Chapter 1- Decision Making, Problem Solving, Critical

Thinking, and Clinical Reasoning

Decision Making: complex, cognitive process of choosing a particular course of action; it’s the thought
process of selecting a logical choice from available options
● Out of several choices a choice is made to eliminate uncertainty and the decision is made not to
solve the original problem.
● Instead of firing a late coworker wait till she quits.
● Decisions making is step one in the problem solving process that relies on critical thinking and
clinical reasoning skills.

Problem Solving: part of decision making; systematic process focusing on analyzing a difficult situation
involving higher-order reasoning and evaluation and needs the decision making step.
● It’s possible to make a decision without full understanding in problem solving.

Critical Thinking / Reflective Thinking: the mental process of actively and skillfully conceptualizing,
applying, analyzing, synthesizing, and evaluating information to reach an answer or conclusion
● Broader than decision making and problem solving; involves forming judgments about facts.
While uses knowledge and experience to make sound decisions.
● Characteristics of a Critical Thinker
○ Insight, Intuition, empathy, and willingness to take action.

Clinical Reasoning: integrating and applying different types of knowledge to weigh evidence, critically think
about arguments, and reflect upon the process used to arrive at diagnosis
● Structured approach to problem solving and decision making increases clinical reasoning.

Successful Decision Makers ARE:

● Self-aware
● Courageous - successful decision maker should be willing to take risks
● Sensitive
● Energetic
● Creative

Experiential Learning - Problem Based Learning [PBL] (used in Case Studies)

● Provides mock life experiences to learn from
● Allows learners to apply leadership and management theory
● Promotes whole-brain thinking and improved problem-solving skills
Marquis – Huston Critical Thinking Model
● The desired outcome for teaching and learning decision making is...in management it is an
interaction between learners and others that results in the ability to critically examine management
and leadership issues
● The learning of appropriate social/professional behaviors rather than a mere acquisition of
knowledge; this works best in groups and PBL
● Marquis-Huston How to Teach Critical Thinking - Taught in 4 steps (pic)
1. Didactic Theory is the material presented in each chapter
2. Formalized approach to problem solving and decision making must be used
3. There must have use of some of a group process (large or small)
4. The material must be made real for the learner, so that they can internalize the learning (writing
exercises)

Traditional Problem Solving (bad due to time used for implementation = less effectiveness)
● Identify = identify the problem
● Gather data = establish decision criteria
● Explore alternatives
● Evaluate alternatives
● Select solution = or choose best alternative
● Implement the solution
● Evaluate = evaluate the decision

Feedback Mechanism of the Nursing Process and Nursing Process: A Problem-Solving and Decision-
Making Model
● Assess ● Implement
● Diagnose ● Evaluate
● Plan

Intuitive decision making

● What is it? --- A gut feeling, a strategic action that impacts patient outcomes based on knowledge.
● Can it be helpful? --- YES
● Can it or should it be used in conjunction with evidence-based practice? --- YES
● Perceived as a cognitive skill

Critical Elements in Problem Solving and Decision Making

1. State a clear objective/goal
2. Gather data carefully - prevent no confirmation bias
3. Take the time necessary
4. Use an evidence-based approach to gather data and make decisions
1. Evidence-Based Approach - PICO - guides the researcher or decision maker in which way to
proceed and address the problem
1. Patient or population
 2. Intervention
3. Comparison
4. Outcomes
2. Strategies for New Nurses to Promote Evidence-Based Practice
1. Keep abreast of the evidence
2. Use multiple sources of evidence
3. Use evidence to support clinical interventions and teaching strategies
4. Find established sources of evidence
5. Implement and evaluate nationally sanctioned clinical practice guidelines
6. Question and challenge nursing traditions
5. Generate/think many alternatives - brainstorming
6. Think logically
1. Overgeneralizing - this is good then all of the same is good as well - stereotypical
statements used in arguments/decisions
2. Affirming the consequences -if A. is good and nurses are doing B. then B. is bad - don’t think
in good or bad
3. Arguing from analogy - if A and B are present then both are good - this is not true all the
time (working being better than their boss at work)
7. Choose and act decisively

Influences on decision making Successful Decision Maker Understands:

● Gender
● Values
● Life experience
● Individual preference - self-awareness and
honest with oneself (doing unpopular things)
● Thinking Styles - Right brain …intuitive,
creative vs. Left Brain ..Analytical
● Gender
● Personal individual values
● Life experience
● Preferences
● Willingness to take risks
● Brain hemisphere dominance
● Predominant thinking style

Overcoming individuality in Decision Making - being aware of vulnerability and influences

● Overcoming a lack of self awareness ● Courage
● Inexperience ● Sensitivity
● Self honesty ● Energy
● Use of heterogenous groups ● Creativity

Questions Asked in Data Gathering

● What is the setting?
● What is the problem?
● Where is it a problem?
● When is it a problem?
● Who is affected by the problem?
● What is happening?
● Why is it happening? What are the causes of the problem? Can I prioritize the causes?
● What are the basic underlying issues? Areas of conflict?
● What are the consequences of the problem? Which of these are most serious?

