NURSING LEADERSHIP AND MANAGEMENT NOTES

NURSING LEADERSHIP AND MANAGEMENT

 DECISION MAKING - choosing a particular course of action

 PROBLEM SOLVING - analyzing a difficult situation
 CRITICAL THINKING - reflective thinking

Comparing the Decision-Making Process with the Nursing Process

Decision Making Process Nursing Process

Identify the decision ASSESS

Collect Data
Identify criteria for decision PLAN
Identify alternatives
Choose alternative IMPLEMENT
Implement alternative
Evaluate steps in decision EVALUATE

ORGANIZATIONAL PLANNING
 VISION - future goals or aims of an organization
 MISSION - typically no more than 3 or 4 sentences; identifying the reason WHY an
organization exist

SAMPLE VISION:
"County Hospital will be the leading center for trauma care in the region."

SAMPLE MISSION:
"County Hospital is a tertiary care facility that provides comprehensive, holistic care
to all state residents who seek treatment. The purpose of the County Hospital is to combine
high quality, holistic health care with the provision of learning opportunities to students in
medicine, nursing, and allied health sciences."

 PHILOSOPHY - flows from the purpose or mission and delineates the set values
and beliefs that guide all actions of the organization
 GOALS - desired result towards which effort is directed; aim of the philosophy
 OBJECTIVES - more specific and measurable than goals; HOW and WHEN the goal
is to be accomplished
 POLICIES - plans reduced to statements or instructions that direct
organizations in their decision making
 PROCEDURES - establish customary or acceptable ways of accomplishing a
specific task and delineate a sequence of steps of required action

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 RULES AND REGULATIONS - specific action or non-action; rules are fairly

inflexible

THE MANAGEMENT PROCESS

1.PLANNING
 Encompasses determining the philosophy, goals, objectives, policies, procedures,
and rules carrying out long and short range projection determining a fiscal course
of action managing planned change

2. ORGANIZING
 includes establishing the structure to carry out plans, determining the most
appropriate type of pt care delivery, and grouping activities to meet unit goals
working w/in the structure of the organization and understanding and using power
and authority appropriately

3. STAFFING
 recruiting, interviewing, hiring, and orienting staff scheduling, staff development,
employee socialization, and team building

4. DIRECTING
 entails human resource management responsibilities such as motivating, managing
conflict, delegating, communicating, and facilitating collaboration

5. CONTROLLING
 performance appraisals, fiscal accountability, quality control, legal and ethical
control, and professional and collegiate control

MANAGEMENT THEORY DEVELOPMENT

Distinguish between a leader and manager

Similarities:
(a) Both focus on goals
(b) Both direct followers

Differences:
(a) Managers have legitimate power
(b) Leaders inspire followers by interpersonal charisma and may not have an assigned
position of power within the organization
(c) Managers’ outcomes focus on the organization or unit goals
(d) Leaders’ outcomes focus on their peers, which ultimately may accomplish the
organization’s goals if not in direct conflict

LEADERSHIP THEORIES

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I. The Great Man theory – asserts that some people are born to lead whereas others are
born to be led.

II. Trait theory – some people have certain characteristics or personality traits that make
them better leaders than others.

III. Behavioral Theories

1) Authoritarian leader
- Strong control is maintained over the work group
- others are motivated by coercion
- others are directed by commands
- Communication flows downward
- decision making does not involve others
- emphasis is on the difference in status (“I” and “you”)
- criticism is punitive
2) Democratic leader
- Less control is maintained
- economic and ego awards are used to motivate
- others are directed through suggestions and guidance
- communication flows up and down
- DM involves others
- emphasis is on “we” rather than “I” and “you”
- criticism is constructive
3) Laissez-faire leader
- Permissive, with little or no control
- motivates by support when requested by the group or individuals
- provides little or no direction
- uses upward and downward communication b/w members of the group
- disperses DM throughout the group
- Places emphasis on the group
- does not criticize

IV. Interactional Leadership Theories

1) Theory Z (Ouchi)
 An expansion of McGregor’s theory Y and supports democratic leadership
 Characteristics: consensus DM, fitting employees to their jobs, job security, slower
promotions, examining the long term consequences of management DM, quality
circles, guarantee of lifetime employment, establishment of strong bonds of
responsibility b/w superiors and subordinates, and holistic concern for workers.
2) Developmental levels of orgs and leaders (Nelson and Burns)
a) Reactive – leader that focuses on the past, crisis driven, and is frequently abusive to
subordinates
b) Responsive – leader is able to mold subordinates to work together as a team,
although the leader maintains most DM responsibility

