays on the team. However, care can be
fragmented and the model ineffective when staff is limited. In addition, the amount of time required to
communicate among team members may decrease productivity.

PRIMARY NURSING
In this system, a nurse plans and directs the care of a patient over a 24-hour period. This approach
is designed to reduce or eliminate the fragmentation of care between shifts and nurses, because one nurse
is accountable for planning the care of the patient around the clock. Progress reports, referrals, and
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discharge planning are usually the responsibility of the primary nurse. When the primary nurse is off duty,
an associate nurse continues the plan of care.
An RN maybe the primary caregiver for some of the assigned patients and an associate nurse to
others. Some forms of primary nursing evolved into an all-RN staff (see figure below).

Lines of authority: Primary-care nursing

You may also find primary nursing being mixed and modified with nurse extenders, such as
paired partners, or partners in care. Although team nursing took the RN away from bedside care, primary
and modified primary care puts the nurse back in close contact with the patient.

Relationship-based practice is the new name for primary nursing. The RN, who may be called
the care coordinator, the responsible nurse, the principal responsible nurse, the case manager, or the care
manager, manages and coordinates patient’s care in the hospital and the discharge plan. This nurse
develops a relationship and can be identified by the patient, their families, and the health care team as
having the responsibility and authority for planning the nursing care the patient is to receive.

PATIENT-FOCUSED CARE
This is another delivery system that has evolved during the last 15 years. In this system, the
patient comes into contact with fewer people, and the RN, who is familiar with the patient’s plan of care,
supervises the delivery of care. This model also moves RNs to a higher level of functioning, because they
are now accountable for a fuller range of services for the patient. Tasks that do not require an RN can be
delegated to UAP under the supervision of the RN.

What is the Most Effective Model of Nursing Care?

There has been a great deal of literature about models of care delivery. However, there is lack of
systematic evaluation regarding the use of the various models, often because of the lack of similarity in
staffing and patient populations on comparison units. As a result, it is impossible to determine the impact
models of nursing care have on patient outcomes, costs, or job satisfaction. It may be that model of
nursing care delivery is less important than the other factors, including the nurse-to-patient ratios, use of
overtime, and the organizational structure in which the nurse works, in influencing outcomes. ?

Critical Thinking ?: What factors influence the patterns of nursing care delivery?

In today’s health care system, nurse managers continue to follow the trend of moving away from
the close supervision of the staff nurse’s work to a role of helping them complete their work safely and
effectively. As this role continue to evolve, the emphasis to highly supportive functions as are seen in the
leadership role.
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Comparison of Common Client Care Models

Model Nurses Are Description Where Model is Used

Called
Hospitals
Functional Charge Nurse Nurses are assigned to specific Nursing Homes
Medical Nurse tasks rather than specific clients Nursing Consultants
Treatment Nurse Operating Rooms
Nursing staff members are Hospitals
Team Team Leader divided into small groups Nursing Homes
Team member responsible for the total care of a Home care
given number of clients Hospice
Nurses are designated either as Hospitals
Primary nurse the primary nurse responsible for Specialty units
Primary Care Associate nurse clients’ care or as the associate Dialysis
nurse who assists in carrying out Home Care
the care.
Nurses are paired with other less- Hospitals
Modular Care Pair trained caregivers. Home health care
Generally involves cross training Transport team
of personnel.

What is the Impact of Staffing Patterns on the Quality of Care?

In 2004, the AHRQ released a report that summarized the latest findings of AHRQ – funded and other
research on the relationship between nurse staffing levels and adverse patient outcomes. This report
concluded that:
 Lower levels of hospital nurse staffing are associated with more adverse outcomes.
 Patients in hospitals today are more acutely ill than in the past, but the skill levels of the nursing
staff have declined.
 Higher acuity patients have added responsibilities that have increased the nurse workload.
 Avoidable adverse outcomes, such as pneumonia, can raise treatment costs by up to $28,000.
 Hiring more RNs does not decrease profit
 Higher levels of nurse staffing could have positive impact on both quality of care and nurse
satisfaction

The largest of these studies found significant associations between too few nurse on a unit and higher
rates of pneumonia, upper gastrointestinal bleeding, shock/cardiac arrest, urinary tract infections, and
failure to rescue. Other studies in the review found associations between lower staffing levels and
pneumonia, lung collapse, falls, pressure ulcers, thrombosis after major survey, pulmonary compromise
after surgery, longer hospital stays, and 30-day mortalities.

JCAHO data confirm the effect of insufficient staffing on the outcomes of nursing care. As of September
2004, insufficient staffing levels were listed as a cause in 64% of the sentinel vents that were entered into
the JCAHO database. Sentinel events are any unexpected occurrences involving death or serious
physical or psychological injury, or the risk thereof. Serious injuries specifically include a loss of limb or
function. The phrase “risk thereof” includes any variation in the process of care for which a recurrence
would carry a significant chance of a serious adverse outcome.
 63

Determination of the number of nursing staff needed relative to the number and acuity of patients on a
unit is the challenge of staffing. In the past 20 years, patient classification systems (acuity systems) have
been used to determine the number of nurses needed on a unit at any one time. Patient acuity is the
measure of a patient’s need for nursing care in a 24-hour period, considering the extent of each patient’s
illness. Patient classification systems, particularly with increased computerization and the ability to access
the system online, provide many benefits. Not only do they determine acuity (patient mix) and workload
for patient care units or specific clinical populations, they also (1) help managers determine how and
where staff spend time; (2) identify trends in patient population; (3) document staffing patterns and
workload and care practices; (4) effectively allocate limited resources; and (5) benchmark units to support
financial decisions.

How Are Nursing Work Assignments Determined?

Once appropriate staffing levels for a unit are determined, specific nurse must be scheduled. How work
assignments are given vary with individual institutions.

A major problem in scheduling nurses is the fact that patient acuity fluctuates
dramatically from day to day and from season to season.

For example, over the Christmas holidays there is often a significant decrease in the number of elective
surgeries. In response, some hospitals may close units or reduce the number of staff on any given unit. By
contrasts, in the middle of the influenza season, the hospital unit might be full and understaffed.
Nursing has tried a variety of approaches to anticipate the number and qualifications of nurses
that will be needed for a specific period of time for a specific group of patients. Regulatory agencies as
JCAHO require staffing be based on some sort of organized system. Staffing in organizations may be
based on budgeted nursing hours per day. Hours per patient per day are calculated by the number
of patient care staff working during a 24-hour period and divided by the number of patients served
in a day.
Whether nursing resource requirements are defined by nursing hours per patient days or as nurse-
patient ratios, the underlying assumption is that all patients, patient days, and nursing staff are equal.
However, the need for nursing care varies significantly among patients and over the length of each
patient’s stay in the hospital. As the intensity of patient care increases and length of stay decreases, hours
per patient day or nurse-patient ratio may not adequately express the resources needed.
The competencies of the staff also influence the numbers and types of staff needed. The
most accurate way of determining optimal staffing is through the judgment of an experienced nurse
who is knowledgeable about quality and fiscal management.

There were two approaches to document that the organization has a minimum number of nurses
to ensure safety in any given acute care unit: (1) establishment of a hospital-specific written staffing
plan, which typically uses computerized patient acuity systems as a basis and (2) identifying and
mandating fixed staffing ratios. A written plan should include the following factors:

 Establishing initial staffing levels that are recalculated at least annually or more often as
necessary
 Setting staffing levels on a unit by unit basis
 Identifying ways to adjust staffing levels from shift to shift, based on intensity of patient care
 Using outcomes and nurse-sensitive indicators to evaluate the adequacy of the plan

Written staffing plans should be developed by an advisory committee composed of a number of

registered nurses, a significant portion of whom are involved in direct patient care at least part
of the time.
 64

WHAT ABOUT SCHEDULING PATTERNS?

Nursing also always been concerned about scheduling practices and options because in many
health care environments, nursing care must be provided 24 hours a day, 365 days per year. That is why
there are numerous scheduling patterns other than the typical 8-hour shift 5 days a week. From working
10 hour days 4 days a week to the weekend alternative (known as the Baylor plan) of two 12-hour
weekend shifts for 36 hours of pay, nurses have tried numerous patterns and combinations of shifts.

WHAT ABOUT THE USE OF OVERTIME?

With the current shortage of health professionals, employees are also encouraged and sometimes
required to work overtime.
According to the National Sleep Foundation (NSF), a deficit of sleep can result in decreased
alertness, problems with completing tasks, reduced concentration, irritability, and unsafe action
and decision making. These problems known as “the fatigue factor” have an impact on the care
delivered by health care providers. Lack of sleep can also result in slower response times, altered mood
and motivation, and reduced morale and initiative.
The review of sleep studies in nurses found that self-reported alertness, performance, and job
satisfaction lessen with longer shifts. The risk for making an error greatly increased when nurses had
to work shifts that were longer than 12 hours, when they worked significant overtime, or when they
worked more than 40 hours per week.
The likelihood of making an error was three times greater when nurses worked that lasted
12.5 hours. Working overtime also increased the odds of making at least one error, regardless of
how long the shift was originally scheduled.
JCAHO has recognized problems associated with overtime, and in the 2002 white paper on the
nursing shortage, stated that mandatory overtime should only be used in emergency situations.

2. UTILIZING / REVISING/ UPDATING NURSING SERVICE POLICIES AND PROCEDURES

3. SUPERVISION – to inspect, guide, evaluate, improve work performance of employees

Managers at different levels of institutional hierarchy are referred to in different terms:

Top ----------- Administrator

Middle ----------- Supervisors

First Line ----------- Head Nurses/ Senior Nurses

Operating Level ----------- Staff Nurses/ Nursing Attendant

 65

Name: _______________________________________ Section: ______ Date: ___________

Review Questions # 7: Please write the letter of your choice in the space before the number

___1. An approach used in which one nurse assumes responsibilities for the complete care of the group of
patients on a 1:1 basis.
a. Functional nursing c. Modular nursing
b. Primary Nursing d. Total Patient Care or Private Duty Model

___2. Approach designed to reduce or eliminate the fragmentation of care between shifts and nurses,
because one nurse is accountable for planning the care of the patient around the clock.
a. Functional nursing c. Modular nursing
b. Primary Nursing d. Total Patient Care or Private Duty Model

___3. It is broke nursing into a series to tasks performed by many people, resulted in a fragmented,
impersonal kind of care.
a. Functional nursing c. Modular nursing
b. Primary Nursing d. Total Patient Care or Private Duty Model

___4. The new name for primary nursing.

a. Relationship-based practice c. Primary nursing
b. Patient-focused care d. Private Duty Model

___5. _____ in organizations may be based on budgeted nursing hours per day.
a. Scheduling b. Staffing c. Development d. Vacancy

___6. It is calculated by the number of patient care staff working during 24-hour period and divided by
the number of patients served in a day.
a. Nursing time needs c. Hours per patient per day
b. Nursing care d. Staffing and scheduling

___7. The _____ of the staff also influence the numbers & types of staff needed.
a. Education preparation c. Areas of assignment
b. Years of work experience d. Competencies

___8. This can result in decreased alertness, problems with completing tasks, reduced concentration,
irritability, and unsafe action and decision making.
a. Drug use b. Smoking c. Caffeine intake d. Deficit of sleep

___9. An element of directing that inspects, guide, evaluate, improve work performance of employees.
a. Communication b. Delegation c. Supervision d. Coordination

___10. The risk for making an error greatly increased when nurses had to work shifts that were longer
than _____ hours, when they worked significantly overtime, or when they worked more than ___
hours per week.
a. 8, 72 b. 12, 40 c. 12, 72 d. 8, 40
 66

4. COMMUNICATION - the transmission of information, opinions, and intentions between

and among individuals.
- It binds the organization together to ensure common under-standing

Purposes: * facilitate work * increase motivation * effect change

* optimize care * increase worker satisfaction and facilitate coordination

Lines of Communication

Downward – from superior to the subordinate which may pass through various levels.
e.g policies, rules and regulations, memos, handbooks, interviews, job descriptions, and
performance appraisal
Upward – emanates from subordinates to superior, usually in the form of feedback and does not flow as
easily as downward communication.
e.g. discussions between subordinates and superiors, grievance procedures written reports,
incident reports and statistical reports.
Horizontal – or lateral – flows from between peers, personnel or departments on the same level.
e.g. endorsements, between shifts, nursing rounds, journal meetings and conferences, or referrals
between departments or services
Outward – deals with information that flows from the care-givers to the patients, his family, relative,
visitors and the community.
e.g. information about the nature of their illness, medical and nursing plans of care

Communication can be enhanced by carefully choosing the words or information you wish to
convey, by creating an environment that promotes its acceptance, by avoiding preconceived opinions and
biases about a person, by listening to and understanding the other person’s point of view and by being
open and supportive. Most people learn to communicate through example.
Nurse managers should promote a responsive communication climate in their units.

EFFECTIVE COMMUNICATION AND TEAM BUILDING

To effectively communicate, we must realize that we are all different in the way we perceive the world and
us this understanding as a guide to our communication with others.
- Anthony Robbins
If you can laugh together; you can work together.
- Robert Orben

Communication is like breathing – we do it all the time, and the better we do it the better we feel.

At times communication can be so subtle; others are not

able to comprehend the sender. Communication between people in
everyday life is an exercise in subtleties and interpretations. The
more personal the information, the more indirect and obscure the
messages becomes. In nursing, indirect communications and
obscure terminology can be the difference between life and death.
When you say, “ I want to be clear when I communicate to others,”
it is not different from washing windows. The clearer the window,
the better we see. Communicating what we see, what needs to be
done, and teaching a client what they need to know is part of the
foundation of nursing care.
 67

THE COMMUNICATION PROCESS

What Are the parts of the Communication Process?

Communication begins with a person who creates a message on the

basis of his or her own perception of a situation. This person is the sender,
who transmits the message using words, actions, body language, tone of
voice, and facial expression. The message goes to a receiver , who has to
interpret and evaluate the message, including all the words and the signals.
When the receiver sends a message back to the sender to let the sender know
what to he or she heard or saw, that is called feedback. So communication is
basically the giving and receiving of information that involves responding
with meaning. Much of the skill involved in effective communication
involves how clear the message is. The actual words that are used are known
as the message’s content. Sometimes the words are very clear and the
message is easily understood. But at other times, the words might mean
different things to different people. The way in which the words are said may
also change how they are interpreted.

Different Ways Information can be Interpreted

TRY THIS…
1. How many different ways can you communicate this sentence to change its meaning?
“I do not care how you’ve done that procedure before; do it my way now.”
2. When the instructor says to you:
“ Come to my office at 2:00. There’s something I want to talk to you about.” What are some of the
possible interpretations of the message?
3. When a patient’s spouse says to you:
“I do not need your help when we go home.”
How many possible explanations can you come up with regarding the meaning of the communication?

We all know that spoken words make up what we call verbal communication. When we
include body movements, facial expressions, and tone of voice, we are adding the nonverbal
communication components that make up nearly 90% of the message. An angry voice and crossed arms
can change a friendly, supportive message to a hostile and critical one. The way we choose to
communicate is known as process. The process may clarify the message or confuse the receiver. Consider
the following one-pact play as an example:

Scene # 1

Susan has been working on a very busy surgical unit for 6 weeks since she graduated from nursing
school. She is approached by the dietitian, who says to her, “ I was so relieved when I got to the unit and
saw that you had already requested a dietary modification for Mr. Smith following his surgery. Imagine
that; I didn’t even have to tell you to do it.”
Scene # 2

Susan: “ Can you believe the arrogance of that dietitian? Just because she’s been here forever and I’m
new, does that give her the right to treat me like I’m a stupid third-grader? Nancy (another recent
graduate): “How do you know that’s what she meant?” Susan: “ I could just tell by the frustration in her
voice and how she moved away from me so quickly. It was as if she couldn’t stand to talk to me
anymore,”
 68

Scene # 3

Dietitian: “ Susan, I wanted to thank you again for your initiative yesterday with Mr. smith. I was having
a particularly stressful day, and the thought of having to do one more task just seemed to overwhelm me.
You really helped me out.” Susan: “I’m glad you said something about it. I wasn’t sure what you meant
then, and I feel much better.”

Huber ( 2000) suggests several reasons why communication fails to be effective that can be applied to our
one-act play. Nonverbal signals may mean different things to different people and can easily be
misinterpreted; so can the words we use. In addition, if we are short of time, it is hard to hear clearly and
remember pieces of important information. Finally, the personalities of the sender and the receiver may
create a bias or distortion of the message.

What Are The Basic Principles Of Effective Communication?

Here are some suggestions for improving our communication with others.
1. Communication is a process involving interaction between at least two people. Merely giving
information is not communication unless the opportunity for a response is given.
2. The sender has a responsibility to make the message as clear as possible. You can verify what has
been received by asking “Would you share with me how you interpreted what I just said?”
3. Whenever possible, use the simplest, most precise words you can. Your words must be
understood by the listener.
4. Encourage the receiver of your message to provide feedback so you can verify that the message
has been interpreted in the way it was intended. The receiver might say “ so, what you’re saying
is….” Or “Let me make sure I understand you..”
5. Remember that nonverbal behavior communicates a message even when words are not used. Try
to match your nonverbal behaviors to the feeling or tone of the message you want to send to
others.
6. Your reputation and credibility will make easier for you to communicate during difficult
situations. When you are trustworthy, reliable, and competent, people will listen more carefully
and be more likely to interpret your messages in a positive way.
7. Because communication is an interactive process, it is much more successful within the context
of a sound relationship. To create and maintain that positive relationship with others, you need to
acknowledge the needs, feelings, and contributions of others. This helps create a climate more
open to communication.
8. Whenever possible, communicate directly with the person you want to receive your message.
This allows for immediate feedback and verification and can reduce the chances of
misunderstanding.
9. Concentrate on the communication happening in the present. Avoid the temptation to daydream
or plan ahead what you might say or do next.
10. Be aware of your personal values and biases, and try to keep them from interfering with your
ability to communicate.
11. When you are caring for a patient in his or her home, be especially respectfully of the personal
nature of the surroundings.
 69

What Does My Image Communicate To Others?

Remember that old saying “ Do not judge a book by its cover”?
Unfortunately, we know that most people do not follow that suggestion. People get
impressions about us from the way we look, sound, talk, and act. Often we are less
careful about the messages we send with our appearance and behavior than we are
when we choose our words. But our image may speak louder than our words. Think
about it. Would you feel comfortable accepting nutrition advice from a 300-pound
nurse? How would you like it if your instructor criticized your professionalism while wearing dirty shoes,
a wrinkled uniform, bright red nail polish, and four earrings in each earlobe? What would you think about
a physician whose progress notes contain man misspelled words and poor grammar?
Communication is enhanced by your credibility. And people listen more to people they respect. Your
image will help you communicate your professional credibility. The place to start projecting a positive
image is with the first impression your appearances creates ( Vengel, 2000). Good personal hygiene is a
must. Each day you must pay attention to your grooming. This means a flattering, neat haircut; clean,
well-fitting clothes; reasonable makeup and perfume; minimal jewelry; and clean, sensible shoes. Your
image is improved greatly if your weight is appropriate for your height and bone structure. Your
appearance at work should conform to the norms for professionals in your work setting; save your
individuality for your personal time away from work.

