PART I: NURSING LEADERSHIP AND MANAGEMENT I. NURSING LEADERSHIP 1. Leadership 2. Management 3. Leadership versus Management 4.

Power in Nursing Leadership 5. Accountability in Nursing Leadership PRIMARY SKILLS OF THE NURSING LEADER 1. Communication Skills of the Nurse Leader 2. Decision-Making Strategies of the Nurse Leader 3. Time-Management Skills 4. Change Management Skills 5. Conflict Resolution Skills 6. Team Building Skills

II.

PART I: NURSING LEADERSHIP AND MANAGEMENT

A.
I.

NURSING LEADERSHIP Leadership a. Leadership is defined as a process of influence in which the leader uses interpersonal skills to influence others toward goal achievement. b. Leadership is a reciprocal relationship. c. Leadership may be informal or formal. d. Nurses function as leaders when they influence others towards goal achievement. e. NURSES ARE LEADERS. They lead the nursing practice; lead other nurses, lead patients, family and community toward improved health. Core traits of Leaders a. A guiding Vision i. A leader is able to see a picture of the desired future which allows the leader to set goals toward the desired future. b. Passion i. A leader is enthusiastic about future possibilities ii. A leader has the ability to inspire people and align them in a common effort to make possibilities a reality. c. Integrity i. A leader is trustworthy, honest and is mature d. Curiosity i. Leaders take risks to facilitate change

II.

III. Leadership Theories a. Behavioral (Lewin, Lippitt, and White) i. Employee-centered Leadership focuses on human needs ii. Autocratic Leadership- involves centralized decision making, with the leader making decisions and using power to command and control others. iii. Democratic Leadership is participatory, with authority delegated to others. To be influential, the democratic leader uses expert power and power afforded by having close, personal relationships. iv. Laissez-faire Leadership is passive and permissive, and the leader defers decision-making b. Situational Theory i. This theory suggests that the traits required of a leader differ according to varying conditions. A person may be a leader in one situation and a follower in another or a leader at one time and a follower at another time. c. Charismatic Theory (House) i. A charismatic leader has an inspirational quality that promotes an emotional connection from followers. ii. Charismatic leaders display self-confidence, have strength in their convictions, and communicate high expectations and their confidence in others. d. Contingency Theory (Fielder) i. Views pattern of leader behavior as dependent upon the interaction of the personality of the leader and the needs of the situation. The needs of the situation or how favorable the situation is toward the leader involves the following: 1. Leader-member-relations: feelings and attitudes of followers regarding acceptance, trust and credibility of the leader. Good leader-member relation exists when followers respect, trust, and have confidence in the leader. 2. Task-structure: refers to the degree to which work is defined, with specific procedures, explicit directions, and goals. High task structure involves routine, predictable or clearly defined, such as creative, artistic or qualitative research studies.

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f.

3. Position power: the degree of formal authority and influence associated with the leader. High position power is favorable to the leader than low position power. Transformational Leadership Theory (Burns) i. There are two types of leaders: 1. Traditional manager concerned with day-to-day operations; and the 2. Transformational leader who is committed to a vision that empowers others, called the. New Leadership Concept (Wheatley) i. States the leaders role in an organization 1. use his vision to guide followers 2. help followers make choices on values 3. provide meaning and coherence in an organization