Questions Asked in Analyzing Solutions

● What factors can you influence? How can you accentuate the positive factors and minimize the
negative factors?
● What are the financial, political, time, and resource implications of each possible solution?
● What are the weighting factors?
● What is the best solution?
● What are the means of evaluation?
● What are the consequences of each alternative?

Problem-Solving vs. Decision-Making Models

The Traditional Problem-Solving Process Managerial Decision-Making Model

● Identify the problem ● Determine the decision and the desired

● Gather data to identify the causes and outcome (set objectives)
consequences of the problem ● Research and identify options
● Explore alternative solutions ● Compare and contrast these options and their
● Evaluate each alternative consequences
● Select appropriate solution ● Make a decision
● Implement solution ● Implement an action plan
● Evaluate results ● Evaluate results

Strategies for New Nurses to Promote Evidence-Based Practice—(cont.)

● Dispel myths and traditions not supported by evidence
● Collaborate with other nurses locally and globally
● Interact with other disciplines to bring nursing evidence to the table

Decision-Making Tools
● Decision grids ● Consequence tables
● Payoff tables ● Logic models
● Decision trees ● Program evaluation and review technique

Economic Man versus Administrative Man

Vicarious Learning to Enhance Decision-Making Skills
● Case studies: provide stories that impart learning
● Simulations: provide opportunities for learning with no risk to patients or organizational performance
● Problem-based learning (PBL): provides opportunities for learners to address and learn from authentic
problems vicariously

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Chapter 2 - Classical View of Leadership and Management

Leadership/Management - What are the differences
● Leadership- interpersonal behavior that looks forward and sees possibilities if they set a direction. Term
entered the english language in the first half of the 19th century
○ LEADERS ARE:
■ Fordaring moving, taking risks, challenging the staus quo, guides direction, are out
front, attempting to achieve shared goals
■ Those who follow leaders choose to do so
■ Leaders use interpersonal characteristics to influence
■ Obtain power through influence
■ Wider variety of roles
■ Empowering, gathering of info, feedback,
■ Emphasize interpersonal relationships
■ Leaders have goals that may or may not reflect those of the organization

● Management –shapers of structural features of an organization and that goals are being met
○ Process of directing an organization by deployment and manipulation of resources

● Good leadership is good management

Managers - "the act or manner of guiding or taking charge"

● Have an assigned position
● Legitimate source of power
● Expected to carry out certain functions
● Emphasize control, decision making, analysis
● Manipulate people, money, time, and resources
● Formal accountability and responsibility
● DIRECT WILLING AND UNWILLING SUBORDINATES

Leadership Flaws
● A lack of energy ● Not collaborating
● Acceptance of their own mediocre ● Not walking the talk
performance ● Resisting new ideas
● A lack of clear vision ● Not learning from mistakes
● Poor judgement ● Lack of interpersonal skills
● Failing to develop others ● Workers achieving minimum standards doing
● Systematic soldiering the least amount of work possible

Historical Developments of Management Theory

● Systematic Soldiering - workers achieving minimum standards doin the least amount of work
possible
○ Scientific Management
■ Rule of thumb replaced with scientific methods - use of time and motion
studies to promote how to work with the greatest efficiency of time and energy
■ Scientific personnel system - workers hired, trained, promoted based on
technical competence and abilities
■ Workers can view how they and their skills fit in the organizations - provides a
shared goal (a give financial incentives as a reward)
■ Relationships between workers and managers should be cooperative- work
should be equally shared
● Max Weber - wrote an essay called “Bureaucracy”
○ Saw the need for legalized, formal authority and consistent rules and regulations for
personnel in different positions
○ More rules, regulations, and structure to increase productivity
● Management functions
○ Henri Fayol in 1925 created 5 function for each management process:
○ Planning, organizing, coordination, staffing, directing, planning, reporting, and
budgeting
● Human Relations Management
○ 1930-1970 (in 1920’s during worker unrest)
○ Participative decision making and participative management
○ Management should have authority with and not over employees
○ If managers paid attention to employees then productivity would increase
○ THEORY X and THEORY Y
■ Theory X believe employees are lazy and need constant supervision
■ Theory Y managers believe that they employees enjoy their work and are self
motivated
○ Some believe that humanistic view is time consuming and decreases objectives

Historical Development of Leadership Theory (before this most of the concentration was on management
styles)
● The Great Man Theory
○ Some men born to lead and other born to be led
○ Some believe people are born with traits, characteristics that make for better leaders
○ Contemporary opponents argue that leadership skills can be developed
● Leadership Styles
○ 1951 lewin and Lippit
 ○ Authoritarian Leaders characterized by:
■ Strong control is maintained
■ Others are motivated by coercion
■ Directed with commands
■ Communication flows downward
■ Decisions do not involve others
■ Status differences
■ Criticism is punitive
○ Ex. US Army, top down
● Democratic leadership
○ Less control
○ Economic and ego are used to motivate
○ Directed through suggestions and guidance
○ Communication up and down
○ Decision making involves others
○ We rather than I and you
○ Criticism is constructive
● Laissez-faire leadership
○ Permissive with little or no control
○ Motivates by support when asked for by the group
○ Provides little or no direction
○ Up and down communication between meers
○ Places emphasis on the group
○ No criticism