Another aspect of your image is your depth and breadth of knowledge. You need to know your
particular area of nursing thoroughly if you want the respect of others. However, you also need to know
something about a wide variety of subjects so that you can have conversations with people beyond
nursing. This means keeping up with current events, learning things about art or sports, and reading
books. When people discover common interests, they are more willing to communicate with you.
Flexibility is necessary for effective communication with different kinds of people. This means that you
are willing and able to adapt your behavior to relate more comfortably or effectively with others.
Flexibility is part of a positive image because it says to people that you are willing to accept responsibility
for changing your behavior to meet the professional needs or requirements of others.
People who achieve success in their professional careers are enthusiastic. They let others know they are
happy to be at work. They work harder, longer, and more accurately. They are pleasant to be around.
They are sincere in their efforts to create a professional image that can be trusted.
Take an inventory of your appearance, knowledge, and attitude. If you are not sure what kind of image
you are communicating, ask several trusted friends.

What Are Facilitative Messages?

Two types of messages: facilitative and obstructive. Facilitative messages create a positive outcome in
which the people communicating with each other feel good about their interaction. It takes self-awareness
and practice to send facilitative messages, but it is worth it. Your relationships with other health care
workers will be satisfying and, ultimately, the patients you care for will benefit.

Strayhorn (1977, p. 7) summarizes the benefits of learning to use facilitative messages: “ If I can avoid
antagonizing the other person, make my wishes known, find out the other person’s wishes, explore
various options, and make decisions accordingly, then I am much better equipped to bring happiness to
others and to allow them to bring happiness to me.”

Facilitative Messages
Type Definition
1.I want statement Asks for a specific
behavior
Shares your feeling in
2.I feel statement response to the other
person’s specific
behavior
Indicates your pleasure
3.I like and I do not or displeasure with a
like statements specific behavior
Tells the other person
4.Reflection what you think you
heard so he or she can
verify or deny your
interpretation
Indicates general area
5.Open-ended of interest, but leaves
statement specifics to other
person
Refuses to argue by
6. Agreeing with agreeing or
part of a criticism sympathizing with
or argument some part of the
other’s statement
Allows you to ask what
7. Asking for more behaviors the critic
specific criticism didn’t like, what
behavior he or she
would like in the future
Names specific
8. Citing specific behaviors and events
behaviors and and describes them
observations without drawing
conclusions about
meaning
Asks the other person’s
9. Asking for reaction to what you
feedback have just said
10.You are good,
You did Conveys something
something good, was worthwhile
your something
is good statement
11.I intend Conveys independent
statement action the person plans
to take
Asks for postponement
12.Communication of a discussion until a
postponement more favorable time
Modified from Strayhorn JM Jr: Talking it out: a guide to effective communication and problem solving, Champaign, Ill, 1977, Research press, pp.
Example
“I want you to let me practice
this skill by myself and then
check me in 3 days.”
“I felt irritated jus then when
you told me to clean the
nurses’ station.”
“I like it when you told me I
did a good job with that
patient.”
“Sounds like that really upset
you.”
“Tell me your reactions to the
new medication cart.”
The head nurse has just said to
you, “You do not have any
sense.” You say, “ It’s true
that I could be smarter than I
am.”
The patient’s family says,
“You’re doing that all wrong.”
You reply, “what would you
like me to be doing instead?”
“I noticed during the meeting
that you weren’t saying much,
weren’t smiling. I’m
wondering what was going
on?
“I’m interested in how you
react to that idea.”
“You’ve really grown in your
ability to handle complex
situations.” “ That was good.”
“I intend to be more careful
about my charting.”
“I’m feeling hurt and angry
right now and would like some
time to think before we talk
more
53 – 76.
70
Effect
Simplest way to communicate
what you want within a
relationship.
Allows you to get in touch with
and share your feelings in a way
undistorted by assumptions
Helps define what would make
you happier; positive
reinforcement most effective in
changing another’s behavior.
Helps increase listening skills,
reduces distorted messages,
acknowledges feelings.
Offers attention and encourages
communication to begin.
Avoids wasting time arguing;
allows you to remember that you
do not have to be perfect;
focuses energy on negotiation of
wants
Turns an argument into an
opportunity for productive
negotiation; keeps anger at a
minimum
Allows the other person to hear
about his or her behavior and
clarify what specific behaviors
mean; reduces misperception
Allows the sender to be sure the
message was received as it was
intended; allows further
clarification
Draws attention to positive
aspects of the other person and
makes the other person feel
good, appreciated
Indicates the person accepts
responsibility for his or her
behavior
Allows you to be in emotional
control
 71

How Do Sex Differences Influence Communication Styles?

Men and women view their work environments from different
perspectives ( Vengel, 2000; Mindell, 2001). Men often see the world
from a logical, sequential, focused perspective. Women often tend to see
the big picture and to seek solutions based on what makes people feel
comfortable rather than on logic. Subtle communication differences can
create barriers to open, healthy communication between men and women
in the workplace. Men may ask fewer questions in a public situation,
especially if they feel that their questions might suggests ignorance.
Women seem to be more comfortable asking questions ( Mindell, 2001).
In fact, there are times when a person can benefit from remaining silent and looking up information later
in private so that others do not conclude that the asker lacks sufficient knowledge. At other times, a
person must be assertive and ask questions so that he or she does not threaten the health of patients.

Within the workplace, the dominant communication style is direct, confident, and assertive. This style
may be more familiar to men because they are often raised hearing more aggressive, direct language from
their parents, whereas many women may be more used to a soft, supportive tone of voice and choice of
words. Cultural values learned in childhood also play a role in the communication style a person chooses.
This style may have to be modified to make interactions more successful. A woman who is
communicating with a man may need to be more direct and
assertive than usual, whereas a man may need to learn to be
less aggressive in many situations.
Another sex difference in communication is related to
childhood experiences with sports. Men often grow up with
participation in team sports. They have worked toward a goal
and have learned to strategize together for the good of the
team, building a network of allies. Women have tended to be
less involved with team sports than men. Women are more
likely to have spent more time interacting with a few people
they really like who share similar values and behaviors.
Women are generally taught to be polite and to say nice things
about and to others, whereas men are encouraged to do
whatever it takes to help the team win. In the workplace, men
and women need to understand their different points of view
so that they can be team players and value cooperation and
respectful relationships with each other.
To summarize, men and women have innately different communication styles. Often developed from
childhood experiences. To be successful in the workplace, we all have to
learn as much as we can about communication differences, identify our
own styles, and have the flexibility to use other communication
techniques that call for it.

How Can You Improve Communications In Group Meetings?

Nurses participate in many meetings, from patient are conferences to

more formal committee meetings. Communication within a group of
people can be an opportunity to influence the quality of care given to
patients. When you participate as a member of a group, the following
are positive behaviors that will help you to communicate effectively and
will also help the group to accomplish its tasks more efficiently:
 72

 Come prepared. Bring all the “stuff” you need.

 Listen. Be open to other viewpoints.
 Keep on track. Do not visit or chit-chat.
 Present your ideas or opinions. Ask other members for theirs.
 State disagreements. Be able to back them up.
 Clarify when needed. Do not assume.

What Are The Responsibilities Of A Group Leader?

If you are the leader of a group meeting, you have additional responsibilities. If you are organized
and able to communicate effectively, the meeting is as much more likely to run smoothly. This is
especially important when you and your group members are busy. You cannot afford to waste time sitting
in an unproductive meeting. Nothing is as irritating as time spent arguing with others when you know
your work is piling up on your desk. If the irritation continues to build, you and the other group members
will be less committed to the goals of the group and some will even stop coming. The key to effective
meetings is the planning and organization that occurs before the meeting is actually held. Planning should
allow the leader to think through what the meeting is for, who should be there, and how it would run (
Huber, 2000). There should be a clear purpose for every meeting and every item on the agenda. Every
item should require some action by the group. If the purpose could be achieved in another way, such as by
making a telephone call or sending a memo, there should be no meeting.

It is the leader’s responsibility to send out an agenda ahead of time and to indicate any preparations that
members need to make or materials they need to bring. The leader must also be concerned with the room
where the meeting will be held. If you are making a formal
presentation, some audiovisual equipment will be
necessary, and chairs will need to be arranged so that
everyone can see the presenter and the audiovisuals. If the
meeting if for discussion and decision making, a table at
which everyone can sit face-to-face is more effective.
Look at the figure below. This type of note-taking clarifies
who is responsible for what activities. Ask for a volunteer
to keep track of the timeline information. At the conclusion
of the meeting, summarize the decisions, and identify the
plan of action. Review the timeline information for clarity
and understanding regarding group member responsibilities.
At the end of the meeting, the time should be established
for the next meeting. All members should receive a copy of the timeline information.

What Who When Completed

Schedule inservice on glucometer 8/28/05
Janet & Linda
Revise suction procedure 4/23/05 5/8/05
Sue & Bill
Review charting, and report back to next 4/1/05 5/16/05
unit meeting. Jom & Amy
 73

COMMUNICATION IN THE WORKPLACE

Sharing information with the members of the health care

team requires different approaches. This communication in a daily
basis may involve delegation of a nursing procedure, clarification
of a physician’s orders, reevaluation of a patient care assignment of
another health care team member, or coordination of various
hospital departments ( e.g radiology, dietary, pharmacy) to provide
nursing care.

How Can I Communicate Effectively With My Supervisor?

Upward communication with supervisor takes on a formal
nature. It is important to learn and then use the channels of
communication. If you are a team member, this means you share
information with your team leader. The team leader shares
information with the supervisor, the assistant vice president of nursing, and the vice president of nursing,
and so on. You can see that there are many levels of nursing between the bedside nurse and the people
with major decision-making responsibility.
Remember the point that messages can get very distorted when they travel through many people in the
upward flow of communication. Arrendo (2000) says it is important in communicating with superiors to
state needs clearly, explain the rationales for requests, and suggest the benefits to the larger unit. It is also
important to listen objectively to the response of the supervisor because there may be good reasons for
granting or not granting the request.
Arrendo ( 2000) gives the following tips for talking to your supervisor:
1. Keep your supervisor informed
2. If a problem is developing, make an appointment to talk it over. Have a specific information
available, especially written documentation of facts. Focus on problem solving, not just the
problems.
3. Show that you have important information to share and a sense of responsibility.
4. Be careful which words you use. Avoid blaming others, exaggeration, and overly dramatic
expressions.
5. Do not talk to your supervisor when angry, and do not respond with anger. Use “I” statements,
and explain what you think.
6. If you want to present a new idea, give your supervisor a written proposal, then meet to discuss it
after the supervisor has read it.
7. Accept feedback, and learn from it.
8. Never go above or around your supervisor. Always communicate directly with your supervisor
first before going further up the chain of command.

How Can I Communicate Effectively With Other Nursing Personnel?

When you speak with other professional nurses, you are
communicating in a lateral, or horizontal, flow of information. This flow is
based on a concept of equality, in which no person holds more power than
the other. This type of communication is best done in a work climate that
promotes a sense of trust and respect among colleagues. When nurses work
well together, their cohesiveness makes success more likely. This takes
work and the deliberate use of facilitative messages ( Northouse, 2001).
Ideally, professional nurses should view themselves as equals in their
interactions with members of other health care disciplines, and their
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approach to communication should be lateral one, even with physicians. At the basis of this
communication is the ability of the nurse to see himself or herself as competent and worthy of being an
equal to physicians, social workers, dietitians, and others. To gain this self-confidence is a major goal of
every recent graduate.

How Can I Communicate Effectively With Patient Care Assistant?

Even a recent graduate will soon be providing direction to licensed and unlicensed nursing
personnel. It is important to remember that these people have needs for satisfaction and self-esteem, too.
Directions do not need to be given in the form of authoritative commands unless an emergency demands
immediate action in a prescribed way. Marquis and Huston ( 2000) suggest that when you provide
direction, you need to think through exactly what you want to be done, by whom, and when. You need to
get the full attention of the other person so that you know he or she is hearing you accurately. You should
then give clear, simple instructions in step-by-step order, using a supportive tone of voice. Before the
other person goes to do the task, ask for feedback to verify that he or she has accurately heard
instructions. Finally, follow-up is necessary to be sure your directions were carried out and to find out
what happened, in case something more needs to be done. Involving personnel who are at other levels of
nursing care in the planning and evaluation of the care will increase their sense of responsibility for the
outcomes and will help you to seem less authoritarian.

How Can I Communicate Effectively By Using Technology?

Many of us are learning to use the technology that is changing our
workplace and making communication easier. Although cellular
telephones, fax machines, portable personal computers, modems, and
voice mail may be conveniences, they must be used thoughtfully to
make a positive contribution to your overall image as an effective
communicator. Deep and Sussman ( 1995) give the following tips for
the successful use of communications technology:

Do not misuse or overuse fax machines. Remember that the person on

the other end must read every page faxed to him or her, so be brief. If you need to send a long
document, use the mail. Send faxes only when you do not mind if the quality of the copy is not
first-rate, because many people have fax machines that print less clearly than computers or even
copying machines.

When you leave someone a voice-mail message, speak slowly and distinctly. This is especially
important when you are leaving your telephone number so that the other person can return your
call. It is frustrating to receive a message but not be able to understand the name or have to replay
the message to get all of the digits in the phone number. Make your voice-mail brief but complete,
saying when you called, what you want the other person to do, and when you can be reached.

Do not leave callers on hold if you are using call waiting. Explain to the first caller that you must
briefly answer another call, then take the number of the second caller, with the assurance that you
will call back as soon as you finish your first call. This interruption should take no more than 10
seconds. Be sure to write down the telephone number of the second caller so that you do not forget
it by the time you finish the first call.
When you call people, ask if they have time to talk and offer to call back at a more convenient time
if necessary. People appreciate the courtesy and will be more likely to have a positive conversation
with you if it is conveniently timed and is respectful of their busy schedule.

If you are conducting a conversation or a meeting with a speaker telephone or by means of a

teleconference, make sure that each party to the call is introduced to the other people. Do not
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use the speaker telephone unless you are including a group in the conversation. Even with a
conference call, there should be some structure to the discussion, including an agenda or a specified
purpose and time for the call.

When you have business cards printer, include your e-mail address and fax number. If you are
sending messages by e-mail, be sure to read your words carefully before sending them. Because
you are sending words without the benefit of clarifying nonverbal communication, the likelihood of
being misinterpreted is greater. Make sure your messages are as clear as they can be. Include your
name and subject in the e-mail note.

Do not send an emotional outbursts in an e-mail. These messages can seem more hostile then you
intended, and you can alienate or anger many people. If you cannot state your message in person,
then do not send it by email.

Learn to use basic computer software. Most people can effectively use fewer than half of the programs
to which they have access. Know how to use word- processing software. This is especially helpful in
making your communication easier and more credible.

When you need to send a personal message, especially a reminder or a thank you, the most
powerful way is to send a handwritten note. This conveys the importance you connect with the
message and continues the interpersonal aspect of the communication. If you need to communicate
something that you expect will have a real emotional impact, do it face-to-face. This communication
style has more force, too, but it also allows you an opportunity to read the other person’s nonverbal
communication and offers a chance to negotiate a comfortable understanding following your
message delivery.

ASSERTIVE STYLES OF COMMUNICATION

All of us have a style or way of communicating with others that is often based on our own
personality and self-concept. In other words, the kind of person we are and the way in which we see
ourselves influence the process of communication. This style can be divided into three common types:
passive or avoidant, aggressive, and assertive ( Marqyiz & Huston, 2000). The following are some
characteristics of each style.

Passive or Avoidant Behavior means that a person lets others push him around; does not stand up for
himself; does what he is told, regardless of how he feels about it; is not able to share his feelings or
needs with others; has difficulty asking for help; and feels hurt, anxious, or angry at others for
taking advantage of him.

Aggressive behavior means that a person puts his or her own needs, rights and feelings first and
communicates that in an angry, dominating way’ attempts to humiliate or “put down” other
people; conveys a righteous, superior attitude’ works at controlling or manipulating others; is seen
by others as punishing, threatening, demanding, or hostile; and shows no concern for anyone else’s
feelings.
Assertive behavior means that a person stands up for himself or herself in a way that does not violate the
basic rights of another person; expresses true feelings in an honest, direct manner; does not let
others take advantage of him or her; shows respect for other’s rights, needs, and feelings; sets
goals and acts on those goals in a clear and consistent manner and takes responsibility for the
consequences of those actions; is able to accept compliments and criticisms; and acts in a way that
enhances self-respect.

See if you can match the person with his or her style by using the descriptions you have just read.
 76

JANE

Jane is a very shy, quiet senior nursing student who can’t think straight when her instructor asks
her questions in the clinical area. She wishes she could be more like her classmates, who seem to
find it easy to talk about their experiences during clinical conference. During her evaluation. Her
instructor says she does not know enough theory and can’t handle the pressures of the clinical
unit. Jane says nothing and signs her evaluation. When she gets back to her room alone, she cries
uncontrollably.

SUSAN

Susan is a senior nursing students who is highly verbal with her classmates. She is known to be
opinionated and in every conference with her clinical group finds a chance to criticize someone.
She blames the nursing staff on the clinical unit for making her look bad by giving her too much
work to do and not enough time or help. When her instructor tells her she has not used enough
theory in her written assignments, she says, “ It’s not my fault; you should have told me sooner.”

MARK

Mark is a senior nursing student who is described by his clinical group as goal-oriented and
confident. He wrote learning objectives for himself at the beginning of the last clinical experience
and brought them with him, along with a self-evaluation, for his final evaluation conference. He
listened to his instructor’s suggestions, thanked her, and said,” I appreciate your concern for the
quality of my nursing skills. I’m aware now of what I need to pay attention to in my first few
months in my new job.”

If you decided that Jane used a passive or avoidant style, Susan used an aggressive style and Mark used
an assertive style, you were right. Congratulations!

WHY NURSES ARE NOT MORE ASSERTIVE?

It seems as though many nurses do not consistently act
or communicate in an assertive way. Some have a hard time
believing in their own rights, feelings, or needs. This difficulty
may have gotten its start in childhood through exposure to
many negative statements or experiences. It is important to
recognize that communication style is learned and reinforced
over time. While in nursing school and working in the nursing
profession, additional experiences or comments may reinforce
those negative messages about self-worth. It can be very
difficult to change behavior, especially when risk-taking is
necessary. The first step is to recognize what the barriers are.
What is it that prevents you from being more assertive? Is it
previously learned behavior, or are you afraid of the
repercussions of assertive communication? Check the list in
the Box below. If this list includes statements you feel are true,
then you have identified some roadblocks to your ability to
develop more assertive communication.