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c) Proactive – leader and followers become more future oriented and hold common
driving values. Mgt and DM more participative
d) High-performance team – max. productivity and worker satisfaction are apparent
3) Interactive leadership model (Brandt)
 Leaders develop a work env’t that fosters autonomy and creativity through valuing
and empowering followers.
 This leadership affirms the uniqueness of each individual
 Affords the leader greater freedom while simultaneously adding to the burdens of
leadership
4) Collaborative practice matrix (Wolf, Boland, & Aukerman)
 Highlights the framework for the dev’t and ongoing support of relationships b/w
and among professionals working together
 Emphasis on how expectations, personal values, and interpersonal relationships
affect the ability of leaders and followers to achieve the vision of the organization

TIME MANAGEMENT
 To increase and maintain energy levels, alternate physical and mental tasks
 Break large projects into small projects that can be completed
 The first step in time management is to begin each and every shift or project with a
planning period and prioritize
 Delegation can organize your time and increase productivity communication

COMMUNICATION
 Communication is the capability of forming and sending a message so that another
can receive and interpret its true meaning.

Characteristics of communication
(1) Formal or informal: formal is information upheld by the organization; informal is
unofficial information, also known as “grapevine”
(2) Vertical or horizontal: vertical information passes from management to employees;
horizontal information passes between peers
(3) Personal or nonpersonal: interdependent influences may occur; nonpersonal
information has no shared influences
(4) Instrumental or expressive: instrumental information is essential to perform the task;
expressive information may be considered trivial or nonessential

Assertive Communication
(a) Does not violate another person’s rights
(b) Verbal and nonverbal communication are congruent
(c) Uses straightforward honest ways for expression

Aggressive Communication
(a) Often involves hostile manner of expression
(b) Does not consider the rights of the other person
(c) “I want to win at all costs”

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Passive Communication
- individual has powerful feelings about an issue but does not verbalize those feelings.
Passive-Aggressive Communication
- an aggressive message delivered in a passive way. Often verbal and nonverbal are
not congruent.

FISCAL PLANNING
 COST EFFECTIVE - economical in terms of the goods and services received for the
money spent; "product is worth the price"
 COST CONTAINMENT - effective and efficient delivery of services while
generating needed revenues for continued organizational productivity

FISCAL TERMINOLOGY
 DIRECT COSTS - can be attributed to a specific source, such as medications and
treatments; costs that are clearly identifiable with goods or services
 INDIRECT COSTS - cannot be directly attributed to a specific area; usually are
hidden costs (e.g. housekeeping services)
 VARIABLE COSTS - vary with the volume (e.g.. payroll costs)
 FIXED COSTS - do not vary according to volume; (e.g. mortgage, loan payments)
 CONTROLLABLE COSTS - can be controlled or vary; (e.g. number of personnel
employed, level of skill required, wage levels, and quality of materials)
 NONCONTROLLABLE COSTS - indirect expenses that cannot usually be
controlled or varied; (e.g. rent, lighting, depreciation of equipment)

BUDGETING METHODS
 INCREMENTAL BUDGETING
- "flat percentage increase method"
- simplest
- (Current year expense) X (inflation rate/consumer price index) = Projected
budget for coming year
 ZERO-BASED BUDGETING
- must rejustify their program or needs every budgeting cycle
 FLEXIBLE BUDGETING
- adjust automatically over the course of the year depending on variables s/a
volume, labor costs, & capital expenditures
 NEW PERFORMANCE BUDGETING
- emphasizes outcomes and results instead of activities or outputs

Components of Organizational Structure

1) Relationships
a) Formal – lines of communication & authority depicted by solid lines. Solid
horizontal lines depict communication b/w people w/ similar spheres of
responsibility and power but different functions.
b) Informal – dotted or broken lines, staff positions.