B.
I. II.

NURSING MANAGEMENT Management a. Management is the process of coordinating ,directing and allocating resources to achieve organizational goals. Management Functions a. Planning i. Determining the objectives of the institution or organization and what needs to be done to achieve these objectives. ii. The 4 stage Process 1. Establish objectives 2. Evaluate the present and predict future trends and events 3. Formulate a planning statement 4. Convert the plan into an action statement b. Organizing i. 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. c. Staffing i. Selecting the people who are able to carry out the action plan. Selection is based on: 1. the knowledge, skills, and experience of the nurse 2. number and type of patients needing the care 3. number and type of support staff available d. Directing i. Motivating and leading personnel to accomplish objectives. ii. How a person directs others depends on the persons authority, power and leadership style. iii. Effective directing is achieved through strategies such as: 1. setting specific, clear expectations that are realistic and measurable 2. providing sufficient resources to accomplish the tasks 3. fostering a work environment that balances challenge and success 4. finding ways to recognize and reward work that meets or exceeds objectives in a way that is meaningful to workers. e. Controlling i. Establishing standards of performance, comparing results with these benchmarks, and correcting performance that differs from accepted standard. ii. Frequently used means of control: 1. Management by Objectives (MBO) devices : determining objectives, measuring to see if objectives are being met, and comparing objectives with standards (benchmarks) 2. Socialization: often a key part of the MBO, socialization means that nurses internalize professional values and standard codes of behavior. 3. Managerial surveillance: the direct observation of staff behavior by the manager as well as direct observation through managers view of records. a. Narrow span of control fewer numbers of directly supervised staff which results to higher degree of supervision and control. b. Wide span of control may be effective as long as staff members are educated and tasks are relatively routine. 4. Continuous Quality Improvement (CQI): staff members participate in and lead the team, identify ways to improve processes or programs, and constantly enhance and improve the quality of care. Reviewing Budgeting

f. g. III.

Management Theories a. Scientific Management (Frederick W. Taylor) : i. 4 Principles of Scientific Management 1. Organizing work must be replaced by scientific methods. Using time and motion studies and the expertise of experienced workers, work could be scientifically designed to promote greatest efficiency of time and energy. 2. A scientific personnel system must be established so workers can be hired, trained and promoted based on technical competence and abilities. 3. Workers should be able to fit into the organization and how they contribute to overall organizational productivity.

4. The relationship between managers and workers should be cooperative and interdependent, and the work should be shared equally. b. c. Bureaucratic Organizations (Max Weber) i. Need for legalized, formal authority and consistent rules and regulations for personnel in different positions to increase the efficiency of the organization. Employee Participation (Chris Argyris) i. Argyris believed that manager domination causes workers to become discouraged and passive. ii. He believed that if self-esteem and independence are not met, employees become discouraged and troublesome and will leave the organization. Hawthorne Effect (Mayo) i. Paying special attention to workers ability increases productivity regardless of environmental working conditions. Employee Satisfaction (Douglas Mac Gregor) i. Mac Gregor reinforced the ideas that managerial attitudes about employees can be directly correlated with employee satisfaction. He called this Theory X and Theory Y. ii. Theory X managers believe that their employees are basically lazy, need constant supervision and direction, and are indifferent to organizational needs. iii. Theory Y managers believe that their workers enjoy their work, are self-motivated and are willing to work hard to meet personal and organizational goals. Motivational Theory: i. Motivation is interpreted from peoples behavior rather than explicitly demonstrated by actions ii. Motivation is an internal process that directs behavior to satisfy needs.

d. e.

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Theories Abraham Maslow Hierarchy of Needs Frederick Herzberg HygieneMaintenance Factors and Motivator Factors Douglas Mc Gregor Theory X Theory Y William Ouchi Theory Z

Key Aspects Motivation occurs when needs are met. Certain needs have to be satisfied first before one is motivated by needs at the next higher level of needs. a. Hygiene maintenance are extrinsic to the job itself; includes pay. Supervision, organizational policies, relationship with co-workers, working conditions, job security. Unsatisfactory hygiene factors leads to increased absences and resignations. b. Motivator factors includes satisfying and meaningful work, development and advancement opportunities, responsibility and recognition. a. Leaders must direct and control because motivation results from reward and punishment. Employees prefer security, direction, and minimal responsibility, and they need coercion and threats to get job done. b. Leaders must remove work obstacles as under the right work conditions, workers have self-control and self-discipline. The workers reward is their involvement in work and the chance to be creative. a. Uses collective decision making, long-term employment, mentoring, holistic concern, and use of quality circles to manage service and quality. This is a humanistic style of motivation based on the study of Japanese organizations.