Look over this list of barriers to assertive communication and think about yourself. Do any of these
explain your feelings? Assertiveness takes self-awareness and practice. It will help you to identify and
 77

accept your position right now with regard to assertiveness so that you can make a plan to develop this
skill.
Barriers to Assertiveness
 Assertive communication should not threaten others.
 If you do not have anything nice to say, do not say anything at all.
 If you feel uncomfortable when presenting your position or stating your feelings, then you
are nonassertive.
 Assertiveness should come easily and spontaneously.
 Health care facilities do not promote or support assertive behavior.
 You cannot be assertive and consider another person’s feelings and behavior.
 Assertive behavior is just another way of complaining.
 If I am assertive, I will lose my job.
 There is no difference between assertiveness and aggressiveness.

What Are The Benefits Of Assertiveness?

Assertive communication is the most effective way to let people know what you feel,
what you need, and what you are thinking. It helps you to feel good about yourself and allows
you to treat others with respect. Being assertive helps you to avoid feeling guilty, angry,
resentful, confused, or lonely. You have a greater chance to get your rights acknowledged and
your needs met, which leads to a more satisfying life.

What Are My Basic Rights As A Person And As A Nurse?

As an adult human being, you have some legitimate rights. You may have to do some work to
allow yourself to believe in your rights. You may have learned other values that make it difficult to accept
the validity of these rights. But belief in your own value as a separate individual and confidence in the
positive concepts associated with assertiveness as a communication style will help you to believe in your
rights.
Consider the rights and responsibilities of the nurse. The issue of rights can become one-sided.
When nurses consider rights, responsibilities must also be included. These rights are yours as a registered
nurse; acquiring them and holding them are your responsibility ( Chenevert, 1988).

Changing one’s behavior requires a conscious decision.

How Can I Begin To Practice Assertive Communication?

There are a variety of ways to learn to be more

assertive in your communication style, but they all involve
self-awareness and practice. It may not feel totally comfortable
at first, but as you work at it, assertive communication will
come more naturally.

You should practice being assertive in a situation

where there is minimal risk to you, so that you can experience
success. If sharing your feelings with your instructor or head
nurse makes you extremely uncomfortable, set the situation
aside. You can work on it after you are more confident. Share
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your feelings and practice being assertive with someone with whom you are comfortable. Personal risk
should be at a minimum.

It is helpful to practice being assertive by yourself at first. Rehearse what you might say by
talking to yourself while looking in a mirror. Once you feel more comfortable, ask a friend to help you
practice. The two of you can role-play some assertive conversations. You may even want to videotape or
audiotape your practice so you can get an idea of how you look and how you sound. When you are ready,
try out your new assertive communication skills in a mildly uncomfortable situation you would like to
change. Pay attention to how you feel. Ask for feedback from the other person. You will then be able to
evaluate your progress and decide what other information you want to practice.

What Are The Components Of Assertive Communication?

When you communicate assertively, you are able to describe your own feelings and needs, listen to and
acknowledge the other person’s feelings and needs, define the problem clearly and nonjudgmentally, use
body language confidently, and negotiate a workable compromise ( Mindell, 2001).
Following are two ways to think about expressing your feelings and needs:

STRATEGY 1:
I think…
I feel…
I want….

STRATEGY 2:
I feel… about.. because…
Let us look at an example for each of these.
 I think we’ve been working every evening for 2 weeks on that report for the nursing office.
 I feel tired and cranky because I’m not paying enough attention to my family’s needs
 I want to ask someone else to write a section of the report.
 I feel hurt and angry about Dr. Jones yelling at me in front of you because I need to feel
competent and respected at work.

These statements can be successful when you maintain direct eye contact, stand up straight, and speak
in a clear, audible, form tone of voice. After expressing your own feelings and needs, it is helpful to seek
clarification of the other person’s feelings or needs. This can be done with the following questions:
“How do you feel about that?”
“What were you thinking and feeling at that time?”
“ How would that affect you?”

With skillful listening and clear communication, the problem can be defined without placing
blame or “putting down” the other person. Notice the use of “I” messages. That indicates willingness to
accept responsibility for the process of defining the problem and negotiating a workable solution. To find
a compromise, you have to be willing to meet the other person halfway. You may agree to try it your way
one time and the other person’s the next. Or you may both agree to change or give up something. You
may do something for him or her if she does something else for you. Remember that in the work setting
you cannot always have things exactly as you want them. You must be willing to change and compromise
( Elgin, 2000).
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When To Use Assertive Communication

Let us look at some examples of situations in which assertive communication would be helpful.

Communicating Expectations

Supervisor: “You’re being pulled to the unit and the

equipment unit today because they’re short-staffed.”
Nurse: “I expect to be oriented into the unit and the
equipment before I give nursing care because I
haven’t worked on that unit in more than a year.”

Saying No

Physician: “ Come with me right now. I need some help

doing a procedure on Mr. Smith.”
Nurse: “No, I can’t come with you right now. I ‘m doing a
nursing assessment on Mrs. Anderson. I’ll be
finished in 20 minutes and will help you then.”

Accepting Criticism

Head Nurse: “It seems to me that you aren’t very good at doing care plans, and they never done on time.”
Nurse: “I have been falling behind on my care plans. I would like to look at some examples of good care
plans. Do you think you could help me with that? I’d be willing to spend some time at home
reviewing them.”

Accepting Compliments

Home care patient’s spouse: “You give really thorough care. It’s obvious you know what you’re doing.”
Nurse: “Thank you. Your feedback is important to me.”

Giving Criticism

Nurse: “I want to talk with you about your care of Mrs. Samuelson. I found her sitting in a wheelchair
alone in the hallway. It is your responsibility to make sure that she is not left alone, so that
nothing happens to her.”
Aide: “I do not think that’s my job.”
Nurse: “We talked about your responsibilities this morning when you got your assignment. I expect you to
complete your assignment as directed or ask for help.”

Providing Feedback

Head Nurse: “ I wanted to tell you that I have noticed an improvement in your relationship with Dr.
Turner. He has not complained about his patient’s care fro 2 weeks, and yesterday he told me
that he had a satisfying discussion with you about home health care options for Mrs. Atkins.”
Nurse: “Thank you. I have been working very hard at not responding angrily to his sarcastic comments
and criticisms.”
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Asking for Help

Nurse: “It is hard for me to do this because I expect myself to care for all patients without difficulty. But I
am having a hard time with Mr. Jones. He seems to have a way of pushing my buttons so I get
angry.”
Community health Nurse Supervisor: “Are you asking me for something?”
Nurse” “Yes, I need help in understanding why I get so angry at him, and I want to know how to handle
him in a more positive way.”

Remember that you need to evaluate how your assertive communication feels to you and you need
to seek feedback from other people about how you are being interpreted. You need to know whether
people perceive you as aggressive rather than assertive. It may mean modifying your communication to
make sure you are standing up for yourself without violating the rights of others.

It should also be noted that some situations will not get resolved just because you communicated
assertively. Finding a workable solution is a process involving other people who must take responsibility
for their own feelings and needs. When others are unable to acknowledge their feelings, to listen, or to
negotiate a compromise, your assertive communication may make you feel better about yourself but may
not produce an immediate solution. But keep trying. Persistence pays off.

Remember, too, that there are some situations in which you must simply follow orders. You cannot
always meet your own needs; you must do what a physician or your head nurse tells you to do.
Sometimes you must put side your own needs to meet the needs of the patients you are caring for.
However, your judgment will increase as you gain experience, and you will recognize ways to
communicate your needs and feelings, with the goal of improving the processes and procedures used in
your work setting.
_____________________________________________________________________________________

Critical Thinking Questions

1. A patient’s daughter comes to the nurse’s station and asks to speak to the nurse in charge. She is upset
and angry because her mother is very upset about her new diagnosis of cancer, yet the family of the
patient sharing the room is boisterous and laughing. How should a nurse leader handle this situation?

2. When patients and families are faced with a sudden hospitalization, tempers often flare and people are
much more sensitive to the length of time they must wait. Families may also be troubled by standard
rules in a hospital, such as visiting hours and policies. How can the nurse leader mitigate these
situations and use communication skills to keep these situations under control?
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Name: _______________________________________ Section: ______ Date: ___________

Review Questions # 8: Please write the letter of your choice in the space before the number

___1.Asserive behavior is characterized by:

a. apologizing frequently
b. Sarcasm
c. Standing up for one’s rights
d. blaming others

___2. A line of communication that emanates from subordinates to superior, and does not flow as easily.
a. Horizontal b. Upward c. Outward d. Downward

___3. A type of messages that create a positive outcome in which the people communicating with each
other feel good about the interaction.
a. Positive feedback b. Facilitative c. Obstructive d. Assertive

___4. Within the workplace, the dominant communication style is:

a. Non-direct, confident and assertive
b. Non-verbal, confident and assertive
c. Direct, confident and assertive
d. Assertive, Understandable and Sensitive to the needs

___5. Sharing information with the members of the health care team requires _________approaches.
a. Different b. Delegation c. Standardized d. Assertive

___6. A style of communication wherein the person lets others push him around.
a. Passive or avoidant c. Assertive behavior
b. Aggressive behavior d. passive – aggressive

___7. A style of communication where in the person stands up for himself in a way that does not violate
the basic rights of another person.
a. Passive or avoidant c. Assertive behavior
b. Aggressive behavior d. passive – aggressive

___8. Changing one’s behavior requires a ___________.

a. Decision making c. Other’s opinion
b. Conscious decision d. Willingness and acceptance

___9. This the most effective way to let people know what you feel, what you need, and what you are
thinking.
a. Assertive communication c. Aggressive communication
b. Passive communication d. Openness and Honesty in communication

___10. When you communicate _________ you are able to describe your own feelings and needs, listen
to and acknowledge the other person’s feelings and needs, define the problem clearly and
nonjudgmentally.
a. Aggressively c. Assertively
b. Directly and clearly d. Actively
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5. COORDINATION
- synchronization of activities with the various services and departments enhances collaborative
efforts resulting in efficient, smooth and harmonious work flow.
- coordination also prevents overlapping of functions, enhances good working relationships and
work schedules are finished on time.

e.g. Coordination with the Medical Service, Administrative Service, Laboratory Service
(Nothing by Mouth After Midnight For Fasting Blood Sugar in AM ),
Radiology Service ( For Chole-GI Series in AM! Pls. withhold Breakfast Until After Exam),
Pharmacy Service, Dietary Service, Medical Records, Community Agencies, Other Institutions and
Civic Organization

6. STAFF DEVELOPMENT

7. DECISION MAKING -A decision is a course of action that is consciously chosen from available
alternatives for the purpose of achieving a desired result.

Real World Interview

To retain our staff and to improve the quality of our client care, we must provide support to
our novice nurses by implementing a mentorship program in our hospital to provide an
ongoing support to develop their skills in problem solving, decision making, and
prioritization.
Terry Kuula
Director

Most people rise to the top of their chosen careers share a common characteristics:
They are decisive. They make decisions and are not afraid to take risks.

Factors Influencing Decision Making

As nurses, we need to have working knowledge of what drives individuals ( i.e. our peers and
our clients) to make choices that set up the cascade of courage, greatness, and autonomy vs. caution,
maintenance, and dependency.

a. Personal Perception and Preference

Understanding how we perceive problems in clinical practice or in our professional lives
helps us to see how we can influence our personal preference in decision making.
b. Knowledge and Experience
Increased knowledge and experience yielded more systematic data acquisition and greater
diagnostic accuracy. Difference in diagnostic accuracy was attributed to the ability of the
expert nurse to intuitively determine the correct region for the assessment, select relevant
data, and recognize the changing relevance of cues as the situation evolves.
c. Competence
Campbell and Mackay ( 2001) identify three concepts as they define competence:
a) The ability to practice in a specific role
b) The influence of the practice setting on competence
c) The integration of knowledge, skills, judgments, and abilities.
Despite these definitions, no single universal definition exists of nursing competence.
Nurses practice individually and in groups, in a wide array of clinical, nonclinical, and
nontraditional settings. What is common to all nurses is the need to make clinical and
professional decisions in their practice. To be effective decision-makers, nurses must
have a solid anchoring in the core competencies related to entry to practice and must
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possess knowledge and abilities related to problem solving and decision making, which
have been integrated into professional practice.
e. Self-confidence
Is a term used to describe how secure people are in their own decisions and actions.
Perceptions of being less intelligent, less educated, and less competent result in
relinquished authority to those perceived as being better. This observation plays itself out
of many units within health care facilities on a day-to-day basis. In nursing, one has to
“earn one’s stripes” by gaining the confidence and the respect of one’s peers. New
graduates and new nurses joining an established team often feel that there is a need to
prove themselves in order to be accepted by the more senior staff. Nurses who possess a
high degree of confidence believe they have the competence ( i.e. the knowledge,
judgment, and skill) to perform an action correctly or achieve some specific goal.
Confident and competent nurses usually have little difficulty making clinical
decisions, such as starting an intravenous in urgent/emergent situations, referring a client
to social work, or ordering a pressure-reduction overlay mattress. Self-confidence is
learned through repeated successful application of the decision-making process.
Decisions that require courage, autonomy, and greatness, and result in positive client
outcomes become strong motivators to support decision making. Decisions that illustrate
caution, dependency, and maintenance have less intrinsic reward for the nurse, and
therefore such decisions have little ability to motivate continued decision making. The
outcome can be a lack of self-confidence, which is reinforced with every missed
opportunity for decision making.
f. Stress
Stress arises when individuals perceive the environment to be demanding, because it
exceeds their resources and threatens their personal well-being. Situations can be an
anxiety-provoking for some and stimulating for others, depending on how people
perceive the environment. Generally speaking, nurses with a internal locus of control in a
clinical setting perceive opportunities to influence outcomes for their clients, other
nurses, and the organization. This approach leads to a greater sense of personal job
satisfaction and reduction of stress. Staff with an internal locus of control believe that
external events and people are in control, and that they have very little choice over
deciding their future. Moderate amounts of stress are required for optimal thinking.
However, long-term effects of functioning within highly stressful environments, such as
today’s health care settings, include stereotypical, unimaginative thinking,
overgeneralization, and loss of interest. Nurses identified the following factors as
producing the greatest stress: interpersonal conflict, inadequate staffing, lack of support
when dealing with death, and physical environment. In 2007, the nursing profession
found that stress is a constant and results in higher rates of job strain, lack of job
satisfaction, and higher illness rates among nurses. These results do not bode well for the
future of nursing. Consequently, nurses and employers need to collaborate to create and
maintain practice environments that support effective decision making at the point of care
and thereby contribute to a high sense of job fulfillment and autonomy for nurses.
g. Extrinsic Factors
g.1 Organizational climate and culture
g.2 Client choice and rights
g.3 Legislation and Regulation

Consideration of regulatory legislation, professional standards, best practice

guidelines, and organizational policies and procedures is foundational to effective
 84

clinical decision making. Thus nurses must have knowledge and understanding of the regulatory
framework that governs their practice, and they must understand other regulatory practice requirements
defined in other types of legislations ( e.g. Laws that Affect the Nursing Practice).

Decision Making – as a behavior exhibited in ‘making a selection and implementing a course action from
alternatives. It may or may not be the result of an immediate problem’. Both decision making and
problem solving use critical thinking.

Critical Thinking - is analyzing the way one thinks. It should be incorporated into all steps of problem
solving and decision making.

Critical Thinking

Decision Problem
making solving

In everyday practice, nurses make decisions about client care. As nurses gain experience in clinical
practice, decision making becomes more automatic, but the complexity of many decisions remains.

5 Steps in the DECISION- MAKING PROCESS

Step 1. Identify the need for a decision

Step 2. Determine the goal or outcome
Step 3. Identify the alternatives or actions along with the benefits and consequences of each action.
Step 4. Decide which action to implement.
Step 5. Evaluate the action.

CLINICAL APPLICATION

Your client is on droplet precautions because he has been diagnosed with tuberculosis. As per
hospital policy, only two visitors are allowed at a time to see the client. No children under 12 years of age
 85

are allowed. The client doe not speak English, and his family speaks very little English. You have noticed
on two occasions that his visitors were not wearing masks. You inform the family about the importance of
infection control practices and remind them of the hospital’s policy regarding visitors. The family
indicates to you that their grandfather really wants to see his 4-year-old grandson, who came to visit him
from another province. Use your decision-making and problem solving skills to help you decide what to
do.

Step 1: Identify the need for a decision. Should you allow the grandson to visit? Consider all the
information ( e.g. the hospital policy, professional practice standards, the client’s wishes, and the
client’s anxiety level).
Step 2: Determine the outcome. What is the goal? Consider the following questions: Can an exception to
hospital policy be made? Is the goal to allow the client to see his grandson? Will the client and his
family be satisfied?
Step 3: Identify all alternative actions and the benefits and consequences of each. If you enforce hospital
policy, the benefits are that all clients are treated equally and the written policy supports the
decision. The consequences are that the client and his family may not be satisfied, and the
grandson and grandfather may be upset. In addition, the grandson’s health may be at risk. The
alternative is to allow the grandson to visit. The benefits are that the client’s level of anxiety will
decrease, and the client and his family will be satisfied. The consequence is that the precedent is
set that may make it difficult to enforce the existing hospital policy.
Step 4: Arrive at the decision. Consider the two alternatives and the benefits and consequences of each.
Make the decision and implement it.
Step 5. Evaluate the decision. Was the goal achieved?
From the beginning of their careers, new graduate nurses are faced with the responsibility of
making decisions regarding client care. Beginning nurses commonly have more questions than answers.
When nurses are faced with a difficult clinical decision, Marquis and Huston ( 2006) recommend
consulting with others, such as other RNs on the unit or supervisors, as early as possible. Depending on
the situation, recognize that you have knowledge and intuition that are valuable. With more experience
comes greater trust in your decision making.

MANAGEMENT APPLICATION

Nurse managers sometimes face complex decisions.

Decisions related to budget are common in our current health care
environment with its emphasis on cost containment and quality
maintenance. Disciplining an employee also creates a complex
situation in which nurse managers must make decisions regarding
the employee’s future. A decision-making grid may help to separate the multiple factors that surround a
situation.
A decision making grid by managers who were told they had to reduce their workforce by two
full-time equivalents (FTE’s). This grid is useful to visually separate the factors of cost savings, effect on
job satisfaction. The manager needs to determine the priorities when developing a grid.

Sample Decision-Making Grid.

Methods of Reduction Cost Savings Effect on Job Effect on Client
Satisfaction Satisfaction
Lay off the two most senior full- $ 93,500 Significant reduction Significant reduction
time employees
Lay off the two most recently $ 63,200 Significant reduction Moderate reduction
hired full-time employees
Reduce by staff attrition $ 78,000 Minor reduction Minor reduction
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A decision-making grid is also useful when a nurse is trying to decide between two choices. Below is an
example of a decision grid used by a nurse deciding between working at hospital A or hospital B.