Interactional Leadership - 1970-present

● People are variable and complex, have many motives for doing things
● People's motives vary over time
● Goals differ from situation to situation
● Performance is effective by circumstance, task, ability, experience, motivation
● No single leadership strategy is effective in every situation
● Kanter ---people must develop relationships with individuals as well as organizational groups

Interactive leadership model - study in 1994

● LEADERS Develop environments that foster autonomy and creativity by valuing and empowering the
individual

Transactional Leadership
● Focus is on management tasks ● No shared values
● Is committed ● Examines causes
● Trade offs to meet goals ● Uses contingency reward

Transformational Leaders
● Identifies common values ● Empowers others
● Is a caretaker ● Traditionally nurses have been over
● Inspires others with visions managed and under led
● Has a long term vision ● Warnings …highly desirable but need to be
● Looks at effects adaptable

Chapter 3 - 21st Century Thinking about Leadership and

Management
Managerial Responsibilities
● Administrators need to be :
○ Knowledge ○ Communications
○ Skilled ○ Organizers
○ Competent ○ Team Builders

MANAGEMENT INVOLVEMENT
● IMPLEMENTING HEALTHCARE REFORM
● ADDRESSING POTENTIAL INTERNATIONAL NURSE SHORTAGE
● HIGH TURNOVER RATES
● ADMINISTRATION SHORTAGE
● UNIONIZATION
● MANDATORY OVERTIME
● MAINTAINING COHESIVE, PRODUCTIVE, INTERPROFESSIONAL TEAMS

LEADERSHIP CRISIS???
● SUGGESTION IS THAT CONTEMPORARY LEADERS HAVE FAILED TO CHANGE WITH THE TIMES
○ WORLD IS CHANGING QUICKLY
○ TRADITIONAL TOP DOWN LEADERSHIP CANT EVOLVE
○ SINGLE DIRECTIVE APPROACHES VS PARTICIPATORY MODELS

STRENGTH-BASED LEADERSHIP and Principles

● FOCUSES ON DEVELOPMENT OR EMPOWERING WORKERS
● WORKS WITH THE WHOLE …APPRECIATING INTERRELATIONSHIPS
● RECOGNIZES THE UNIQUENESS OF THE STAFF AND ORGANIZATION
● ENVIRONMENTS PROMOTES HEALTH
● UNDERSTANDS THE SIGNIFICANCE OF SUBJECTIVE REALITY
● VALUES SELF-DETERMINATION
● RECOGNIZES THE "GOODNESS OF FIT" BETWEEN RN AND FACILITY
● CREATES LEARNING ENVIRONMENTS
● INVESTS IN COLLABORATIVE PARTNERSHIPS

LEVEL 5 LEADERSHIP - WHAT SEPARATES GOOD COMPANIES FROM GREAT ONES

● HIGHLY CAPABLE INDIVIDUALS
● CONTRIBUTING TEAM MEMBERS
 ● COMPETENT MANAGERS
● EFFECTIVE LEADERS
● GREAT LEADERS

SERVANT LEADERSHIP - RECOGNIZED THAT MOST SUCCESSFUL MANAGERS LEAD IN A DIFFERENT WAY
● Put serving others first
○ employees
○ customers
○ community
● Foster an atmospheres
○ collaboration
○ teamwork
○ collective activism

QUALITIES OF SERVANT LEADERS

● ABILITY TO LISTEN OF A DEEP LEVEL
● ABILITY TO KEEP AN OPEN MIND AND HEART WITHOUT JUDGEMENT
● ABILITY TO DEAL WITH AMBIGUITY
● HONESTLY SHARING CHALLENGES WITH ALL PARTIES IS BETTER THAN PERSONAL SOLUTIONS
● BEING CLEAR AND GOOD AT POINTING OUT DIRECTION WITHOUT GIVING ORDERS
● ABILITY TO BE A SERVANT, HELPER, TEACHER
● ALWAYS THINKING BEFORE REACTING
● ABILITY TO USE FORESIGHT

PRINCIPAL AGENT THEORY - SUGGESTS THAT NOT ALL FOLLOWERS ARE INHERENTLY MOTIVATED TO ACT
IN THE BEST INTEREST OF THE PRINCIPAL (LEADER OR EMPLOYER)
● MAY HAVE AN INFORMATIONAL ADVANTAGE OVER THE LEADER
● MAY HAVE THEIR OWN PREFERENCES

HUMAN AND SOCIAL CAPITAL THEORY

● INDIVIDUALS AND ORGANIZATIONS WILL INVEST IN EDUCATION AND PROFESSIONAL
DEVELOPMENT IF
● INVESTMENT HAS FUTURE PAYOFF
● EXAMPLE…IF HOSPITAL PAYS FOR TUITION THEN MORE EDUCATED RNS EQUAL HIGHER
PRODUCTIVITY AND HIGHER RETENTION RATES ….EQUALS….HIGHER FINANCIAL RETURN

EMOTIONAL INTELLIGENCE - THE ABILITY TO PERCEIVE, UNDERSTAND, AND CONTROL ONE'S OWN
EMOTIONS AS WELL AS OTHERS
● INITIALLY DEFINED AS - DEVELOPS WITH AGE
● CONSISTS OF THREE MENTAL PROCESSES
○ APPRAISING AND EXPRESSING EMOTIONS
○ REGULATING EMOTIONS
 ○ USING EMOTIONS IN ADAPTIVE WAYS