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2) Chain of command – solid vertical lines, the formal paths of communication and
authority.
- Those having the greatest DM authority are located at the top, those with the
least are at the bottom.
- The level of position on the chart signifies status and power
3) Unity of command – vertical solid line b/w positions on the org chart
- One person/one boss in which employees have one manager to whom they
report and to whom they are responsible
4) Span of control – number of people directly reporting to any one manager
represents that manager’s span of control and determines the number of interactions
expected of him/her.
5) Managerial levels
a) Top level managers – looks at org as a whole, coordinating internal and external
influences, and generally makes decisions w. few guidelines or structures (e.g. chief
nursing officer)
b) Middle level – coordinate the efforts of lower levels of the hierarchy and are the
conduit b/w lower and top level managers (e.g. unit supervisor)
c) First level – concerned w/ specific unit’s work flow (e.g. charge nurse, TL, primary
nurse)
6) Centrality – organizational distance
- Employees with relatively small org distance can receive more info than those who are
more peripherally located

TRADITIONAL PATIENT CARE METHODS

1. TOTAL PATIENT CARE
- "case method"
- patient assigned as cases
- Advantage: High autonomy and responsibility, patient assignment is simple
and direct, no planning required, holistic and unfragmented patient care
- Disadvantage: if nurse is inadequately prepared or inexperienced
2. FUNCTIONAL NURSING
- economical
- Advantage: efficient, tasks completed quickly, allow care to be provided with
minimal number of RNs
- Disadvantage: fragmented care, possibility of overlooking patient priority
needs, low job satisfaction, not cost effective (needs many coordinators), less
interest on overall results
3. TEAM NURSING
- Leader: Nurse
- more than 5 people
- democratic leadership
- Advantage: members given autonomy and contribution on their expertise/skills
- Disadvantages: improper implementation, insufficient time for planning &
communication
4. MODULAR NURSING

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- mini-team (2-3 members)

- Advantage: more time for planning and coordination, less communication (direct
patient care)
5. PRIMARY NURSING
- "relationship based nursing"
- 1:1 patient-nurse relationship
- Advantage: holistic, high quality nursing care, high job satisfaction
- Disadvantage: incompetent nurse (incapable of coordinating care)
6. CASE MANAGEMENT
- collaborative process
- Multidisciplinary action plans (MAPS) = critical pathways + NCPs
- needs advanced nurses (case managers)
- individual patient
7. DISEASE MANAGEMENT PROGRAM
- plans care for populations or groups of patients w/ same chronic illness

Motivational theory
1) Maslow’s Hierarchy of Needs
2) Skinner’s Operant Conditioning & Behavior Modification
- People could be conditioned to behave in a certain way based on consistent
reward or punishment system
3) Hygiene or motivation factors (Herzberg)
- Employees can be motivated by the work itself and that there are internal or
personal need to meet organizational goals.
4) Expectancy Model (Vroom)
- Looks at motivation in terms of the person’s valence, or preferences based on
social values
- A person’s expectation about her environment or a certain vent will influence
behavior
5) McClelland
- People are motivated by 3 basic needs: achievement, affiliation, and power
6) Saul Gellerman
- “Stretching” – involves assigning taks that are more difficult than what the
person is used to doing (should not be a routine)
- “Participation” – entails actively drawing employees into decisions affecting
their work
7) McGregor’s Theory X and Y

Stages of group development

Stage 1: Forming
 Personal relations characterized by DEPENDENCE
 Gathering of impressions and data about similarities and differences among
members
 Major task: Orientation
Stage 2: Storming

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 Characterized by competition and conflict in personal-task relations

 Group members must move from “testing and proving” mentality to “problem
solving” mentality
Stage 3: Norming
 Interpersonal relations is characterized by COHESION
 Engaged in active acknowledgment of all group members’ contributions
 Major task: Data flow between members -> sharing of feelings and ideas, solicit and
give feedback to each other
Stage 4: Performing
 Not reached by all groups
 Personal relations expand to true interdependence
 Group most productive, task oriented, people oriented, and there is unity
 Task function: Genuine problem solving, leading toward optimal solutions and
optimum group development
Stage 5: Adjourning
 Termination of task behaviors and disengagement from relationships negotiation

NEGOTIATION STRATEGIES
1. Soft Negotiation
 Soft negotiators want to avoid personal conflict so they make concessions to
reach an agreement quickly, even though they may end up feeling bitter and
exploited.
2. Hard Negotiation
 Hard negotiators look at any situation as a contest of personal wills.
 They believe that the person who takes the extreme position and holds out
the longest does better in negotiating.
3. Principled Negotiation
 Principled negotiation is a combination of soft and hard. Issues are discussed
on their merits rather than through a haggling process focused by what each
party says it will and will not do.
 This method allows people to be fair while protecting themselves against
others who take advantage of them.

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