Sample Decision-Making Grid for Weighing Options

Elements Importance Score Likelihood Score Risk
(out of 10) (out of 10) (multiply scores)
If I work at hospital A
Learning Experience 10 10 100
Good mentor support 8 8 64
Financial reward 6 6 36
Growth potential 8 8 64
Good location 10 10 100
Total 364
If I work at hospital B
Learning Experience 8 8 64
Good mentor support 7 7 49
Financial reward 8 8 64
Growth potential 9 9 81
Good location 6 6 36
Total 294

The Program Evaluation and Review Technique (PERT) is useful in determining the timing of decisions.
An advantage of the PERT diagram is that participants can visualize a complete picture of the project,
including the timing of decisions from beginning to end.

The flowchart provides a visual picture depicting the sequence of tasks that must take place to complete a
project.
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DECISION TREE
A decision tree can be useful in making the alternatives visible.

A decision tree to reduce motor-vehicle crash fatalities.

Key numbers represent the figure that event will occur.

Whether to have a Sweetheart

Decision

Advantages Disadvantages
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.

GANTT CHART

A Gantt chart can be useful for decision-makers to illustrate a project from beginning to end.

Gantt chart used to show the progression of a nursing unit’s pilot project.
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SWOT ANALYSIS: S – Strength, W – Weakness, O – Opportunities, T – Threat

GROUP DECISION MAKING

Today’s leadership and management styles include people in the decision-making process who
will be most affected by the decision. Decisions affecting client care should be made by those groups
implementing the decisions. The effectiveness of groups depends on the group’s members. The size of
the group and the personalities of group members are important considerations when choosing
participants. More ideas can be generated with groups, thus allowing for more choices, which increases
the likelihood of higher-quality outcomes. Another advantage of groups is that when followers
participate in the decision-making process, acceptance of the decision is more likely to occur.
Additionally, groups may be used as a medium for communicating the decision and its rationale. A major
disadvantage of group decision making is the time involved. Without effective leadership, groups can
waste time and be nonproductive. Group decision making can be more costly and can also lead to
conflict. Groups can be dominated by one person or become the battleground for a power struggle among
assertive members.
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Advantages and Disadvantages of Groups

Advantages Disadvantages
 Easy and inexpensive way to share information  Individual opinions influenced by others
 Opportunities for face-to-face communication  Individual identify obscured
 Opportunity to become connected with a social  Formal and informal role and status positions
unit evolve- hierarchies
 Promotion of cohesiveness and loyalty  Dependency fostered
 Access to a larger resource base  Time-consuming
 Forum for constructive problem solving  Inequity of time given to share individual
 Support group information
 Facilitation of esprit de corps  Existence of nonfunctional roles
 Promotion of ownership of problems and  Personality conflicts
solutions

TECHNIQUES OF GROUP DECISION MAKING

NOMINAL GROUP TECHNIQUE

Step 1: No discussion occurs: group members write out their ideas or responses to the identified
issue or question posed by the group leader.
Step 2: Presentation of the ideas of the group members along with the advantages and
disadvantages of each. (Presented on a flipchart or a whiteboard).
Step 3: Offers an opportunity for discussion to clarify and evaluate the ideas.
Step 4: Private voting on the ideas. Ideas receiving the highest rating are the solutions implemented.

DELPHI GROUP TECHNIQUE

This differs from nominal technique because the group do not meet face to face. Questionnaires
are distributed to group members for their opinions, and the responses are then summarized and
disseminated to the group members. This process continues for as many times as necessary for the group
members to reach consensus. An advantage of this technique is that it can involve a large number of
ideas.

CONSENSUS BUILDING
Consensus is defined by the The American support the Heritage Dictionary (2000) as “ an opinion or
position reached by a group as a whole; general agreement or accord”. A common misconception is that
consensus means everyone agrees with the decision 100%. Consensus means that all group members can
live with and fully support the decision regardless of whether they totally agree. This strategy is useful
with groups because all group members participate and can realize the contributions each member makes
to the decision. A disadvantage – decision making requires more time. This strategy should be reserved
for important decisions that require strong support from the participants who will implement them.
Consensus decision making works well when the decisions are made under the following conditions:
 All members of the team are affected by the decision
 Implementation of the solution requires coordination among team members
 The decision is critical, requiring full commitment by team members
Although consensus can be the most time-consuming strategy, it can also be the most gratifying.

GROUPTHINK
Groupthink and consensus building are different. In consensus, the group members work to
support the final decision, and individual ideas and opinions are valued. In groupthink, the goal is for
everyone to be in 100% agreement. Groupthink discourages questioning and divergent thinking. It hinders
creativity and usually leads to inferior decisions. The potential for groupthink increases as the
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cohesiveness of the group increases. An important responsibility of the group leader is to recognize
symptoms of groupthink. Examples of these symptoms are:
o Group members develop an illusion of invulnerability, believing they can do no wrong.
This problem has the greatest potential to develop when the group is powerful and group
members view themselves as invincible.
o Stereotyping outsiders, which occurs when the group members rely on shared stereotypes
– such as, all Democrats are liberal or all Republicans are conservative – to justify their
position. People who challenge or disagree with the decisions are also stereotyped.
o Group members reassure one another that their interpretation of data and their perspective
on matters are correct regardless of the evidence showing otherwise. Old assumptions are
never challenged, and members ignore what they do not know or what they do not want
to know.
Strategies to avoid groupthink include appointing group members to roles that evaluate how group
decision making occurs. Group leaders should encourage all group members to think independently and
verbalize their individual ideas. The leader should allow the group sometime to gather further data and
reflect on data already collected. A primary responsibility of the managers or the group leader is to
prevent groupthink from developing.

LIMITATIONS TO EFFECTIVE DECISION MAKING

Past experiences, values, personal biases, and preconceived ideas affect the way people view
problems and situations. Incorporating critical thinking into the decision-making process helps to prevent
these factors from distorting the process. Pitfalls to effective decision making:
 Making the decision based upon the first available information
 Being comfortable with the status quo or not wanting to rock the boat
 Making decisions to justify previous decisions even if those decisions are no longer satisfactory
 Pursuing supporting evidence that verifies the decision while ignoring evidence to the contrary
 Presenting the issue in a biased manner or with a leading question
 Assigning inaccurate probabilities to alternatives

USE OF TECHNOLOGY IN DECISION MAKING

The best source of clinical decision making and judgment is still the professional practitioner; however,
computer technology can be used to support information systems, including decision making, for
managers. Patient classification systems inventory control, scheduling staff, documentation of client care,
order entry for tests, appointments and changes in policies and procedures are but a few examples of how
computers can assist managers with tracking the information needed in a management role. Computer
software for the clinical practitioner is available for clinical decision making and should be carefully
critiqued prior to use.

NURSES’ ROLE IN CLIENT DECISION MAKING

In today’s world, clients are taking a more active role in treatment decisions. Consumers of health
care are more knowledgeable and have more options than in previous years. Nurses must be aware of
clients’ rights in making decisions about their treatments, and they must assist clients in their decision
making. When clients are active participants, compliance with prescribed treatments is more likely to
follow. Empowering the client in this manner ultimately promotes a more positive outcome.

STRATEGIES TO IMPROVE DECISION MAKING

Comfort with decision making improves with experience. Early in the nurse’s career, the nurse is
commonly indecisive or uncomfortable with decisions. Several strategies that help to improve critical
thinking, eventually will also help improve decision making:
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o At times, delaying a decision until more information is obtained may be the best
approach. Asking “why”, “what else”, and “what if” questions will help you arrive at the
best decision. When more information becomes available, decision can be revised.
o Anticipate questions and outcomes. For example, when calling a physician to report a
client’s change in condition, the nurse will want to have pertinent information about the
client’s vital signs, lab values, and current medications readily available.
Nurses who practice strategies to promote their own critical thinking will, in turn, be good decision-
makers. A foundation for good decision making comes with experience and learning from those
experiences. By turning decisions with poor outcomes into learning experiences, nurses will enhance their
decision-making ability in the future.

DOS AND DON’TS OF DECISION MAKING

Do Don’t

Make only those decisions that are yours to make. Make snap decisions.

Write notes and keep ideas visible about decisions Waste your time making decisions that do not have
to utilize all relevant information. to be made.

Write down pros and cons of an issue to help Consider decisions a choice between right and
clarify your thinking. wrong but a choice among alternatives.

Make decisions as you go along rather than letting Prolong deliberation about decisions.
them accumulate
Regret a decision; it was the right thing to do at that
Consider those affected by your decision. time.

Trust yourself. Always base decisions on the “way things have

always been done.”

Source: Adapted from the Small Business Knowledge base, 1999. Retrieved February 19, 2002, from http://www.bizmove.com

Key Concepts
 The ever-changing health care system calls for nurse to be effective decision-makers. The ability
of nurses to make appropriate decisions will affect their employer’s ability to survive.

 A good critical thinker is able to examine decisions from all sides and take into account varying
points of view. Use of the universal intellectual standards will improve a nurse’s critical thinking.

 Practising reflective thinking helps individuals become better critical thinker.

 Decision-making grids may be helpful to separate multiple factors during the decision-making
process.

 The PERT model is useful for determining the timing of decisions.

 In some situations the nurse manager makes an individual decision. Other decisions call for
group decision making.
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 To be an effective decision-maker, individuals must identify and avoid certain traps during the
decision-making process.

 The nurse must recognize the importance of empowering clients in making their own treatment
decisions. The nurse needs to provide the client with information and assist the client to explore
all possible options.

 Many strategies can be used to improve your decision making. Obtaining all the information,
asking yourself “why” and “what if” questions, and developing good habits of iniquity are a few
of the strategies that will help improve your decision-making skills.

Real World Interview

One of my clients at night on the medicine unit was complaining of a vague chest pain. I assessed him and was not
sure what caused his discomfort. I phoned the physician-on-call and was advised that he was busy in emergency and
would come to see the client as soon as possible. Then I called the Rapid Response Team (RRT) to assess the client.
The RRT arrived and completed an ECG; it showed minor ischemic changes. The RRT informed the physician-on-
call of the changes in the ECG. The client was prescribed nitro for his angina. I was glad that I listened to my gut
instinct and decided to call the RRT, instead of waiting for the physician to see the client. The problem was
diagnosed early enough to prevent further damage to the client’s heart. I felt I made the right decision by calling the
Rapid Response Team.
Mara Lopez, RN
New Graduate

Real World Interview

I often find decisions about disciplinary action the most difficult ones to make. But, when I use a decision-making
model, it helps me make the best decision. My goal in the decision-making process is often twofold – to help the
nurse to learn from the experience and to provide the nurse with appropriate tools to prevent similar mistakes
happening in the future.
Erica
Nurse manger Intensive Care Unit

Critical Thinking Question

1. You are a new nurse manager and have been in your position for two months. You are working on the
holiday schedule, and the unit secretary with the most seniority comes to you and says that she needs
both the week of Christmas and the week of New Year’s Day off because she will be out of town. You
remind her that hospital policy does not allow employees to have both holidays off. The secretary tells
you that the previous manager always approved the request and that she has already bought plane
tickets. Apply the steps of decision making to this situation.

2. You are a manager of a 12-bed surgical unit. Your supervisor informs you that 12 more beds will be
opened for neurosurgical clients, and you are to be the manager. Draw a PERT diagram to depict the
sequence of tasks necessary for the completion of the project.
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Name: _______________________________________ Section: ______ Date: ___________

Review Questions # 9: Please write the letter of your choice in the space before the number

___ 1. Decision making is best described as the process one uses to

a. Solve a problem c. reflect on a certain situation
b. Choose between alternatives d. generate ideas

___2. Occasionally, making a decision is difficult because of the multiple factors that surround certain
situations. To separate these factors, the nurse manager may utilize a
a. Decision grid c. Delphi group technique
b. Nominal group technique d. Consensus strategy

___3. Which of the following is the best description of consensus?

a. Everyone in the group agrees with the decision 100 percent.
b. All members of the group vote on the selected action.
c. Every group member compromises
d. Every group member fully supports the decision, once it is made

___4. It has been found that nurses identified the following factors as producing great stress:
a. Interpersonal conflict, inadequate staffing, lack of support, overgeneralization
b. Loss of interest, Interpersonal conflict, inadequate staffing, lack of support
c. Interpersonal conflict, inadequate staffing, lack of support, physical environment
d. Unimaginative thinking, loss of interest, inadequate staffing, physical environment

___5. A term used to describe how secure people are in their own decisions and actions.
a. Self-reliance b. Self-efficacy c. Self-confidence d. Self-dependence

___6. An analyzation of what one thinks that should be incorporated in all steps of problem solving and
decision making.
a. Decision making b. Critical thinking c. Problem solving d. Analysis

___7. Which of the following is a symptom of groupthink?

a. The group members continually disagree with one another.
b. The group members cannot come to a decision.
c. The group members stereotype outsiders.
d. The group members share a common bond.

___8. Nurses who practise strategies to promote their own critical thinking will, in turn, be good decision
makers. a. True b. False c. Not sure

___9. This can be useful for decision makers to illustrate a project from beginning to end:
a. Gantt Chart b. Decision Tree c. Nominal Group d. Delphi Technique

___10. They still remains to be the best source of clinical decision making and judgment:
a. Patient’s condition c. Professional practitioner
b. Patient classification system d. Policies and procedures
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8. MOTIVATING

MOTIVATION
Is a skill in aligning employee and
organizational interest so that behavior results in
achievement of employee wants simultaneously with
attainment of organizational objectives.

Many managers claim that motivating employees is their

most difficult daily task. Managers must stimulate
workers to release their energies constructively toward
the accomplishment of assigned tasks.

Common practical problems encountered by managers include the following:

1. Employees often differ in their needs.
2. Managers often don’t, or may not accurately perceive, what employees want
3. Managers have limited flexibility in offering economic rewards.
4. The reward that may prove to be most motivating for some people are often difficult to use.

Motivation is a function of understanding needs, tensions, wants, incentives, and a perception of the
environment.

2 Types of Needs: 1) Primary (physiological) 2) Secondary (social and psychological )

EMPLOYEE WANTS
The various types of human needs are converted by employees into specific “wants” in the
organization.

1. Pay. This want helps in satisfying physiological, security, and egoistic needs
2. Security of Job. Because of threats from technological change.
3. Congenial associates. This issues from the social need of gregariousness and acceptance.
Management can aid the process by carefully planned and executed induction programs,
provision of means to socialize through rest periods and recreational programs, and promoting the
formation of work teams through work-station layout and human-related work procedures.
4. Credit for work done. This issues from the egoistic classification of needs and can be supplied
by management through verbal praise of excellent work, monetary rewards for suggestions, and
public recognition through awards, releases in employee newspapers, and the like
5. A meaningful job. This issues from both the need for recognition and the drive toward
self-realization and achievement.
6. Opportunity to advance. Not all employees want to advance but
most like to know that the opportunity is there, should they desire to
use it. This feeling is influenced by a cultural tradition of freedom
and opportunity.
7. Comfortable, safe, and attractive working conditions.
8. Competent and fair leadership
9. Reasonable orders and directions
10. A socially relevant organization
These wants provide an array of motivational tools that managers may utilize to motivate
behavior toward desired directions. Motivational force is greatest if the wants is highly valued, if the
person feels capable of performing as specified, and if he or she perceives that the reward will
actually be allocated.
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IV CONTROLLING/EVALUATING
- the process by which managers attempt to see that actual activities conform to planned
activities
- performance is measured & corrective action is taken to ensure the accomplishment of
organizational goals

Basic Components
1. Establishing standards, objectives and methods for measuring performance
2. Measuring actual performance
Honest CORRECTION
3. Comparing results of performance with standards & objectives &
is appreciated more than
identifying strengths & areas for correction
flattery.
4. Acting to reinforce strengths or successes & taking corrective action
Proverbs 28:23
as necessary

Nature & Purpose

1. Establishes trust and commitment to the system by all personnel through the use of an effective
communication system
2. Clarifies organization & individual objectives
3. Presents uniform & fair standards with precise definitions of each standard, goal & objective
4. Compares expectancy with performance

EVALUATION OF MANAGEMENT
PERFORMANCE

A manager’s performance can be measured

by two criteria:

EFFECTIVENESS

Is defined by Peter Drucker, one of the most

respected writers in management, as “doing the right thing”

This means that a manager has the responsibility for selecting the right goal and the appropriate means for
achieving that goal. Thus, a manager needs to be able to select the right decision from among all
alternatives and then to select the right method from many methods for implementing that decision.

EFFICIENCY
Is measuring the cost of attaining a given goal. It is concerned with how resources (money, time,
equipment, personnel) are used to get the desired results. If the minimum cost is spent to obtain the
desired goal, the manager is being efficient.

The manager’s responsibilities require that she or he be both effective and efficient.
From an evaluation viewpoint, efficiency is important but effectiveness is vital. A manager who does
the wrong things (ineffectiveness) with minimum use of resources (efficiency) is not helping the
organization.

On the other hand, the manager who makes the right choices but may not have a completely smooth
operation as the change is implemented is, despite partial inefficiency, assisting the organization.
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Control Mechanics
1. Standards of Care
Yardsticks for gauging the quality and quantity of services. Established criteria of
performance, planning goals, strategic plans, physical or quantitative measurements of products,
units of service, labor hours, speed, cost, capital, revenue, program and intangible standards. An
acknowledged measure of comparison for quantitative or qualitative value, criterion or norm, a
standard rule or test on which a judgment or decision can be based.

2. Total Quality Management (TQM)

- A way of ensuring customer satisfaction through the involvement of all employees in learning
how to reliably produce and deliver quality goods and services.

Primary Goal: To improve internal and external customer satisfaction through quality control.

Components of TQM: 1. Quality Planning 2. Quality Teams 3. Quality in Daily Work

Principles of TQM 1. Customer Satisfaction

2. Management by Facts (“speaking with facts”)
3. Respect for People
4. P-D-C-A (Plan-Do-Check-Act)

The real meaning of Quality is TOTAL QUALITY which means:

* integrity of function and composition * doing “right things right”

The Quality Grid

Right Things Wrong Right Things Right

Ordered the right equipment Ordered the right equipment
but installed incorrectly and installed correctly

Wrong Things Wrong Wrong Things Right

Ordered the wrong equipment Ordered the wrong equipment but
and installed incorrectly installed correctly

3. Nursing Audit – an examination, a verification or an accounting of predetermined indicators.

The three basic forms are:

3.1 Structure audit – focuses on the setting in which care takes place: physical facilities,
equipment, caregivers, organization, policies, procedures and medical records are
measured by means of checklist.

3.2 Process audit – implements indicators for measuring nursing care to determine whether
nursing standards are met. Generally task-oriented

3.3 Outcome audit – evaluates nursing performance in terms of establishing client outcome
criteria: may either be concurrent or retrospective
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Control Techniques

1. Nursing rounds – cover issues like patient care, nursing practice and unit management

2. Nursing operating instructions – policies which become standards for evaluation as well as
controlling techniques

3. Gantt charts – depict a series of events essential to the completion of a project or program

4. Critical control points and milestones – specific points in a master evaluation plan at which the
nurse judges whether the objectives are being met, qualitatively and quantitatively.