FIVE COMPONENTS OF EI
1. SELF AWARENESS
2. SELF REGULATION
3. MOTIVATION
4. EMPATHY
5. SOCIAL SKILLS

AUTHENTIC LEADERSHIP
● IN ORDER TO LEAD ..LEADERS MUST BE TRUE TO THEMSELVES AND THEIR VALUES AND ACT
ACCORDINGLY
● IT IS THE LEADER'S' PRINCIPLES AND THEIR CONVICTION TO ACT ACCORDINGLY THAT INSPIRE
FOLLOWERS
○ Purpose: understand their own …self aware
○ Values: link purpose and passion
○ Heart: care for themselves and the people they lead
○ Relationships: value building relationships
○ Self-discipline: incorporate balance into personal and professional lives

Thought Leadership
● Applies to a person who is recognized among his or hers peers for innovative ideas and who
demonstrates the confidence to promote those ideas
○ Attract followers with vision and risk taking not empowerment or representation

QUANTUM LEADERSHIP - BUILDS UPON TRANSFORMATIONAL LEADERSHIP

● WORK TOGETHER
● IDENTIFY COMMON GOALS
● EXPLOIT OPPORTUNITIES
● EMPOWER STAFF TO MAKE DECISIONS
● WORK ENVIRONMENT IS FLUID ..EVER CHANGING ..FLEXIBLE …SO EMPLOYEES AND LEADERS MUST
BE EVER CHANGING AND ADAPTABLE

Industrial Age
● Machine and Capital were primary concern
● People were needed but replaceable
● Focus on controlling workers ..fitting in slots
● Reward and punishment for external motivation
Relationship age leadership and health care
● Leading people who have the power to choose
● Embrace the whole person
● Contemporary health care organizations can not must not focus solely on relationships
 ● Becoming a better leader manager means knowing what leading-managing mean ..and balance
traditional industrial age management with relationship age leadership

Chapter 9 - TIME MANAGEMENT

Time as a resource and being overwhelmed by time restraints leads to :
● Increased errors
● Omission of important tasks
● General feelings of stress and ineffectiveness
Time management - defined as making optimal use of available time

Leadership Roles Management Functions

● Self aware regarding personal blocks and
barriers
● Function as a role model and resource
● Recognize ones own values on use of time and
the expectation of others
● Assist followers in working cooperatively
● Prevents and or filters interruptions
● Presents calm during high acuity
● Prioritizes conflicting time requirements
● Prioritizing day to day planning to meet unit
goals
● Builds time for planning
● Analyzes how time is managed
● Eliminates environmental barriers
● Handles paperwork promptly and effectively
● Breaks down lareger tasks to smaller to make
easier to accomplish
● Utilizes technology and evaluates staffing

Basic steps to Time Management

● Set aside time for planning and establishing priorities
● Completing the highest priority task before starting a new task
● Reprioritize tasks based on new information
● Taking time to plan and establishing priorities
○ "Fail to plan…plan to fail"
○ Plan by efficiency rather than by crisis
○ Allow optimal time to finish the goal –planning fallacies ..
○ Being optimistic you will get more accomplished than you actually have time to do
○ The belief that you are unproductive if you take the time to plan ..in actuallity the individual
is less productive and starts to manage by crisis

SMART Approach
● Set specific, clear goals
● Record your progress ..measurable progress maintains interest
 ● Identify steps
● Be realistic about time constraints
● Set a time frame
● Examples in day to day nursing
○ Staffing schedules
○ Patient care assignments
○ Coordination of lunch /break schedules
○ Interdiscipinary coordination of patient care
○ Handoff reports
○ Med administration
○ Documentation

Work environment
● Is it poor planning or is it work environment???
● The use of industrial engineering principles
● Gather all supplies
● Group activities that are in the same location
● Use time estimates
● Document activities as soon as possible strive to end the work day on time

Management daily planning activities

● At the start of day …identify key priorities
● Determine the expected level of accomplishment
● Assess the staff assigned to work with you
● Review the short and long term plans of the unit regularly
● Allow time at different times throughout the day to assess progress
● Take regular breaks …allows to refresh physically and mentally
● Use of electronic scheduling/calender

Priority setting - Divide all requests into 3 catagories:

● Don’t do ● Do later ● Do now

Procrastination - How to avoid

● Break into small tasks ● Making lists ● Reprioritization

Dealing with Interruptions

● Lower level to middle management have more do to increased interaction with staff
○ Results in stress
○ Lowered job satisfaction
○ Leader flexability- staff look at leadership to see how they are coping

Time wasters
● Technology
● Socialization
 ● How to avoid socialization as a manger
○ Don’t make self overly accessible
○ Innterupt
○ Avoid promoting socialization
○ Be brief
○ Schedule long winded pests
○ Many of these things can also promote team building and trust …so mange them wisely

Self awareness
● Staying focused on things that matter
● Taking care of ones self
● Following through in a timely and consistent manner
● Self awareness regarding completing tasks in an isolated setting vs. group
● Beware of ones own work style and how it influences others
● How and when are we most productive

Stress - In a relatioonship with time management - YES?

● Communication skills
● Involve team members
● Good leadership-managers keep control longer and keep energy levels higher

Chapter 12 - Organizational Structure

Organization is formed when the number of workers is large enough to require a supervisior.
● Formal Organization- organizatonal positions and formal power
● Informal Organization - employees, relationships, and informal power inherent with those
relationships

Formal Organization
● Departmentalization, work division …provides a framework for defining managerial authority,
responisibility, and accountability
○ Roles and functions are defined, differing roles, and rank and hierarchy are evident

Informal Structure
● Natural forming social network
● Fills in the gap with connections and relationships
● Based on camaraderie
● Result in more immediate responses from individuals
● People rely on informal structure if formal structure has stopped being effective
● Informal has it’s own communication network-THE GRAPEVINE !!!
● Communication is fast and easily facilitated in all directions
● Difficult to slow or stop and source of rumor or gossip
 Leadership roles and Management Functions

Leadership Roles Management Function

● Evaluates organizational structure ● Knowledgeable about organization structure

● Encourages employees to follow chain of
command
● Supports personnel
● Models responsibility
● Assists staff
● Facilitates constructive informal groups
● Fosters a positive organizational culture
● Promotes participatory decision making
● Facilitates formal structure
● Provides accurate organizational chart
● Maintains unity of command
● Strives to create positive organizational
structure
● Uses informal organizations to meet formal
organizational goals
● Identifies, analyzes, and promotes stakeholder
interests

Organizational Theory and Bureaucracy

● Max Weber – point of view was a manger not as a scholar
● Weber created 3 ideal types of authority or why people throughout history obeyed their rulers
● Legal-rational authority
○ Based on a belief in the legitimacy of the pattern of normative rules and the rights of those
elevated to authority under such rules to issue those command
○ OBEDIENCE the bases of bureaucracy
● Great virtue of bureaucracy –institutional method of applying rules –makes actions of management
fair and predictable

Characteristics of Bureaucracy
● There must be a clear division of labor
● A well defined hierarchy of authority must exist in which superiors are seperated from subordinates
● There must be impersonal rules –people are not free to act as they please
● A system of procedures for dealing with work situations must exist
● A system of rules covering the rights of each position must exist
● Selection for employment and promotion are based on technical competence

Dealing with the 21st Century

● Bureaucracy was a tool of the Industrial Revolution
● Most modern organizations have modified their structures and created environments that are less
rigid and less impersonal
● Components of Webers findings can still be found in the designs of most large organizations

Components of Organizational Structure

● Knowledgeable manager can derive much information from reading organizational charts
 ○ Who reports to who
○ Who has more or less organizational influence
○ Managers who understand organizational structure can expedite decisions and have
greater understanding of the organization's structure

Relationships and Chain of Command

● Formal Relationships represented on a chart
● Solid vertical and horizonal lines stand for communication
● Horizonal Lines represent similar spheres of responsibility
● Vertical Lines denotes offical chain of command
○ Formal communication and authority
○ Greatest decision making at the top
● Dotted or broken lines = staff personnel

Advisory Positions
● Clinical specialists and in-service directors (educators)
● Staff
● Lack Authority
● Descriptions and responsibilities need to be spelled out to maximize productivity

Unity of Command - Employees have one manager to whom they report ..simplifies relationships and
communication

Span of Control
● The number of people directly reporting to any one manager
● The narrower the span the greater number of levels in the organization..
● Ideal span depends on various factors
● Nature of the job
● The manager's abilities
● The employees' maturity
● The task complexity
● The level of the organization in which the work occurs
● Increased financial pressures
● Electronic communication
● Technology advances
● All have had an impact on reducing the number of adminsitrators ---flattinging the organization

Managerial Levels
➢ Effectiveness of these first level managers tremendously affect the organization
➢ Leadership skills influence productivity and satisfaction
● Top Level Managers ---CEO, CNO, COO etc..
○ Coordinate internal and external influences
○ Make decisions with few guidelines or structures
○ Setting policy, creating goals, organization philosophy
 ○ Greater need for leadership skills
○ Not as involved in daily opperations
● Middle Level Managers –nursing supervisors, unit managers
○ Coordinate efforts of the lower levels of hierarchy and serve as go between between lower
and top level managers
○ Handels Day to day opperations
○ Involved in some long term planning
○ Unit policies
○ Some institutions have changed titles of nurse managers to directors, while other smaller
facilities use director in indicate CNO
● First-Level mangers –RNs
○ Concerned with their units work flow
○ Immediate problems
○ Personal needs of the employees

Centrality - is where ones position falls on the organizational chart

● Employees with relatively small organizational distance can receive more information
● Middle manager has a broader view of the organization - receives information upward as well as
downward
● Communication at different levels may be influenced by position in the oraganization

Limits of organization charts

● Does not show the informal structure of the organization
● Includes interpersonal relationships
● Formation of primary and secondary groups
● Indentification of group leaders without formal authority
● Informal leaders are often found among long-term employees or gatekeeping positions
(CNO secretary)
● Usually develops during activities outside the work settings
○ Limits knowledge of the degree of authority
○ Status without authority
○ Charts become obsolete quickly and can be hard to keep updated
○ Too rigid to define the jobs of the people working in the organization
○ Doesn’t define responsibility for roles must have responsibility as well as authority
○ Accountability-agrees to be morally responsible for the consquences for their
actions
○ Leader-manager should know the interrelationships and differences of authority,
responsibility and accountability