5. Program Evaluation and Review Technique (PERT) – uses a network of activities, each of
which is represented as a step on a chart. Includes time measurement, an estimated budget and
calculation of the critical path (the sequence of events that would take the longest time to finish)

6. Benchmarking – technique whereby an organization seeks out the best practice in its industry so
as to improve its performance. It is a standard or point of reference, in measuring or judging
quality, values and cost.

What is 5 ‘S?
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What is 5S?

Is a systematized approach to organize work areas, keep rules and standards, and maintain the discipline
needed to do a good job.

It utilizes workplace organization and work simplification techniques to make work easier, faster,
cheaper, safer and more effective.

The practice of 5 S develop positive attitude among workers and cultivates an environment of efficiency,
effectiveness and economy.

Other Benefits of 5 S
5 S improves…
CREATIVITY of people
COMMUNICATION among people
HUMAN RELATIONS among people
TEAMWORK among people
enhances COMRADESHIP among people
gives VITALITY to people
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WHY 5 S
1. Workplace becomes clean and organized.
2. Work becomes easier and safer.
3. Results are visible to everyone.
4. Visible results trigger generation of more and new ideas.
5. People are automatically disciplined.
6. People become proud of well-organized workplace.
7. Resultant good image of the organization generates more business and positive impression to the
public.

SEIRI (Sort)

Remove unnecessary items and dispose them properly

 Make work easy by eliminating obstacles
 Provide no chance of being disturbed with unnecessary items
 Eliminate the need to take care of unnecessary items
 Prevent accumulation of unnecessary items

Some SEIRI Practices

1. Sorting and evaluation criteria
2. Disposal tags
3. Designated storage area
4. Disposal procedure
5. Material list

SEITON (Systematize)

Arrange necessary items in good order so that they can be

easily picked up for use
 Prevent loss and waste of time
 Easy to find and pick-up necessary items
 Ensure first-come-first-served basis

Some SEITON Practices

1. Place goods in wider frontage along passages
2. Store goods for first-in-first-out retrieval
3. Have a fixed location for everything
4. Label items and their locations systematically, mark everything
5. Separate special tools from common ones
6. Put frequently-used items nearer to the user
7. Make things visible to reduce searching time, organize by color
8. Do not pile up items without separator
9. Put everything at right angles to the passage line
10. Fix unstable articles for safety
11. Provide signs for abnormal condition or when help is needed
12. Keep space for safety equipment and evacuation passages clear

SEISO (Sweep)

Clean your workplace completely

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 Easy to check abnormality

 Prevent machinery and equipment from deterioration
 Keep workplace safety and easy to work

Some SEISO Practices

1. Big Seiso (Clean-Up) Day
2. Put aside 3 – 5 minutes cleaning daily
3. Assign owner to each machine
4. Combine cleaning with inspection
5. Make daily maintenance points clear by providing visible instructions
6. Provide necessary tools for critical points of cleaning
7. Prevent causes of dust and dirt (Do not wait until things get dirty)

SEIKETSU (Standardize)

Maintain high standards of housekeeping and workplace organization at all times.

 Maintain cleanliness and orderliness
 Prevent misoperation
 Make it easy to find out abnormality
 Standardize good practices

Some SEIKETSU Practices

1. Visual control signs

2. Color coding
3. Foolproofing (Poka-yoke)
4. Responsibility labels
5. Wire Management
6. Inspection marks
7. Maintenance labels (Create a maintenance system for Housekeeping)
8. Prevention of dust, dirt, noise and vibration
9. “I-can-do-it blindfolded”
10. One-point lessons
VISUAL CONTROL

Visual Control is a technique to enable people to make the rules easy to

QUALITY
follow, differentiate normal and abnormal situations and act
accordingly, with the use of visual aids. The TOTALITY of
features and
TYPES OF VISUAL CONTROL characteristics of
1. Display to help people avoid making operating errors products or services
2. Danger alerts that bears on its
3. Indicators of where things should be put ability to satisfy
4. Equipment designation stated and implied
5. Cautions and operating reminders
6. Preventive maintenance displays needs.
7. Instructions
ISO 8402
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SHITSUKE (Self-discipline)

 Enhance autonomous management activities (Do things spontaneously without being told or
ordered)
 Maintain the discipline needed to do a good job
 Upgrade productivity and quality consciousness

Some SHITSUKE Practices

1. Wash hands after going to the toilet
2. Wash hands before and after meals
3. Eat and smoke at designated areas
4. Keep workplace always clean and tidy
5. Wear clean uniform and shoes
6. Observe proper office decorum
7. Follow safety rules
8. Put things back in their proper place after use
9. Work according to standards
10. Treat workplace as your second home
11. Always remember that much of your waking time is spent in the workplace
12. Practices the above-mentioned 4S’s until it becomes a habit

What can an individual gain from 5 S?

 Makes our workplace pleasant
 Makes our work more efficient
 Improves our safety
 Improves quality of our work and our products

What can a company gain from 5 S?

A clean and well-organized workplace
Is high in PRODUCTIVITY
Produces QUALITY products and services
Reduces COST to a minimum
Ensures DELIVERY on time
Is SAFE for people to work in
Makes employee MORALE high

Why 5S brings such benefits?

 5S gives vitality to people
 5S rationalizes operation of the company

PRODUCTIVITY
….above all, an attitude of the mind. It seeks to improve what
already exist. It is based on the belief that one can do things
better than yesterday and better tomorrow than today.
Atsuko Ishiwara, JICA Expert
102
 103

CONCEPTS IMPORTANT TO LEADERSHIP & MANAGEMENT

A. TIME MANAGEMENT
Gain control of your time, and you will gain control of your life. Anonymous.
Time and Planning
When you get your personal life organized, you will become
effective n getting priorities accomplished at home. When you get
your school activities organized, you will study more effectively, be
less stressed, and be able to prioritize more effectively. With these two
areas organized, there will be more time for you to spend on yourself!
You will find that once you get organized with your clinical schedule,
you will become a more effective nurse and begin to have the time to
perform the type of nursing care that you were taught. Often you will
hear nurses complain about not having enough time in clinical to
provide the type of bath or teaching they would like to do because of
the lack of time. Check them out; most often they are the most guilty of
wasting time (e.g. taking time to gossip after report, wasting time
complaining that they do not have enough time, not delegating effectively, allowing unnecessary
interruptions, not organizing their patient care, or not delegating when appropriate).
Work hard, and you will have a lot of
food; WASTE TIME, and you will have
a lot of trouble.
Proverbs 28:19

Time Management - is a technique for allocation of one’s time through the setting of goals, assigning
priorities, identifying and eliminating time wastes and use of managerial techniques to reach
goals efficiently.
THE URGENT VS. THE IMPORTANT
URGENT BUT UNIMPORTANT URGENT & IMPORTANT
B C
THE 80/20 LEADER THE CRISIS LEADER
NON-URGENT & UNIMPORTANT NON-URGENT BUT IMPORTANT
A D
THE SHUFFLER THE PLANNER

Beginning in the lower left corner with quadrant A, we find people who are caught with the
“shuffles”. They don’t really know where to turn to escape the trifling minutia that demand attention. E.g.
the demands of the trivial, the unimportant, the inconsequential, the irrelevant -- puny problems,
sometimes the junk mails.

Quadrant B: Someone did a survey on a leader’s urgent telephone interruptions while in personal
conference with someone else. The result: 70% of the telephone calls were less important than
the issues involved in the personal conversation. The 80/20 rule said the that we tend to spend
 104

80% of our time on what produces just 20% of the results. Apparently we devote most of our
time to that which may be urgent but often turns out to be unimportant. As managers we must
work toward turning the ratio around. Let’s spend our time on things that bring the greatest
results

Quadrant C. Nothing is wrong with the important. But if the important item is always in the urgent
position, you’ve got a crisis. There are times that crisis leadership is the way to go. If there is
a fire in the house, that’s urgent – and important. But who wants to be putting out fires
everyday? There is a better way to manage the work we do within the time frames we have.
This brings us to

Quadrant D: If you can truly deal with the important before the important becomes urgent, you are a
winner. You will not only save time but save the need to manufacture energy bursts that
frustrate you and everybody around you.

How do you get into the 4th quadrant? You organize and prioritize your life. Good planning
won’t rid you of all your hassles or ‘lightweights’ but it will help you evaluate where you may be
operating from the many situations you face everyday. If you spend most of your time on the
important rather than the urgent, you will accomplish much more than most other people --- and
thus save a whale or a lot of time.

MANAGING TIME in THE CLINICAL SETTING

One of the main sources of job
dissatisfaction reported by nurses is too
little time. This “limited time” to provide
patient care has been accelerated by the
nursing shortage and the increase in
numbers of patients and the acuity of these
patients. In response to these issue, nurses
must develop competent skills in time
management and priority-setting.

Nurses can use several techniques to

maximize the time spent providing patient
care. Remember the 80/20 rule. Another
example – 20% of your patients will require
80% of you time! Those 20% should be the
sickest patients; when their care and needs
are met first, then the rest of the assignment Time management and work organization can be challenging
is much easier. It will be important to
determine which patients require the most time (the 80%): do they require time that can be delegated to
someone else, or do they require the time because they are the most unstable and ill patients.

GET ORGANIZED BEFORE THE SHIFT REPORT

Develop your personal flow sheet, or use one provided by the agency to write down information
you need to begin coordinating care for the group of patients. Modify this form as you discover areas
needing improvement. Make several copies so you will always have one handy. Avoid gossiping and
other distractions as you receive a report and begin to fill out your time-management ( or work
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organization) form. Get the information needed to plan the care for your patients, and begin to organize
your shift activities. ~

Critical Thinking: Can you prioritize and delegate this RN’s assignment appropriately?

WORK ORGANIZATION WORKSHEET

Time Activities Room 416 Room 417 Room 418
7-8  MAR Blood sugar IV @ 125 /hr 7:45 pre-op
Shift report 7:30 insulin Turn NPO
 Vitals  pulses  Consent
form
8-9 Assessments Meds x 3-9 Meds x2 9
Meal up for meals lf leg dsg To OR
Assists with meal
9-10 Shower Complete bath
Chg bed  Pulses
 Pain meds Turn
10-11 Chart Chg bed
11-12 Meal trays Up for meals Turn
lunch  Bld sugar  Pulses
Insulin ? Assist with meals
12-1 Return frm OR?
Chart assessment Meds x 2 - 12 IVPB - 12 NG suction
I.V.
1-2 Turn
Diabetic teaching  Pulses
Lf leg dressing
change
2-3 I & O’s
IV’s
Report info

Prioritize patients by using the ABCD system or Maslow’s Hierarchy of Needs. Of highest
priority are the patients with problems or potential problems related to the airway, next are those having
any difficulty with breathing, and then circulation. When using Maslow’s Hierarchy of Needs to assist
with prioritization, you need to meet physiological needs first: that is, resolve any difficulty with
oxygenation first. Again, remember to be flexible and reprioritize as emergencies occur.

For example, a characteristic assignment for the day could be:

A patient who is 1 day postoperative and wants something for pain.

A geriatric patient who is vomiting.
A patient with diabetes who is angry about the care from the last shift.
A geriatric who has soiled the bed with urine.
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Which of these patients needs your immediate

attention? Most likely the one who is vomiting because he is
at increased risk for aspiration, then probably the patient who
is in pain, then the angry patient, and so on. With each patient,
you may spend less than 5 minutes in the room before you
move on the next patient. But you will have a good idea of
what each patient’s immediate needs are.

Identify the busiest times on the unit; do not schedule a

dressing change when medications need to be given. Plan on
preparing medications at least 30 to 45 minutes before the
hour they are due. This will provide time to research any
medications with which you are unfamiliar. Do not
procrastinate; start early. If you have dressing changes for
several patients, start with the cleanest and progress to the
more contaminated wounds. If you have diabetic teaching for
three patients, maybe you can get them together and do it at
one time.

Critical Thinking #
How do the efficient nurses on your clinical unit prioritize their time and their patients?

PRIORITIZE YOUR CARE

Setting priorities has become difficult in relation to the dichotomy between the expected
outcomes of efficiency and effectiveness and the perceived limitation of resources, including “time”.
Priority setting is not only based on patient needs, but it is influenced by the needs of the organization and
the accountability of the nurse. Priorities are established and reprioritized throughout the day according to
patients’ assessed needs and unscheduled interruptions, both minor and emergent. Plan your day around
the patient that you perceive to be the sickest. This is the patient who is at the greatest risk of harm if you
do not address his needs first.
Prioritize your patients after you receive report and immediately proceed to the patient whom
you have placed highest on your priority list. Remember, this prioritization may change as you complete
your initial assessments. Additional modification will be made according to the placement of patient’s
rooms to avoid wasted time and movement. When you first enter the patient’s rooms, introduce yourself
as you wash your hands and complete a quick environmental assessment. Think about any supplies you
will need when returning to the room. Complete the focused assessment, validate the safety of your
patient, and proceed to your next patient. Once you have completed your initial rounds, reassess your
initial prioritization, modify according to your assessments and plan your day.

PLAN TIME FOR CHARTING

Do not put charting off until the end of the shift. On a busy unit, you will forget half of what you have
done for all your patients by the end of the day. How many times have you seen staff nurses staying late
so they can complete their charting? Make notes for charting on your work organization form, and cross
through it when it is charted. Plan on stopping about three to four times a shift to make charting entries.
Do not obliterate anything on your form because you will need the information for an accurate shift report

Watch for those nurses who always seem to get everything done, done well, and still enjoy
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nursing. Ask them about their ‘secrets” of time management, and try out some of their tips.

REQUEST CONSISTENT PATIENT ASSIGNMENTS WHENEVER POSSIBLE

This allows you to develop relationships with your patients and their families and
promotes time management as you become familiar with the special needs of these patients.

ORGANIZE YOUR WORK BY PATIENT

By using this technique, the nurse maximizes the number of tasks that can be accomplished with
each visit to the patient. The nurse thinks strategically about “How can I multitask or accomplish several
objectives in one visit to the patient?” By using this technique, the nurse would combine the assessment,
administration of medications, and teaching during one patient visit.(refer to work organization sheet)

DEVELOP AND USE ASSERTIVE COMMUNICATION

Assertive communication is a technique used to get one’s needs met without purposely hurting
others. It incorporates the principles of therapeutic communication, active listening skills, and willingness
to compromise. When you use these skills, you will be able to express yourself more effectively during
challenging situations and handle confrontation in a professional manner. When you are confronted by a
situation that provokes anger, take a deep breath, pull yourself away, get your emotions under control, and
then approach the individual privately in a nonthreatening manner. Following are some hints for using
assertive communication:
Use I statements: “ I am really upset…..”

Describe the behavior that has upset you and focus on the present: :You have been having
excessive personal telephone calls over the past 2 days..”
Discuss the consequences of the behavior: “this behavior is contrary to the agency policy and
could result in….”
State how the behavior needs to be modified and the time for this change: “You must
immediately stop this interruption to your work and request that only emergency phone calls
be….”

Hints that can help you make use of time: (by Don Reynolds, Adventist Education, Dec-Jan. 1993)

1. Be industrious but not over- anxiously busy. “A relaxed attitude lengthens a man’s life
(Prov. 14:30). Solomon’s analogy about ants has much to teach us on this point. They busily but
calmly do whatever needs to get done.

2. Avoid spinning your wheels. Be like Mary. Among all the things clamoring for attention,
keep focused on what’s important.

3. Do it now if possible. Postponing something that can be done immediately wastes time. E.g. if
a memo in your hands should be processed immediately but you set it aside for later actions that’s
inefficient as well as stress-producing

4. Share our workload. Many of you have readers or teacher aides. Some do not utilize them to their
full potential. Then there are volunteers. This kind of help is available as never before –are living
longer and retiring earlier. WE need to tap into this growing pool of talent.
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5. Use your time twice. During your travel time you can listen to audiotapes. Or fill them with your own
dictation – your creative thinking, planning ideas or whatever.

6. Chart your energy cycle. Some people are morning people. They are ready to go when their feet hit
the floor at 6:00 a.m. Others—well don’t talk to them for the first 30 minutes in the morning. They
don’t reach their peak of productivity until later in the day. Chart your own energy cycle and work
accordingly.

7. Settle rifles quickly. It’s surprising how much time this can save. If it doesn’t make any particular
difference which way it goes, settle it quickly! Which route should we take? Little or no difference
settle it now.

8. Eliminate the things you shouldn’t be doing. Ask yourself these questions: (1) What am I doing that
should not be done by me – or by anyone else? (What can I stop doing and no one will be affected
or know the difference?) (2) What am I doing that should or could be done by someone else?
Delegate is the one-word answer here. When you assign a task to someone else, also give that
person enough authority to get the job done.

9. Develop foresight. Insight is one thing; foresight is quite another. Foresight deals with the future, and
the demands planning. Little planning time means more work time. Adequate planning time means
less work time. And the total time (work time and planning time) will be less when planning time is
right.
The value of planning ahead is as valid as this text: “If your axe is dull and you don’t
sharpen it, you will have to work harder to use it. It is smarter to plan ahead” (Ecclesiastes
10:10) If you don’t do regular and effective long-range planning, you are not taking your job
seriously. When you will end up with these four key questions in almost any area of your
administration.
 Where are we now?
 Where do we want to go?
 How will we get there?
 How ill we know we have arrived?

10. Schedule regular meetings. This can save everybody’s time. You don’t have to meet just because
you are scheduled to. If there isn’t an agenda, cancel the meeting. No one will be too upset!

12. Plan for the unexpected. In your daily schedule, program some time for the unavoidable
unexpected things that always happen. You will have fewer stress symptoms, and
maybe even fewer ulcers.

13. Make a “to do” list. List what needs to be done for the day and for the week, and then
prioritize – attack the major duties.

Time is irreversible, irreplaceable, inelastic, and keeps on happening.

All of us have the same 0 minutes in an hour. The same 168 hours each week, the same 65 days each
year. What makes effective is getting organized and managing ourselves well.”
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Other Time-saving Technique, Devices, and Methods to Better Use of Time

1. Conduct an inventory of your activities.

 Identify your time problems. Examine your old habits that get in the way of using
your time well. Examine how and when you procrastinate and understand why you
are doing so.
2. Set goals and objectives and write them down. Set priorities. Plan on making things happen
than on reacting to crises.

3. With the use of calendars, executive planners, logs or journals, write what you expect to
accomplish yearly, monthly, weekly or daily. Use an easy method to keep these information
concise and organized.

4. Break down large projects into smaller parts. Do first things first and concentrate on one
thing at a time. Get all the data you need to avoid breaks in your work. Complete each task
the first time.

5. Devote a few minutes at the beginning of each day for planning. At the end of each day,
account for the tasks you have accomplished. Prepare a list of what is to be done the
following day.