Types of Organizational Structures

● Line Structure
○ Large Health Care facilities
○ Most familiar
 ○ Little stress with orientating
○ Authority and responsibility are easily defined
○ BUT: Monotony
○ Alienate workers
○ Rapid adjustment is difficult
○ Restricted upward communication
○ Outside the chain of command is seen as inappropriate

● Ad Hoc
○ Used on a temporary basis
○ Facilitate the completion of a project
○ Project team / task approach
○ BUT: Decreases the strength of the Chain of Command
○ Decreases loyalty to the organization

● Matrix
○ Focus on product and function
○ Function is all the tasks needed to produce the product
○ Formal horizonal and vertical chain of command
○ Less formal rules
○ Fewer levels of hierarchy
○ Centralizing expertise
○ BUT: Slow because of the need for information sharing
○ Confusion and frustration due to dual-authority

● Service Line Organization

○ Sometimes called care-centered organizations
○ Smaller scale
○ Overall goals determined by the larger organization
○ Service line to decide on the processes used to achieve the goals
● Flat Design
○ Goal is to remove layers
○ Decentralizing the organization
○ Single manager overseeing larger numbers of employees
○ More authority and decision making where the work takes place
○ Retain many of the characteristics of bureaucracy

Decision making within the organization

● Centralized decision making
○ Few managers at the top make the decisions –top-down control
○ Vision of a few
○ Execution is rapid

● Decentralized decision making

 ○ Allows problems to be solved by the lowest practical level
○ Solved at the level they occur
○ Delayed execution
○ Benefits larger organizations

Stakeholders
★ Are those entites that play a role in the organizations health and performance or that are
affected by the organization
○ Internal – RN, RT, dietitian
○ External – nursing schools, Home health agency
★ May have an interest in the organization but not the power to change it
★ Organizations usually do not choose their stakeholders
★ Supportive or threatening influence
★ Organization must analyze stakeholders to clarify the consquences of a decision

Organizational Culture
● Organizations values, language, traditions, customs, and sacred cows—things not open for
discussion or change
○ Expectations
○ Philosophy
○ Self image
○ Interactions with the outside world
○ Not to be confused with organizational climate
○ How employees perceive an organization
○ Climate and culture may differ
○ Assessing the culture is a manager role while developing and building the culture is a
leadership role
○ Building a new culture might require new leadership
○ Conflicits between management and leadership in establishing or changing the culture?
○ Organizations may have subcultures
■ Nurse leader must recognize subcultures and do what is needed to create shared
norms and priorities
■ Assist individuals with different values to understand the organizations culture

Shared governance - described as a flattened structure –some differences

● Governance is shared between board members, RNs, MDs, and management
● Joint practice committees are formed to develop power for decision making, and communication is
spread aout and equal between the members
● Gives RNs more control over their nursing practice by being an accountability-based system
● Not to be confused with participatory management – others allowed to but management still has
final authority
● Different councils are formed
● Participation in decision making in all areas
 ● Major impediment is the recultance of managers to change their roles
● Not all nurses want to make decisions, or have a say in the organization's culture

Committee Structure
● Managers are responsible for creating appropriate committee structures
● Committees used to facilitate good upward communication
● Can pool expertise and skills to reduce resistance to change
● If committees are not organized or led well
○ Becomes liability
○ Wastes energy, time, money, and can defer or slow decision making

Responsibilty of the Leader in forming committees

● Become more visible
● Appropriate power stratagies
● Coming well prepared
● Leads to shared decision making
● Cultural diversity
● Not to rely on them to much
● Not used to slow down decision making
● Group think … fail to take risks
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Chapter 17 - Staffing Needs & Scheduling Policies

Why important? Because staffing patterns and scheduling policies directly affect the daily lives of
personnel
–Must be administered fairly
–Economically
–Must be reevaluated periodically
–Develops trust

Managers responsibilities
● Managers should do what they can to see that employees feel they have some control over
scheduling, shift options, and staffing policies
● The use of staffing clerks and computers can help with staffing
● But staffing is an important function for first and middle managers

Centralized Staffing
● Centralized Staffings when decisions are made by personnel in a central office or staffing center
○ Good Points
■ Manager has limited roles
 ■ Minor adjustments
■ Ultimate responsibility for meeting organizations needs
■ Illness or acuity changes
■ Generally fairer
■ Policies are consistent and impartial
■ Frees manager to do other priorities
○ Bad Points
■ Less flexibility
■ Less responsive to budget issues

Decentralized Staffing
● Decentralized Staffing is when the manager is responsible for:
○ covering all absences,
○ reducing staffing in periods of low census
○ preparing monthly schedule
○ Preparing holiday and vacation schedules
● Good Points
○ Manager understands the units needs
○ Feels more in control
○ Increased autonomy and flexibility
● Bad Points
○ Risk of unfair or inconsistent scheduling
○ Time consuming
○ Staffing is unequal or higher quality in certain areas

Complying with Staffing Mandates in States

● Licensed staffing requirements
○ Nurse to staff ratios
○ Legislation and regulations addressing nurse staffing in many states
○ Mandate certain ratios dependent on the patient load
○ Patients negatively affected
○ Patient outcomes
○ Safe care
○ Government control
○ Serve as a band-aid due to shortage in nurses
○ Decline in staffing due to criteria
○ Restrictions on employers
○ Conflicts between individuals and organizations

Staffing and scheduling options

● 10-12 hour shifts
● Premium pay for weekends
● Weekend shifts
 ● Staffing cycles
● Job sharing
● Self scheduling
● Flextime - selecting a time the fit employees needs
● Agency and float pools
● Self trades
● Shift bidding - nurses big on how much to be paid to work a shift

Workload Measurement Tools

● Workload Measurement Tools are requirements based on standard unit of measurement for
productivity
● A formula for nursing care hours per patient day
○ nursing and ancillary staff are counted the same
○ no difference in acuity levels of patients
● The formula results in inaccurate or incomplete pictures of nursing care
● Staffing needs fluctuate among shifts but during shifts as well
● Restrictive
● Patient Classification Systems (PCS) / Patient Acuity / Workload Management
○ Meausre # of staff need to take care of # patients.
○ Provides language that nurses need to make work visible on all levels
○ Optimal balance of patient care and financial viability
○ Critical indicator uses broad indicators such as
■ Bathing
■ Diet
■ IV Fluids
■ Medications
○ Summative indicator types require the RN to note the frequency of occurrences,
treatments, and procedures
○ Once a indicator is picked then nursing hours need to be assigned to each classification.
○ Staff to documented rather than perceived patient needs, increasing trust, fostering
collaboration, and moving finance and patient management to a common goal
○ PCS will not solve all staffing problems
○ PCS give a better definition of the problems - so make better judgements to solve staffing
problems
○ External forces
■ Increase in nursing or medical students using the unit
■ Lower level of graduate skill level
■ Cultural or language difficulties
■ Classification system by be inaccurate
■ Workload measurement systems are /might be the future - For it evaluates work
performance as well as necessary resource levels
○ Regardless of the system used it needs reevaluated periodically and regularly
Relationship between nursing care hours, staffing mix, and quality of care
● Restructuring and Reengineering - made by acute care hospitals to reduce costs, increase
efficiency, decrease waste and duplication, and reshape the way that care was delivered
● 1990s decreased use of RNs ..increased use of UAP….lead to increased studies and funding in
regards to staffing mix and nursing care hours
● As the number of staff members increased adverse effects decreased
● Another study showed that the greater use of agency, float, or overtime nursing resulted in a
higher number of falls

Staffing Issues in Restructuring

● Increased use of UAP
● Part time staff use
● Shift lengths variety
● Cost containment
● Floating taff to other units
● Use of patient numbers and not workload
● Primary nursing
● All this benefitted organization and staff but not the patient

Staffing Diversity
● Managers must be aware to have ethnically and culturally diverse staff to meet the needs of
increasingly diverse patient populations
● 2013 US department of health and human services put 15 standards into effect
● Several of these directly addressed cultural and linguistic diversity
○ Language assistive services
○ Competency of the interpreters
○ Verbal and written notice be given that services exist

Generational Considerations - Study from 2013

● 4 generations of nurses have worked together and each have a different value system
○ Veteran (65-88)
■ Disciplined
■ Respect for authority
■ Supports the status quo
■ Less likely to question the organization
○ Boom Generation (46-64)
■ Work longer hours
■ More materialistic
■ Include many of today's nursing leaders
■ WORKAHOLICS
○ Gen X’ers (30-45)
■ Lack interest in lifetime employment
■ More emphasis on family
 ■ Self reliant
■ 40% of RN workforce
○ Generation Y (10-29)
■ Brash
■ Entitlement
■ Work well in teams
■ Multicultural ease
■ Less loyal to employers

Impact of shortages on staffing

● Cross training - giving employees various backgrounds and skill to take task outside scope of
practice and move between units
● Advanced planning
● Closed unit staffing - unit staff members commit to cover all absences and extra help needs in
return not being pulled for the unit in low census.
● Central pool of nursing
● Extra duty
● Mandatory overtime - nurses forced to work extra shifts (hospitals use to keep few people on
payroll)
● Patient outcomes - they don't want it too but does jeopardize patient care.

Fiscal and Ethical Accountability

● Base unit staffing on their organization's system and PCS
● BUDGET
● Managers will increase staffing with increased acuity and decrease with low census
● Use staff to provide safe and effective care
● Patient acuity allows for more consistent staffing = better budget responsibility
● Fairer

Developing staffing and scheduling policies

Vs. integrating leadership roles and management functions in staffing and scheduling
● Use consistency, and be fair
● Ethical accountability to patients
● Formalized
● Reviewed and updated
● Using evidence based practice