6. Organize your work space so it is functional. Sort paper work on your table according to
priority.

7. Close your door when you need to concentrate. Agree on a period of quiet office time. Avoid
having an “open door” policy during the entire workday.

8. Learn to delegate. Delegation extends results from what one can do to what one can control.
It also develops subordinates’ more time in training and motivating people than to doing the
technical work. To accomplish this, activities and tasks should be delegated to the lowest
practicable level.

9. In a meeting, define the purpose clearly before starting. Distribute the agenda in advance
and control interruptions during the meeting. Conduct the meeting according to time
schedule.

10. Take or return phone calls during specified time. Maintain a telephone log so you can return
calls at one time if possible. Prior to call, outline your basic points. Move immediately into
the business of the call.

11. Develop effective decision-making skills. Do not be afraid to say “no”.

12. Take rest breaks and make good use of your spare time. Reward yourself periodically.
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Name: _______________________________________ Section: ______ Date: ___________

Review Questions # 11: Please write the letter of your choice in the space before the number

___1. This refers to a technique for allocation of one’s time through the setting of goals, assigning
priorities to reach goals efficiently.
a. Time and Planning b. Time management c. Time organization d. |Scheduling

___2.A type of a leader that in most times deals more with the urgent and important:
a. The Planner b. 80/20 leader c. Shuffler d. Crisis leader

___3. In this, you will not only save time but save the need to manufacture energy bursts that frustrate
you and everybody around you.
a. The Planner b. 80/20 leader c. Shuffler d. Crisis leader

___4.In using the Maslow’s Hierarchy of Needs, of highest priority are patients with problems or
potential problems related to:
a. difficulty of breathing b. circulation c. airway d. fluid

___5. ____ is not only based on patient needs, but it is influenced by the needs of the organization and the
accountability of the nurse.
a. Time management b. Priority setting c. Priorities d. Staffing

___6.Once you have completed your initial rounds, ______ your initial prioritization, modify according
to your assessments and plan your day.
b. Identify d. Assess c. Reassess d. Write down

___7.This allows you to develop relationships with your patients and their families and promotes time
management as you become familiar with the special needs of these patients:
a. Organize your work by patient c. Plan time for Charting
b. Develop and use assertive communication d. Consistent Patient Assignments

___8.A technique used to get one’s needs met without purposely hurting others:
a. Assertive communication c. Facilitative messages
b. Facilitative communication d. Therapeutic communication

___9. This technique will help the nurse maximize the number of tasks that can be accomplished with
each visit to the patient.
a. Prioritization of Care c. Consistent Patient Assignment
b. Planning of Time for charting d. Organizing work by patient

___10.Work hard, and you will have a lot of food; __________, and you will have a lot of trouble.
a. Waste time b. Waste resources c. Waste money d. Procrastinate
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B. CHANGE

Change is the process of making something different from what it was ( Sullivan & Decker, 2001, p.249)
i. Different actions are performed to achieve outcomes
ii. Goals or outcomes may or may not change
iii. Most changes are implemented for positive reasons ( to improve patient care, efficiency,
accuracy)
iv. Most organizational changes are planned and purposeful

The CHALLENGE OF CHANGE

Change is frightening only when you are not a part of it or you have no input into it. The staff
nurse has a responsibility to provide input, even if it is not invited, and to become involved in the
planning and implementation of change. Equally important is the evaluation of change. Evaluating
honestly and making necessary modifications are as important to the success of a change project as the
planning and orderly implementation. If nothing else is learned, learn to embrace change as an
opportunity to improve client care and to advance the profession of nursing. Look at conflict resolution as
an opportunity to learn something new or as the opportunity to persuade others.

Most change is implemented for a good or reasonable purpose. Most organizational change is
planned. The change is intentional and goal-oriented, with activities that are proactive and purposeful. If
employees do not understand the reason behind change, they should ask.

TYPES OF CHANGE

1. Personal change
a. made voluntarily for one’s own reasons, usually for self-improvement. May include altering
your diet for health reasons, taking classes for self-improvement, removing yourself from a
destructive or unhealthful environment or situation.
b. For example, a nurse moves to a smaller hospital setting to decrease stress and work day
instead of night hours or a nurse changes work setting to become a telephone triage nurse after
sustaining a back injury while lifting patients in a long-term care facility.

2. Professional change
a. Voluntarily and planned change in a job position or obtaining credentials ( training or
education), to further an individual’s career goals
b. For example, a nurse seeking professional change may take a nursing certification examination
or choose to work in a different specialty area for professional development.
c. It is often planned and can involve extensive change in both your personal and professional
lives.
Although either personal or professional change may be stressful, if it is voluntary and carries
intrinsic or extrinsic rewards, it is often considered important and worth the stress.

3. Organizational change
a. Planned and change undertaken to improve outcomes, efficiency, financial standing, or to
meet some other organizational goal
b. Changes in organizations may take employees by surprise if plans are not clearly
communicated
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c. For example, an organization decides to move all nurses from eight-hour to twelve-hour shifts.
This is a major operational change and those affected need to be informed about and include in
the change process.
d. Organizational change that is not handled well causes an increase in staff stress and resistance
and often mistrust of management ( Sebastian, 1999; Anderson, 2003).

Organizational change can affect 5 different aspects of an organization: its culture, structure,
technology, physical setting, and human resources. Changing an organization’s culture may be
one of the most difficult changes because the underlying values and goals of the organization
need to change.

a. Changing structure involves altering authority relations, job redesign, or similar structure
variables.
b. Changing technology includes modification in the way work is processed, or in the methods
and equipment used.
c. Changing the physical setting involves altering the space and layout arrangements.
d. Changing human resources refers to changes in employee skills, expectations, or behavior.

Note: The first thing that a manager need to know about the change process is that resisting change is a
natural response for most people. All of us are most comfortable in our state of equilibrium,
where we feel in control of what we are doing. To deal effectively with change, it is important to
understand that every change can be understood, evaluate in light of its impact on the individual,
and one hopes, eventually be embraced.

Various reasons why people resist change, and understanding them will help the manager to implement
the change process effectively. The following are the most common factors that cause resistance to
change:
 A perceived threat to self in how the change will affect the individual personally
 A lack of understanding regarding the nature of change
 A limited ability to emotionally cope with change
 A disagreement about the potential benefits of the change
 A fear of the impact of the change on self-confidence and self-esteem

“Those who want to change have a tendency to push, but those who are being asked to change tend to
push back to maintain things as they were.”

PLANNED OR UNPLANNED

Change can be planned or unplanned. Planned change is more productive & it occurs when there
is a directed and designed implementation of some element within the organization. Changes can affect
all aspects of an organization, including policies, goals, organizational philosophy, work environment,
and even structure. Planned change can be used for all sorts of projects, ranging from the minor to the
most complex.
Unplanned change, sometimes called reactive change, occurs when a problem forces a person or
organization into a situation in which it must respond. These changes are often minor but sometimes can
involve projects that are large in scope and complexity. Examples in nursing include changes in staffing
because of nurse who call in sick, clients who experience cardiac arrest, or even equipment failures, such
as when electricity fails or a water main breaks. Nurses often take on the role of the change agent, that is,
the one who brings about the change.
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Nurses as change agents (one who is responsible for bringing about change)

a. In institutions
a. Nurses are most significant determiners of the length of patient stay in hospitals
b. Nurse expertise and organizational skills determine cost and quality of care provided
c. Nursing is the largest part of any organization’s personnel budget
d. Organizations known for outstanding nursing care have a competitive advantage in the health
care marketplace.

b. Outside institutions
a. Nurse change agents help move the health care system from a medical to a nursing model
b. Promote healthy living
c. Develop and manage prevention programs
d. Create quality, cost-effective care for a wide range of patient populations
e. Provide case management services for most efficient use of technology and other resources
f. Fill service gaps after people leave institutions
g. Work as advocates for undeserved populations

c. Entrepreneural role of nurse change agent

a. Entrepreneurial nurses see change as healthy
b. Characteristics of entrepreneur nurse include imagination, ingenuity, and persistence
c. Changes in nursing roles resulting from entrepreneurial change include advanced practice
nursing, case management, critical paths, and other professional practice models.

Do’s and Don’ts of Effective Change Agents

Do
o develop a sense of trust
o establish common goals
o facilitate effective communication
o establish a strong team identity
o contribute as much as possible
o find reasons to celebrate and recognize
o accomplishments
Don’t
o have a hidden agenda
o be unpredictable
o miss or reschedule meetings frequently
o use threats or bluffs to manipulate
members
o volunteer to be the record keeper
o follow the rest of the crowd.

Change in nursing environments

A. According to Marquis and Huston ( 2000), there are three basic reasons to introduce change:
a. solve a problem; for example, inadequate staffing of RNs for a hospital’s weekend or holiday shifts
b. improve efficiency; for example, provide care for postoperative patients using the most cost-
effective mix of credentialed and noncredentialed care providers.
c. Reduce unnecessary workload on a person or group, for example, to ensure that an RN on the 3-
11 p.m. shift is supervising no more than a certain number of assistive staff.

B. Other reasons why change occurs in the nursing environment

a. Technology. Automation for patient recordkeeping, billing, and diagnostics is constantly changing
and becoming more networked. Although few organizations are completely “paperless” the trend is
toward more, not less, technology.
b. Changes in corporate structures. Restructuring is an ongoing activity, as organizations try to
survive changing demands and markets by adding, expanding, or reducing services.
c. Reimbursement. Pressure from payors and others, such as governments to control spending by
emphasizing preventive care and less expensive outpatient vs. more costly inpatient services.
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d. Advances in treatment and medications. Increasing emphasis on preventive treatments,

community health initiatives, outpatient services, ambulatory surgery centers to meet patient care
needs most effectively while controlling cost.
e. Biomedical discoveries. Stem cell research, genetic therapies that can cure disease and improve
quality of life.

CHANGE AGENT CHARACTERISTICS AND STRATEGIES

A. Effective change agents tend to have most of the following characteristics, which can be cultivated
and practiced:
 Ability to combine ideas from a variety of unconnected sources
 Ability to energize and motivate others
 Well-developed interpersonal skills, including group management and problem-solving skills
 Ability to work with system details while keeping the “big picture” in mind
 A balance of flexibility and persistence – effective change agents are open-minded enough to see
when they need to change, but are persistent enough to stick with their ideas in the face of non-
productive resistance from others.
 Confident and not easily discouraged
 Ability to think realistically and strategically
 Ability to inspire others’ trust in them; often occurs due to a history of integrity and success with
other change efforts
 Ability to articulate ideas and vision
 Ability to handle resistance from those who oppose change

B. Change Agent Strategies that can be used to facilitate change, depending on the amount of resistance
and the characteristics of the change agent:

a. Power-coercive
a.1 application of power by legitimate authority, such as law, policy, or financial appropriations
a.2 people in control enforce changes; those not in power may not even be aware that changes;
those not in power may not even be aware that changes are occurring and, even if aware,
have little or no power to alter the course of change
a.3 leadership response to resistance: accept it or leave it
a.4 used when high levels of resistance are expected, change is critical, time is short, and there
may be little or no chance of securing organizational consensus.
a.5 an example is the government’s change in payment for patient care based in a diagnosis-
related group (DRG) rather than costs

b. Empirical-rational
b.1 Knowledge is the most powerful element for change
b.2 This model assumes that people are rational and will act in their own self-interest, when that
self-interest is made clear to them
b.3 Assumes that the change agent is able to persuade people that changes will benefit them
b.4 Effective when there is little resistance to change and the change is perceived as reasonable or
beneficial
b.5 This model could effectively be used to implement a technology change; for example, having
nurses use PDAs to track procedure scheduling in an outpatient surgical setting. The change
agent’s job would be to explain the benefits to staff and patients of such a system as well as to
provide appropriate training and backup, to further decrease any resistance.
 115

c. Normative-reeducative
c.1 assumes that people act in accordance with social norms and values, and that they are less
likely to change, based on information and rational arguments
c.2 change agent focuses on people’s behavioral motivators – such as roles, relationships,
attitudes, and feelings – rather than rational motivators.
c.3 emphasis is not on persuasion but on interpersonal relationships between the change agent
and the people he or she is influencing to change.
c.4 seen as an effective way to implement change in a health care environment
c.5 effective for starting new services, for example, a postsurgical follow-team, or to make
systematic changes, for example, changing from inpatient to ambulatory surgical programs.

All change requires the ability to overcome resistance to change (called restraining forces) by a driving
force that pushes toward change. When the driving force and restraining forces are equal, then no
change occurs and the status quo is maintained.
Change occur only when the driving force is greater than the restraining force. Those who want to
change have a tendency to push, but those who are being asked to change tend to push back to maintain
things as they were. It is important when attempting to implement change to identify the restraining
forces and ways to overcome them. Habit, comfort, and inertia are
the three most common restraining forces.
Planned change works best when it is well organized, proceeds at a steady pace, and has a
definite date for achievement. There is a level of excitement that raises energy levels when a change is
near completion, but postponing the date for the change can drain that energy and lead to disappointment.

THEORIES OF CHANGE

How change occurs fall in two categories: Linear change theories ( assumes that change occurs in a
step-wise, logical way) and nonlinear change theories ( assumes that change is more chaotic than
controlled).

A. Traditional (linear) change theories include:

a. Lewin’s Force-Field Model (1951) which is made up of 3 steps:

1. Unfreezing – refers to the thawing of the current or old way of doing things. Individuals begin
to be aware of the need for doing things differently, that change is needed for a
specific reason.
2. Movement – (moving to a new level) intervention or change is introduced and explained. Those
affected by change learn its benefits and disadvantages therefore are discussed, and
the change – the move to a new level – is implemented.
3. Refreezing – the change or the new way of doing or operation becomes the norm as it is
incorporated into the routines or habits of the people affected.

b. Lippitt’s Phases of Change (1958) . Derived from Lewin’s model but defines seven total steps in
the change process.

1. Diagnose the problem: for example, inadequate supervision of assistive staff

2. Assess motivation and capacity for change: does the staff want to be more closely supervised;
is an RN available and willing to take on this challenge?
3. Assess change agent’s motivation and resources: does the RN have excellent organizational
and communication skills? Is he or she motivated by the desire to improve how patient care
is delivered ( as opposed to “doing supervision” to avoid other job responsibilities)?
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4. Select appropriate progressive change objectives: for example, in the next month, assign all
staff to a mentor , institute weekly meetings of noncredentialed personnel, and arrange for
the supervisory RN to complete a “managing difficult people” course.
5. Choose appropriate role for change agent: for example, mentor, facilitator ( rather than
“criticizer” or “enforcer”)
6. Maintain the change once it has started: provide logistical support to meet the RN’s needs to
continue to act as a change agent; provide feedback forum for the assistive staff
7. Terminate the helping relationship: once the change is instituted and has become the norm, no
need to supervise the supervisor or otherwise oversee his or her staff.

c. Havelock’s six-step model. Like Lippit’s model, this is based on Lewin’s model, but breaks the
change process into additional steps. Havelock particularly emphasized the essential role of
planning in any change endeavor
Planning Stage:
c.1 build a relationship: people affected by the change need to be involved in it, and this occurs
through building relationships in the organization
c.2 diagnose the problem
c.3 acquire resources: gather the money, technology, staff, etc. needed to successfully implement
change
Moving Stage:
c.4 choose the solution
c.5 gain acceptance for the solution: Havelock believed that this step would occur only if the first
step ( building relationships) had occurred.
c.6 Stabilize and self-renewal: organization functions on the new level; change becomes part of
the norm and the organization enjoys the benefits of the change.

d. Rogers’ Diffusion of Innovations theory ( 1983) this emphasizes the changeability of change itself
– that efforts to implement change may be rejected at first, then later accepted. The initial word is
not the final word. This method involves a five-step process of innovation and decision-making.
1. Knowledge: people who can make the decision are introduced to the change and begin to
understand it. For example, a home care agency begins to learn about telemonitoring technology
for patients with CHF.
2. Persuasion: people form a favorable ( or unfavorable) attitude about the change. For example,
some nurses discuss how the technology saves travel time, while others express their frustration
with computer compatibility problems in the field. After a time, a general perception forms (
such as:”there are glitches but the system works overall” or “the technology is flawed and
increases our workload”).
3. Decision: people engage in various activities that lead to a decision to either adopt or reject the
change. For example, nurses with more computer experience mentor others in troubleshooting;
supervisors call all nurses using the telemonitoring technology, and have them fill out a survey
that rates their satisfaction or dissatisfaction about the telemonitoring program. Supervisors then
solicit specific feedback that can guide modifications when necessary.
4. Implementation: the change is put into action; at this stage, the change maybe adapted to better
fit the situation. For example, the home care staff may decide to add an autorecord feature to a
blood pressure monitor, to compensate for inaccurate reporting by visually impaired patients.
5. Confirmation: decision makers seek reinforcement that their decision was correct; conflicting
feedback might result in the nurses look for data that confirm that technology benefited both
patients ( avoiding rehospitalization) and nurse ( less travel, quicker response time).
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B. Nonlinear change theories

a. Chaos theory – developed by Thietart and Forgues and they say that:
a.1 most organizations have the potential to be chaotic
a.2 organizations often undergo a series of rapid changes, and stabilize until the next round of
rapid changes occurs
a.3 leadership in these organizations must be flexible and able to respond quickly and
appropriately to the rapid changes

THEORIES ABOUT REACTIONS TO CHANGE. Bushy identified 6 behaviors that people exhibit in
response to change:
1. Innovators: people who enjoy the challenge that change brings and often instigate or implement
change
2. Early adopters: open to change; will work with change that is brought to them but are not as
change-focused as their innovators
3. Early majority: people who enjoy the status quo but who will adopt change earlier than average,
to avoid being left behind.
4. Later majority: slower to adopt change; often express reluctance about or skepticism of change
efforts.
5. Laggards: last people to adopt to change; may be suspicious of change; prefer stability and
tradition
6. Rejectors: people who openly oppose or reject change; they maybe direct or indirect in their
resistance.

The Change Truck – how will you respond?

React - move out of the way. Let the truck (change)

pass you by. However, opportunities may be
missed.
Do not act – just stand there and let the truck run
over you. It will leave you behind and more
than likely in worse shape than when you
started.
Act – start running when you see it coming. Pace
with it until you can decide when to jump on
and steer it in the direction you want to move.

Example:
Patti is working in a medical-surgical unit at a 200 bed acute-care hospital. She constantly
hears her peers complaining about the lack of adequate nursing staff, and over the past 3
months, two full-time staff nurses have resigned. To cover the unit, part-time staff from
temporary agencies and from the hospital staffing pool are being used to supplement the
remaining regular staff. Because this staff has little orientation to the unit and is
frequently assigned where they are needed the most, the continuity of care and a potential
for increased errors in patient care became a major concern.