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Chapter 20 Delegation
Delegation - getting work done through others or directing the performance of one or more people to
accomplish organizational goals.
● Giving someone the authority to complete a task or action on your behalf - but you're still
responsible
● Joint Statement of Delegation –ANA and NCSBN
● States that delegation ts a skill that must be taught, practiced and developed.
● Delegation is also used for learning opportunities - without them subordinates become bored and
non-productive.
Delegating Effectively by the following
● Plan ahead to prevent crisis situation or become overwhelmed
● Identify necessary skill and education level to complete the task
● Select capable personnel
● Communicate goals clearly
● Empower the delegate
● Set deadline and monitor progress
● Monitor the role, be a role model, and provide guidance
● Evaluate performance
● Reward accomplishment
Before Delegation you must Identify Necessary skills and education levels
● Scope of practice for RN is typically defined by the Board of Nursing in each state
● Challenge for RN is to understand the scope of practice for others on the team
● Nurse must be aware of the essential elements of delegation in their states NPA
○ Items that can not be delegated
○ Items that can be routinely delegated
○ Guidelines about delegated tasks
○ Description of professional nursing practice
○ Description of LVN/LPN and unlicensed roles
○ Degree of supervision required
○ Guidelines for lowering delegation risks
○ Warnings about inappropriate delegation
○ Restricted use of the word nurse to licensed staff
Select Capable Personnel
● Leadership role is to stretch new and capable employees who want opportunities to learn and grow
● Look for employees who are innovative and willing to take risks
● Important that the person whom the task is being delegated considers the task to be important
● Ask the individual if they are capable of completing the task (if they have enough resources), then
validate it by observation
Communicate Goals Clearly
● Identify limitations or qualifications that are being imposed on the task
● Communicate specifically WHAT, HOW, and by WHEN
● Should also provide the purpose, limitations, and expectations for reporting
Empower the delegate
 ● Delegate the authority and the responsibility to complete the task
● Frustrating to the employee not to have the resources available to carry out the plan
Set deadlines and monitor progress
● Informal but regularly scheduled meetings
● Encourages ongoing communication to clarify any questions or misconceptions
● Leader/manager must be ready to intervene on patients behalf at any moment, and if so provide
feedback
Model the role and provide guidance
● Convey a feeling of confidence and encouragement
● Be available to identify alternative solutions
● Encourage employee to solve problems first but be available to answer questions
● Reassuming the task should be manages last resort for it fosters a sense of failure in the employee
Evaluate performance and Reward Accomplishment
● Evaluate the experience
● Include positive and negative aspects
● Shared reflections on what could have been done differently
● The more recognition team members receive, the more recognition will be given to their leader
Common Delegation Errors
● Under Delegation
○ Can be seen as a lack of ability by leader where in fact delegation can be empowering
○ Lack of trust
■ Communicate frequently to decrease fears and increase sense of control
○ Not enough time to delegate due to not having enough time to teach
○ Lack of experience in delegating
Over Delegating
● Poor managers of time
● Insure about their ability to perform a task
● Over Delegate to exceptional employees that can become overworked and tired thus less
productive
Improper delegating
● Wrong time, wrong person, or for wrong reason
● Beyond the capabilities of the individual
Five Rights of Delegation
● Right task ● Right direction/communication
● Right circumstances ● Right level of supervision
● Right person

Delegation as a function of Professional nursing

● Organizations must have clearly defined structure where RNs are recognized as leaders
● Job descriptions have clearly defined roles
● Educational programs are developed that help personnel learn roles and responsibility
 ● Programs that foster leadership and delegation, consistency, and teach delegation principles
● Nursing Schools and healthcare organizations need to do better at preparing RNs to be delegators
● Need to be supported in early efforts to delegate
○ Open communication
○ Respect
○ Delegate without being looked upon as lazy or incompetent
Delegating to Unlicensed personnel
● UAP and NAPs
● Nurse extenders, care partners, nurse's aides, health care assistants, techs, orderlies
● Primary argument for using is they can free up professional nurses from tasks and assignments
(non-nursing) that can be completed by less extensively trained personnel at lower costs
● Negligent or Liability is based on a supervisor's failure to determine patient needs could be safely
assigned or if doesn’t closely monitor
● Many institutions do not have clearly defined scopes of practice for NAPs
● Some limit scope of practice or non-nursing functions while other allow
○ Insertion of catheters
○ Reading EKGs
○ Trach Suctioning
○ Sterile dressing changes
● Organizations interrupt regulations broadly, no standardized curriculum
● State boards of nursing starting to issue task lists
○ Tasks lists do not require delegation
○ 1990s NCSBN established decision tree for delegation
Helpful hints on what to delegate to UAP (unlicensed assistive personnel)
● Frequently recur in the daily care of a client or a group of clients
● Performed according to standardized sequence of steps
● Involve little or no modification from client to client
● May be performed with a predictable outcome
● Do not involve ongoing assessment, interpretation, or decision making
● Do not endanger the health or well-being of the client
● Allowed by agency policy or procedure
Outcomes
● RN ultimate responsibility is patient well being which is a desired outcome- achieved
● Activities that rely on nursing the nursing process, or require specialized skill, expert knowledge, or
professional judgement should not be delegated
○ Assessment
○ Evaluation
○ Teaching and counseling
○ Teaching and supervising students
Subordinate resistance
● Failure of delegator to see their perspective
● Highly challenging workloads
 ● Delegation imposed by more than one delegator
● Believe that they are incapable
● Resistance to authority - Be calm and assertive about expectations
● Tasks over delegated in terms of specificity ..no room for creativity

Transcultural work team

● Some people and cultures need more time to develop delegation skills
○ Communication
○ Space
○ Social organization
○ Time
○ Environmental control