Rather than continuing to complain about the situation or considering leaving it, Patti decided to
act and try to steer the change truck. She approached a few of the nurses and initiated a discussion about
the changes in staffing and how scheduling had become a nightmare for the charge nurse. She enlisted the
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support of several of the staff to begin problem solving possible outcomes. They agreed that increased
staffing was probably not a possible immediate solution and determined to work within the constraints
that they had. Several of the pool nurses were receptive to requesting that their assignment be limited to
this one unit and agreed to schedule their hours to complement each other. This, in essence, would add a
shared full-time position, at no additional cost, and would also provide consistency of patient care. When
the proposal was presented to administration, they agreed to support the idea on the basis of its economic
and patient-centered benefits.

Strategies the change agents can use to manage change (Anderson 2003).

1. Articulate vision
a. use the same key words for all discussions about the change
b. constantly remind people of the goals and vision – the positive things that will come as a
result of the change
2. Map out a timeline for the change and the steps required
3. Plant seeds
a. talk to key people in the organization about what will happen or what is expected; use and
repeat key words or core message(s)
b. information will quickly filter through the rest of the organization
4. Carefully select the change project team, making sure that
a. stakeholders are strongly represented
b. there are sufficient experts to evaluate the change
c. people who are expected to resist change are also included
5. Create consistency
a. set and keep meeting dates
b. use timeline to stay on track with change process activities
6. Provide regular updates
a. in writing
b. to supervisors, peers, and subordinates
7. Deal with conflict directly
a. check out rumors; it is essential for change agent leaders to tap into the “grapevine” – the
informal communication structure of any organization. Even if information being passed on the
grapevine is incorrect, it establishes a reality for many of those who will be affected by change.
b. Do not seek conflict, do not ignore it either
8. Maintain a positive attitude, and avoid getting discouraged in the face of resistance
9. Be aware of political forces at work
a. get consensus on key actions as the change process progresses, especially for issues of policy,
finance, or operating philosophy
b. recognize barriers that arise and work to get consensus to overcome them
10. Know who the leaders are
a. recognize both formal and informal leaders
b. create a relationship with them and consult them regularly
11. Maintain self-confidence and foster trust with others

CHANGE AGENT STRATEGIES ( Lancaster, 1999)

Following are some strategies the change agent can use in managing process:

1. Begin by articulating the vision clearly and concisely. Use the same words over and over.
Constantly remind people of the goals and vision.
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2. Map out a tentative timeline and sketch out the steps of the project. Have a good idea of how the
project should go.
3. Plant seeds or mention some ideas or thoughts to key individuals from the first step through the
evaluation step so that an idea of what is expected is under consideration.
4. Select the change project team carefully. Make sure it is heavily loaded with those who will be
affected and other experts as needed. Select a variety of people. For example, an innovator,
someone from the late majority group, a laggard, and a rejector are probably good to include.
These people provide insight into what others are thinking.
5. Set up the consistent meeting dates and keep them. Have an agenda and constantly check the
timeline for target activities.
6. For those not on the team but affected by the project, give constant and consistent updates on
progress. If the change agent does not update staff, someone on the project team will, and the
change agent wants to control the messages.
7. Give regular updates and progress reports both verbally and in writing to the executives of the
organization and those affected by the change.
8. Check out rumours and confront any conflict head on. Do not look for conflict, but do not back
away from it or ignore it.
9. Maintain a positive attitude and do not get discouraged.
10. Stay alert to political forces both for and against the project. Reach consensus on important issues
as the project goes along, especially if policy, money or philosophy issues are involved. Obtain
consensus quickly on major issues or potential barriers to the project from both executives and
staff.
11. Know the internal formal and informal leaders.
12. Having self-confidence and trust in oneself and one’s team will overcome a lot of obstacles.

Additional Ways To Facilitate Change

1. Recognize and respond to the impact of change on people

a. Avoid arguing with people about their feelings regarding change, and avoid telling them that
“it isn’t so bad;” support the need for change with facts that are important to people unsettled
by the change taking place.
b. Acknowledge with empathy that people are often unsettled by changes
2. Use communication skills to help people process the impacts of change.
a. Give people a chance to talk through their feelings
b. Use conversations to provide information about the change – who, what, when, where, why,
how
c. Repeat the message. Use the “7x7 rule” of saying a message seven different times in seven
different ways
3. Anticipate grief
a. People undergoing change often experience grief stages (shock, denial, anger, bargaining,
anxiety, and sadness)
b. Openly recognize that even positive change can mean the loss of a valued way of doing
things, and that grief may occur.
4. Acknowledge period of confusion, when people maybe confused or unhappy about the changes
that are occurring
5. Expect resistance, a natural reaction to change

WHO INITIATES CHANGE AND WHY?

Another aspect to consider when evaluating change is who wants the change and why. Is it the
system? Is it the management? Is it you, the nurse? Or is it the patient? Change should be carefully
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planned and implemented for specific reasons. By identifying who is initiating change, the
implementation can be better understood.

System. The most common reason for change is that ‘what you did before is no longer
effective.’ For example, the handwritten medical record system is largely being
replaced by the electronic medical record because the old system does not allow
for the integration of the information in the record, generates volumes of paper, and is not
adequate to keep pace with the number of patients and the need to access key information
qusickly from various individuals both inside and outside of the traditional hospital
(home health nurse or hospice nurse at the patient’s home).
Management: Change frequently occurs when new management enters the scene. This provides a
new perspective and view regarding how the system operates. For example, a new vice
president of nursing decides to implement critical pathways. The overall organization
may benefit from the change; however, the employee may be wondering “How will the
implementation of critical pathways change my job? Do I know how to implement a
critical pathway?”

CRITICAL THINKING
What changes have you made in your life?
How long did one situation last before it changed again?
You have just learned to deal successfully with the changes associated with being a
student. Now you are facing the challenge of change again as you prepare for your role
as a practicing registered nurse.

Patient. When costumers are not happy, something within the system needs to change. What
are the specific problems, and how can they be resolved? For example, patients are
complaining about lengthy admission procedures. Faxing physician orders or allowing
direct admission to units may streamline the admission process.

Yourself. Sometimes we impose change on ourselves – we may or may not like it, but we see a
need for it. Who ever wanted to go on a diet and enjoyed doing it? Stop to
consider how you are going to implement the change. How will your work environment
be affected? Can you delegate any part of it? If change involves other employees, make
them a part of that change. They will own the results – that is, you will use the WIIFM
principle: What’s In It For Me?

Note: Change depends on your own perspective. You will be either actively involved in changes or
choose to take a passive role. The choice is yours.
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Five Steps toward conquering change.

“People do not change until the pain of staying the same is greater than the pain
of change”
Unkown
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The table below summarizes the characteristics and helpful interventions associated with the change
process.
Emotional Phases of the Change Process
Phase Characteristics Interventions

Equilibrium High energy; feelings of balance, peace, and Explain how changes will impact the
harmony status quo.
Denial Denies reality that change will occur; Actively listen, be empathetic and use
experiences negative changes in physical health, reflective communication. Offer stress-
emotional and cognitive behavior. management programs.
Anger Blames others; may demonstrate envy, rage, or Be assertive and assist with problem
resentment. solving. Encourage employee to
determine the source of his/her anger.
Bargaining Efforts made to try and eliminate the change; Search for real needs and problems and
frequently talks in such terms as “If only.” explore ways to achieve outcomes
through conflict management and win-
win negotiation skills.
Chaos Diffused energy; feelings of powerlessness and Encourage quiet time for reflection as
insecurity and a sense of disorientation. inner search for identity and meaning
occur.
Depression No energy left; nothing seems to work; sorrow, Encourage expression of sorrow and
self-pity and feelings of emptiness. pain. Have lots of patience as employees
learn to go.
Resignation Lack of enthusiasm as change is accepted Allow employees to move at own pace.
passively.
Openness Some renewal of energy and willingness to take Patiently explain again, in detail, the
on new roles or assignments resulting from desired change.
change.
Readiness Willingly expends energy to explore new events Assume a directive management style,
that are occurring, reunification of emotions and assign tasks, provide direction.
cognition.
Reemergence Feelings of empowerment as new projects ideas
Mutually explore questions and develop
are initiated. an understanding of role and identity.
Employees take actions based on own
decisions.
Adapted from Perlman D, Takacs GJ: The ten stages of change. Nurs Manage 21 (4): 34, 1990

Leaders/managers must act as role model during the change process. It is important that change is
presented in a positive light, particularly because change frightens most people. Remember the phrase
“fear of the unknown”. Does it apply to change? One can never overcommunicate when it comes to
change, particularly to those affected by the change. The only thing really constant about change is
change itself! Malloch (2003) suggest that “ change is…. A never-ending journey” (p.12). Every point of
arrival is also a point of departure. As a result, leaders must carefully balance periods of effort and action
with periods of rest and celebration so that the stakeholders will be regularly refreshed and reenergized to
meet future challenges.

Real world Interview

One of the things I have learned about change it to include everyone affected by the change in the plan from the
beginning. Everyone is encouraged to voice an opinion regarding the change and the change process. It is
understood that if their ideas are not realistic, the rationale would be explained and not ignored. This encourages
everyone to be committed to the process.
Sheila Joseph, BScN
Unit Manager
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Note the relation between change process and nursing process

Nursing Process vs. Problem Solving vs. Change Process
Nursing Process Problem Solving Change Process
Assessment Data gathering Recognition that a change is
needed; collect data
Identification of possible Definition of problem Identification of problem to
nursing diagnoses be solved
Selection of nursing Selection of one of possible Selection of one of possible
diagnosis alternatives alternatives
Development of plan Development of plan Implementation of plan
Implementation of plan Implementation of plan Implementation of plan
Evaluation Evaluation of solution Evaluation of effects of
change
Reassessment Evaluation of solution Stabilization of change in
place

ROLES and CHARACTERISTICS OF THE CHANGE AGENT

 Lead the change process by  Maintain vision of change
example  Communicate change, progress, and
 Manage process and group feelings
dynamics and show others how to  Knowledgeable about the
adapt to change organization
 Demonstrate that the change is  Honest and direct
critical and inspire response from  Respected
others  Intuitive
 Understand feelings of the group
experiencing the change; engage
them in the process
 Maintain momentum and
enthusiasm

Real world Interview

I have always enjoyed trying new things and development to my potential. However, I have no
patience for a manager who is not truthful. Once she pretends to have the answers, and makes up her plan
as she goes, I lose all respect, and trust is destroyed. It’s okay to say, “I don’t know,” but you need to find
the answer, and report back to me. Don’t lie to me.
Margaret Mary, RN
Staff Nurse

CONCLUSION
As a new graduate, you will be facing many transitions, including the transition from staff nurse
to a leadership position of nursing manager. Having a good understanding of management styles and your
own early adoption of a leadership and management style that fits both your personality and needs of your
particular place of employment’s nursing staff will be important to your success. Decision making skills
and understanding change theory will provide you with the tools to build effective nursing management
practices.
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Name: _______________________________________ Section: ______ Date: ___________

Review Questions # 12: Please write the letter of your choice in the space before the number

___1. A voluntarily and planned change in a job position or obtaining credentials such as training or
education is an example of:
a. Personal change c. organizational change
b. Professional change d. resistance to change

___2. When people in control enforce changes in an organization and others in the organization have no
input into these changes, this is an example of which of the following change strategies?
a. Normative-reeducative c. change-stabilization
b. Power-coercive d. rational-empirical

___3. The change strategy that assumes that people act more in accordance with social values and are less
likely to change based on information or rational arguments is called the:
a. Stabilization-evaluation strategy c. Normative-reeducative strategy
b. Rational-empirical strategy d. Power-coercive strategy

___4. Unfreezing, moving to a new level, and refreezing are steps that make up which of the following
theories / models of change?
a. Lewin’s Force-Field Model c. Havelock’s Six-Step Change Model
b. Lippit’s Phases of Change d. Roger’s Diffusion of Innovations

___5. According to this change theory, effort to implement change may be rejected at first and accepted
later; thus an initial rejection is not that final word. Which theory is this?
a. Lewin’s Force-Field Model c. Havelock’s Six-Step Change Model
b. Lippit’s Phases of Change d. Roger’s Diffusion of Innovations

___6. This theory says that organizations often undergo a series of rapid changes, and then stabilize until
the next round of rapid changes occurs.
a. Lippit’s Phases of Change c. Chaos theory
b. Havelock’s Six-Step Change Model d. Learning organization theory

___7. In Bushy’s theory about people’s reaction to change, the people who enjoy the status quo but who
will adopt change earlier than average to avoid being left behind are called:
a. Innovators b. Laggards c. Early majority d. Early adopters

___8. Identify the problem or opportunity and collecting or analyzing data about a possible change are
activities of which step of the change process?
a. Assessment b. Planning c. Implementation d. Stabilization

___9. The final step needed to complete the change process is called:
a. Assessment b. Planning c. Implementation d. Stabilization

___10. The “7 x 7 rule” of communicating a message about change means:

a. Send the message seven different times in seven different ways
b. All methods should be 7x7 inches
c. There should be no more than 49 messages in any change process
d. Send seven messages a day for seven days
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C. CONFLICT RESOLUTION

Everything that irritates us about others can lead us to an understanding of ourselves.

(Carl Jung)

Can you imagine a world without

conflict? Why, it would be a world
without change! Conflict is
inevitable wherever there are
people with differing backgrounds,
needs, values, and priorities. The
presence of conflict in a situation is
not necessarily negative but may, in
fact, have some positive results.
As a process, conflict is
neutral. Following are some
possible outcomes of conflict:

There is a better approach to conflict resolution than o Disturbing issues

fighting it out. are brought into the open, which
may avert a more serious conflict.
o Group cohesiveness may increase as individuals resolve issues.
o New leadership my develop as a consequence of resolution.
o The results of conflict can be constructive, which occur when productive outcomes are
achieved; or destructive, leading to poor communication and creating dissatisfaction.
Conflict
- A disagreement or clash between ideas, principles, or people ( Encarta )
- Competitive or opposing action of incompatibilities (Merriam-Webster)
- conflict exists when an inner or outer struggle occurs regarding ideas, feelings or actions

CAUSES CONFLICT?
Let us look at some common factors of conflict as they relate to nursing:

Role Conflict. When two people have the same or related responsibilities with ambiguous boundaries,
the potential for conflict exists.
For example, a nurse in the 11 pm to 7 am shift may be uncertain whether he or the nurse on the 7
Am to 3 PM shift is responsible for administering enemas until clear on a patient scheduled for
a barium enema.

Communication conflict. Failing to discuss differences with one another can lead to problems with
communication. Communication is a two-way process; when one person is unclear in a
communication, the process falls apart. A recent graduate may find that with a busy schedule,
numerous patient demands, and a shortage of time, it is easy to forget to notify a patient’s family
of a change in visiting hours – a great annoyance to the family members who can visit when they
arrive.

Goal Conflict. We all have unique goals and objectives for what we hope to achieve in our places of
employment. When one nurse places his or her personal achievement and advancement above
everyone else’s conflict can occur.
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Personality Conflict. Wouldn’t it be great if we got along with everyone? Of course we all know that
there are just some people with whom we have a difficult time. The situation is all too familiar,
and many times we may find ourselves with such thoughts as “I’ll try and overlook her negative,
lousy behavior; after all she doesn’t have much of a family life.” Trying to change another
person’s personality is like guaranteeing an unhappy ending to a story.
Ethical or Values Conflict. During a cardiac arrest, a young graduate nurse has difficulty with the
physician’s order of “No Code,” on a young adolescent patient. She has difficulty taking care of
the adolescents because he reminds her of her younger brother who died tragically in an
automobile accident.

Conflicts in nursing may fit into one or more of the aforementioned categories. Consider some common
areas of conflict among nursing staff, including scheduling days off, determining vacation
leave, assigning committees, patient care assignments, and performance appraisal, to name
just a few.

COMMON AREAS OF CONFLICT BETWEEN NURSES AND PATIENTS – AND BETWEEN

NURSES AND PATIENTS’ FAMILIES

1. Quality of Care. This is by far the most common area of conflict and the easiest to remedy. Families
typically are concerned with how well their loved one is being attended to, how friendly the
nurses are, how well the hospital or home health services are provided and coordinated, and how
flexible the hospital is with visiting hours and meeting their special needs.

2. Treatments decisions. This area of conflict often arises between the family of an elderly adult and the
nurse. A physician may order a treatment with which the family does not agree. In this situation it
is very important that the nurse not defend the physician’s orders or attempt to persuade or
establish with the family that the physician or nurse knows what’s best for the patient.
In these situations the issue is rarely the treatment itself but rather the family’s desire to
decide what is right for their loved one. Be sure to clarify the orders and explain to the family that
you are supposed to carry them out unless the family negotiates directly with the physician to
change them.

3.Family involvement. The situation of a young adult diagnosed with cancer illustrates numerous issues
that may arise concerning the presence of family members during procedures and the extent of
their involvement in the overall care. Such issues are based on the family’s real need to feel
significant and adequate in meeting the young adult’s needs.

4.Quality of parental care. This can become an issue when nurses are unhappy with how parents are
participating in their child’s care. It is helpful to offer parenting classes, to encourage parents to
meet other parents, and to model positive parenting techniques.

5.Staff inconsistency. This is another easily preventable issue. Make sure that each shift is consistent in
enforcing hospital policies and that they notify other shifts of any attempts at manipulation by
family members or patients.

CONFLICT RESOLUTION

WAYS TO RESOLVE CONFLICT

Unresolved conflicts waste time and energy and reduced productivity and cooperation among people with
whom you work. In contrast, when conflicts are resolved, they strengthen relationships and improve the
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performance of everyone involved. The key to successfully managing conflict is tailoring your response
to fit each conflict situation instead of just relying on one particular technique. Each technique represents
a different way to achieve the outcome you want and to help the other person achieve at least part of the
outcome that he or she wants. How do you know which technique to use? That depends on the following:
o How much power do you have in this situation compared with the other person?
o How much do you value your relationship with the person with whom you are in conflict?
o How much time is available to resolve the conflict?

Model for Conflict Resolution

This model above incorporates several views on conflict resolution. Filley (1975) described three
basic strategies for dealing with conflict according to outcome: win-win, lose-lose, and win-
lose. Various others have identified five responses to resolve conflict. They are as follows:
competition, accommodation, avoidance, compromise, and cooperation.

Let us look at an example and apply the model.

Suppose the head nurse on your unit has posted the vacations for the month of December. You, as
a recent graduate, have requested to be off during the week of Christmas so that you can be
with your family. You notice on the schedule that none of the recent graduates has received the
Christmas holidays off. You feel that this is unfair because you will not have an opportunity to
be with your family during the Christmas holidays.

How can you resolve this conflict?

APPROACHES TO CONFLICT RESOLUTION:

Competition. Is a conflict resolution technique that produces a winner and a loser ( win-lose situation).
The concept is that there is an all-out effort to win at all costs. This technique may be
used when time is too short to allow other techniques to work or when a critical, though
unpopular, decision has to be made quickly. This technique is often called forcing
because the winner forces (use of power) the loser to accept the winner’s stance on the
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conflict. It sets up a competition between you and your head nurse. Typically,
competition is used to resolve conflict when person has more power in a situation than
the other. In the given situation, the head nurse refuses your request for Christmas
vacation, explaining that the staff members with more seniority have priority for vacation
at Christmas time.

Avoidance. Is a very common technique. The parties involved in the conflict ignore it, either consciously
or subconsciously. Avoidance is unassertive and uncooperative, and leads to lose-lose
situation. In some situations, avoidance is not considered a true form of conflict
resolution because the conflict is not resolved and neither party is satisfied. In the given
situation, you would not have approached the head nurse with the Christmas schedule
issue. Usually both persons involved feel frustrated and angry. There are some situations
in which avoiding the issue might be appropriate, such as when tempers are flaring or
when strong anger is present. However, this is only a short-term strategy; it is important
to get back to the problem after emotions have cooled.

Accommodation. Is often called cooperating. In this technique, one side of the disagreement decides or
is encouraged to adjust or adapt to the other side by ignoring or sidestepping their own
feelings about the issue. People often accommodate when the stakes are not that high and
the need to move on is pressing. In the given situation, the head nurse would basically put
her own concern aside and let you have your way, possibly even working in the
scheduled slot for you. Accommodation is the lose-win situation, in which you
accommodate the other person at your own expense but often end up feeling resentful and
angry. The head nurse loses and the graduate nurse wins in this situation, which may set
up conflict among staff and other recent graduates. Frequent use of this method, however,
can lead to feelings of frustration or being used – one person is “used” to get the
cooperation of another.

When is accommodation the best response? Is it when conflict would create serious
disruption, such as arguing, or when the person you are in conflict with has the power to
resolve the conflict unilaterally? Basically, in this response to conflict, differences are
suppressed or played down while agreement is emphasized.

Compromise. Is a method used to achieve conflict resolution in situations in which neither side can win
and neither side should lose (bargaining). Compromise is rampant in our society and is
useful for goal achievement when the stakes are important but not necessarily critical.
Compromise is often seen as appeasement – each side gives up something and each side
gains something. Compromise is a good technique for minor conflicts or conflicts that
cannot be resolved satisfactorily for both sides. Both parties win and lose. It is a
moderately assertive and cooperative step in the right direction in which one creates a
modified win- lose outcome. In the given situation, the head nurse compromises with you
by allowing you to have Christmas Eve off with your family, but not the entire week. The
problem lies in the reduced staffing that will occur for a short period of time. The
compromise may not be totally satisfactory for either party, but it may be offered as a
temporary solution until more options become available.

Collaboration. Occurs in conflict resolution when both sides work together to develop a mutually
acceptable outcome. It is an assertive and cooperative means of achievement important
goals, which results in a win-win solution. This technique requires both sides to seek an
acceptable solution to the conflict so all patients feel their goals or objectives have been
achieved. This involves a high level of concern for the problem, the outcome, and the
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relationship. It deals with confrontation and problem solving. The needs, feelings, and
desires of both parties are taken into consideration and reexamined while searching for
proper ways to agree on goals. In the given situation, you and the head nurse discuss the
week of Christmas vacation and the staffing needs and agree that you will work first
three days of that week and the head nurse will work the second half of that week. You
also agree to be there the first part of the week to complete the audit on the charts from
the previous week for the head nurse. In this situation both persons are satisfied, and
there is no compromising what is most important to each person. That is, the head nurse
gets her audit completed and the recent graduate gets to spend half of the Christmas
week with her family.

What is your particular style for resolving conflict?

When there is no immediate, pressing sense of time to solve an issue, then any of the five
techniques can be used. However, when you are facing an emergency situation or a rapidly approaching
deadline, your best bet is to use competition or accommodation. Just remember the following key
behaviors in managing conflict:
 Deal with issues, not personalities
 Take responsibility for yourself and your participation.
 Communicate openly.
 Listen actively.
 Sort out the issues.
 Identify key themes in the discussion.
 Weigh the consequences.

* There is no standardized conflict resolution but it depends upon the situation.

It takes creative nursing management and understanding to recognize that conflict will
exist whenever human relationships are involved. This needs to be tempered with open,
accurate communication and active listening by maintaining an objective, not emotional
stance, as conflict resolution strategies are utilized.
CAREFRONTING
 Carefronting means directly approaching the other person in a caring way is that
achieving a win-win solution is most likely
 With this approach neither party loses anything important and the relationship does not
suffer
 Some believe this is the only biblical way of resolving conflict (Matt. 18:15-17)

Conditions of Carefronting. Both parties must be committed to:

 face to face negotiations
 maintaining good relationships
 crating a solution in which both parties are winners
 calm reasoning without resorting to emotional responses
 separating the person from the issue

LOVE AND FORGIVENESS?

‘ As Christians we have not applied the Scriptures to our own institutional or individual
lives. Jesus’ commandment to love one another has been nullified by division, litigation, and
hostility. At times a veritable civil war has been fought out in the Christian community. One is
reminded of the story of Stonewall Jackson’s observation of fighting among his own men. He
reportedly told them, ‘ Remember, gentlemen, the enemy is over there.’

Lynn and Juanita Buzzard, Resolving Our Difference s. 3.

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Name: _______________________________________ Section: ______ Date: ___________

Review Questions # 12: Please write the letter of your choice in the space before the number

___1. Which of the following is a true statement about conflict?

a. It seldom occurs as part of the change process in health care settings
b. It highlights differences in values, beliefs, or actions
c. It is automatically negative
d. It discourages creativity and innovation

___2. Conflict that occurs between groups or teams is called:

a. Interpersonal b. intrapersonal c. organizational d. dysfunctional

___3. In this conflict resolution method, a person ignores his or her own feelings about an issue in order
to agree with the other side.
a. Collaborating b. confronting c. Accomodating d. Withdrawing

___4. With this method of conflict resolution, each side gives up something as well as gets something.
a. Negotiating b. Competing c. Avoiding d. Compromising

___5. A conflict resolution approach that neither party loses anything and believed to be approaching the
other person in a caring way to achieve win-win solution.
a. Negotiating b. Forgiving c. Carefronting d. Confrontation
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CHRISTIAN LEADERSHIP

THE TESTING TIMES OF A LEADER

Pastor Fredrick Russell

Four Major Testing for a leader:

I. TIMES of DISCOURAGEMENT

“Let us not to be weary in well doing: for in due season we shall reap, if we faint not.’’
(Galatians 6:9)

FOUR Laws for Dealing With Discouragement

Law # 1 The Law of Positive Thinking.

1. Negative thinking brings on discouragement.

2. A positive mental ATTITUDE speeds you trough discouragement.

Law # 2: The Law of REST and RECUPERATION.

“Then as Elijah lay and slept under a broom tree, suddenly an angel touched him,’
Arise and eat..” (1King 19:5)

1. Rest is the single best ANTIDOTE for discouragement.

2. Rest permits a leader TIME to regain their energy.

*You need to take a vacation & you need to pay for it. The higher you go.
The more problems you will have or get into. When you are discouraged you lose perspective.

*Joke time: Sometimes it was Moses who wanted to kill the people.

Law # 3: The Law of Perspective

1. Staying Balanced is a must in keeping perspective.

“I am not able to bear all these people… the burden is too heavy For me,” (11:14) “You
can’t do it all”

Law # 4: The Law of RECALL

1. Call to memory what God has DONE in the past.

2. Call to memory what God has SAID in the past.
* Read your Bible for encouragement.

Jeremiah 29:11 (NIRV)

Comprehensiveness “I know the plans I have for you”

Goodness “I want you to enjoy success. I do not plan to harm you”
Optimism “I will give you hope for the years to come”
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II TEST of CHANGE

“The essence of real leadership is to allow your people to see your need and desire for learning. Your
actions speak louder than your words. Today’s leaders must be students of change first, before they
become teachers of change to others.”
Jack Kahl, Manco,Inc.

“Constant change is here to stay.” Unknown

*People do not change until the pain of staying the same is greater than the pain of change.
Joshua 1:1-18
The Biblical Pattern for Change:

A. Learn from those who have CHANGED. (Joshua 1:1)

B. Let go of the PAST so you can change. (vs.2)
C. Initiate change. (vs. 3)
D. KNOW what you are trying to change. (vs. 5)
E. God HELPS you through the process of change. (vs. 5)
F. To change requires COURAGE. (vs. 6)

“The most striking thing about highly effective leaders is how little they have in common. What one
swears by, another warns against. But one trait stands out: the willingness to risk.” Larry Osborn

G. Don’t get “SIDE TRACKED” as you change. (vs. 7)

H. Embrace GOD’S principles for change. (vs. 8)
I. Don’t get DISCOURAGED as you go through change. (vs.9)
J. Talk to your LEADERS/INFLUENCES before you begin to change. (vs.10)
K. Prepare the people for change. (vs.11)
L. Help Others so they can change. (vs. 13-18)

“When you soar like an eagle, you attract the hunters.”

Milton S. Gould

III TIMES of CONFLICT

The Basic Art of Confrontation:
1. Seek WISDOM.
2. EXAMINE your own heart first.
3. Timing is important, but don’t PROCRASTINATE or give in to unnecessary delays.
4. Conduct the confrontation with a WORD and LOVING attitude.
5. Be direct, succinct stay FOCUS, and make sure they understand the issue at hand.
6. Communicate in a clear way that you understand their position or perspective.
7. Communicate clearly what ACTION you desire to take place.
8. Reaffirm your COMMITMENT to the individual as a person.
9. Put the issue in the PAST so far as you are concerned.

Check list for an effective and redemptive confrontation:

-Did I separate the person from the action?
-Did I do my home work, get my facts straight, and pray first?
-Did I confront only what person can change?
-Were my heart and motives right?
-Was a specific of action agreed upon, and the person affirmed?
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IV TIMES of STAGNATION (Personal)

“You are the way you are because that’s the way you want to be. If you really wanted to be any different,
you would be in the process of changing right now.” Fred Smith

“It’s amazing what happens when you recognize your good qualities, accept responsibility four your
future, and take positive action to make that future brighter.” Zig Ziglar, Over the Ttop
G…ET up
R…EACH out
O…WN up
W…ORK out
T…UNE up
H…ELP out
“ Trying & failing, learning from failure, & trying again works a lot better than waiting for perfection.”
John Ortberg

10 GREATEST LEADERSHIP LESSONS I’VE LEARNED THUS FAR…..

Fredrick A. Russell

“The growth and development of people is the highest calling of leadership.” John Maxwell

“Leaders get out in front and stay there by raising the standards by which they judge themselves, and by
which they are willing to be judged.” Fred Smith

“Leaders need to submit themselves to a stricter discipline that is expected of others. Those who are first
in place must be first in merit.” Unknown

Leadership Lesson # 1: The greatest show of power is the ability to exercise restraint.

The Problem of Power in the Wrong Hands:

Saul, the first King of Israel, is an example of power in the wrong hands.

1. POWER can be used RUSHLY. (1 Sam.14:24)

2. POWER can be used UNREASONABLY.(14:44)
3. POWER can be used SELFISHLY.(15:9)
4. POWER can be used PIOUSLY. (15:30)
5. POWER can be used JEALOUSLY. (18:8)
6. POWER can be used REVENGEFULLY.(18:9-10)

“There are several kinds of power. One is coercive power, used principally to destroy. Not much that
endures can be built with it. Even presumably autocratic institutions like business are learning that the
value of coercive power is inverse to it’s use. Leadership by persuasion and example is the way to build.”
Robert Greenleaf, Servant Leadership.
The Potential of Power in the Right Hands:
David, the second King of Israel, is an example of power in the right hands.
1. POWER can be used MERCIFULLY.(1 Sam. 24:6)
2. POWER can be used REASONABLY.(25:33)
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3. POWER can be used UNSELFISHLY.(26:8-11)

4. POWER can be used KINDLY.(11 Sam. 9:6-8)
5. POWER can be used GRACEFULLY.(16:5-11)
6. POWER can be used RESTRAINTS at all times.(18:5)

Leadership Lesson # 2: When a person or group is attacking you personally, you will know
they’re dealing from a position of weakness, hold your ground---be firm.

Four ways to handle criticism:

A. Consider the SOURCE from which the criticism was given.
B. Consider the SPIRIT of the criticism that was given.
C. Consider the CONTEXT which the criticism was given.
D. Consider the FACTS of the criticism that was given.

Abraham Lincoln was constantly assailed by the most vicious, personal, and hateful attacks. But he
never gave into them. He always stood on principal and handled himself with character. He chose
never to fight back using the tactics of his enemies. He always took the higher road.

LINCOLN PRINCIPLES OF LEADERSHIP WHEN UNDER ATTACK

* Refrain from reading attacks upon yourself s you won’t be provoked.

* Don’t be terrified by an excited populace and hindered from speaking your honest sentiments.

* It’s not entirely safe to allow misrepresentation to go uncontradicted.

* If you yield to even one false charge, you may open yourself up to other unjust attacks.

* If both factions or neither shall harass you, you’ll probably be about right. Beware of being assailed by
one and praised by the other.

* The probability that you may fall in the struggle ought not to deter you from the support of a cause you
believed to be just.
Source: Donald T. Phillips, Lincoln on Leadership

Leadership Lesson # 3: No matter what happens, never loose control of yourself; for
even if you win, you’ll regret it in the morning.

“No man is fit to command himself.” another that cannot command.” William Penn

“A wise man controls his temper, he knows that anger cause mistakes.” Solomon

Victor Frankl suggests that there are three central values in life:
1. The EXPERIENTIAL: That which happens to us.
2. The CREATIVE: That which we bring into existence
3. The ATTITUDINAL: Our response in difficult circumstance.
Frankl makes the point that the highest of the three values is ATTITUDE.
In other words, what matters most is how we respond to what we experience in life.
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“WE HAVE THE POWER TO CHOOSE OUR RESPONSE” Stephen Covey

Leaders Who Do Not Control Themselves:

1. FAILS at modeling before the people.

2. FORFEITS the respect of the people.
3. FACILITATES duplication by the people.

Leadership Lesson # 4: Own up to mistakes immediately! The quicker you do, the
better it will be.
M…AKE your apology sincere.
I…NVITE the offended to talk.
S…END A message of openness.
T…AKE the initiative.
A…SK for forgiveness.
K…NOW who to go.
E…NCOURAGE the growth of all.
S…PEND time in prayer.

“No one lives in a mistake-free zone”

Leadership Lesson # 5 : Always be kind.

The most difficult time to be Kind is when People are Being Unkind. This is Part of the Hurts of
Leadership.
How to Handle the Hurts in Leadership
1. Understand that getting hurt is part of the LEADERSHIP package.
2. Travel the HIGH ROAD.
3. Find a way to RELIEVE STRESS.
4. Focus on the VISION of the organization.

“Remain Calm, Be Kind”

Colin Powell’s Rules for Leadership #10

Leadership Lesson # 6: Be prepared to own up anything you shared in confidence,

for it will probably be shared with others.

Russell’s Rules for Speaking..

A. Speak only what you know to be TRUE.
B. Speak only that which is KIND.
C. Speak only to that which can be BACKED UP.
D. Speak only that which you don’t mind being QUOTED.
E. Speak only to GOD about some things.

Leadership Lesson # 7: When dealing with a people sensitive issue, never delegate it
to someone else.
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Three Leadership Matters You NEVER DELEGATE:

1. Matters of your follower’s HEART (discipline, correction, wrongs etc.)
2. Matters of your organization’s HEALTH (conflict, vision, direction etc.)
3. Matters of your fellow leader’s HEAD (team, unity, esprit de corps etc.)

“Delegation is needful for leaders, for they cannot do it all on their own. But there are some things that a
leader can never delegate, for if you delegate it, you die.”
Fredrick Russell

Leadership Lesson # 8: The leader is always responsible for setting the standard for integrity in
their organization.

In the Year 2002, Enron and MCI, two great American companies, were less known for their products and
services, but more by the lack of integrity displayed by their leaders. When the leader lacks integrity, the
entire organization will be affected. It may take some time, but invariably the “cancer” that comes from a
lack of integrity will metastasize throughout the entire organization.

Great Qualities That leader must display at all Times, Both in Public and in Private:
Honesty Principle Discretion Character
Truthfulness Loyalty Nobleness Christlikeness

Leadership Lesson # 9: Despite what is happening around you, happiness is a choice.

‘Happiness is really about Attitude’

EliminateThese Words Completely Make These Words a Part of Your

Vocabulary
1. I can’t 1. I Can
2. If 2. I will
3. Doubt 3. Expect the Best
4. I don’t think 4. I know
5. I don’t have time 5. I will make time
6. Maybe 6. Positively
7. I’m afraid of 7. I am confident
8. I don’t believe 8. I do believe
9. (minimize) I 9. (promote) You
10. It’s impossible 10. God is able
From John Maxwell book, The Winning Attitude

Leadership Lesson # 10 : I cannot lead unless I pray.

In An Autobiography of Prayers. Albert E. Day asserts that prayer makes us more

“God conscious” and less “me –conscious.”

Prayer is: Affirming our design to realign our lives with principles and will of God
Confessing our inability to consistently do that on our own
Counting our many blessings regardless of appearances or circumstances
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Validating the truth of God’s guidance and grace

Enlisting and unleashing powerful angelic forces to come to our aid
Giving thanks for the opportunity to serve, and the power to grow personally and spiritually
Making the heart large enough until it can contain God’s gift of Himself.

HOW TO KEEP GROWING

A LEADER IS A READER
1. Seek for:
A. WISDOM/UNDEERSTANDING/INSIGHT.
B. APPLICATION
C. OPPORTUNITY
D. MEMORY
E. CONCENTRATION

2. Read with a PURPOSE and read selectively.

3. Read to RETRIEVE
4. Read EVERYDAY
5. Set a GOAL for the year.
6. Don’t feel as if you must FINISH the book.
7. Remember the AUTHOR’S name with the title of the book.
8. Encourage your SPOUSE and your CHILDREN to read.
9. Budget MONEY for the book.
10. Read with a DICTIONARY close at hand.
11. Discuss and APPLY what you are learning.
12. Make a life long COMMITMENT to be a reader.
_____________________________________________________________
MANAGEMENT FUNCTIONS
Planning
Organizing
Staffing PLANNING
Delegating
Directing
Coordinating ORGANIZING
COMMUNICATION =GOAL
Controlling
Monitoring
Evaluating DIRECTING “ bottleneck ’
Budgeting
Auditing CONTROLLING

MANAGER vs. LEADER

Not All Leaders Are Good Managers
“A good manager makes decisions and who can communicate well”
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“ Your attitude determines your altitude”

“ You are the way you are because that’s the way you want to be. If you really wanted to be
any different, you would be in the process of changing right now.”
Fred Smith

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God bless you…. future Christian Nurse Leader and Manager of AUP!

Maam Jackie Polancos