C. LEADERSHIP versus MANAGEMENT I. Leadership and Management a. Leaders do the right thing. Managers do things right. b. Leaders get other people to want to do something. Managers get other people to do even what they do not want to do. c. Management works within the paradigm. Leadership creates new paradigms. Management works within the system. d. Leaders can be effective managers and managers can be effective leaders. II. Leadership is the preferred mode of getting things done in health care: a. Respond flexibly to changes in workplace. b. Disseminate information rapidly and effectively through their teams; c. Develop and maintain strong trust and interpersonal connections with staff peers, patients and other health care professionals d. Build and support team members skills and strengths, while dealing effectively with differences e. Do not avoid uncertainty and chaos but instead thrive on it. III. Roles and Functions of Nursing Managers

a. b. c. d. e.

Excellence in nursing clinical practice and delivery of patient care in a particular unit or area of an organization Managing human, monetary, and other resources needed to provide excellent patient care in a designated unit or department Ensuring that all standards of care practiced in that area are in compliance with professional, regulatory and government standards of care. Developing strategic planning that supports the departments or units and organizations overall mission Facilitating relationships among different departments or disciplines to ensure the delivery of the highest quality patient care.

Levels of Management LEVEL Staff Nurse Management

DESCRIPTION OF WORK

RELATED TITLES Staff Nurse; Nurse on Duty

Charge Nurse Management

First Level Management

Middle Level Management

Although not formally a manager, the staff nurse works with other professionals and assistive personnel. Management responsibilities involve supervising others to ensure safe, quality patient care. An expanded staff nurse role with increased responsibility and the function of liaison to the nurse manager or head nurse. The charge nurse is a role model and a mentor and assists in decision-making Responsible for supervising the work of nonmanagerial personnel and the day-to-day activities of a specific work or units. Responsible for clinical nursing practice, patient care delivery, professional standards and fostering interdisciplinary relationships. Represents staff to upper organization and vice-versa. 24 hours accountability Supervises a level of first-level managers, usually within related specialties or in a given geographic area. Responsible for the people and activities within the departments they supervise Acts as liaison between upper management and first-level supervisors. 24 hours accountability

Charge Nurse, Head Nurse

Assistant

First line manager; Head nurse; nurse manager; coordinator

Supervisor; director; assistant or associate director of nursing.

D. POSITIVE DEFINITION OF POWER I. Power a. Definition Ability to create, get, and use resources to achieve ones goals. Power is how managers and leaders get things done. Effective nurses increase their own power sources and use power for safe, competent care. The personal power of effective nurses is evident in the decisions nurses make. Power may be at personal level, professional level or organizational level Leadership cannot exist without power (Costello-Nickitas,1997) b. Types of Power TYPE Expert SOURCE Power based on the knowledge and skills nurses possess. Power derived from academic degree, licensure, certification, experience and job title in the organization Power based on admiration and respect for individual Power based on inducements offered by the manager in exchange for contributions that advances the managers objectives. Power that comes from the ability to punish others to influence them to EXAMPLES FOR NURSING Bringing expert knowledge to patient care Affixing RNs to name, passing the nurse licensure examinations Gaining power by affiliating with nurses and others who have power in the organization. Using hospital awards to change behavior Using the disciplinary hospitals evaluation

Legitimate Referent

Reward

Coercive

Connection

Information Position

change behavior Power based on the individuals formal and informal links to influential or prestigious persons within and outside the organization. Power based on individuals access to data Power determined by job description and assigned responsibilities Power based on ones credibility, reputation, expertise, experience, control of resources or information, and ability to build trust

system to alter behavior Developing good working relationships and mentoring with your superior. Safeguarding privacy of client Positions like staff nurses, charge nurse, head nurses and chief nurses comes with power Forming good relationship not just with superiors but with all subordinate

Personal

c.

Empowerment of Nurses Empowerment is the process of gaining control Nurses may make use of personal, psychological and material resources to empower ones self. Empowerment is demonstrated through 1. an increased ability to solve problems creatively and effectively 2. improved communication a. between nurses and patients b. between nursing team members c. between nurses and other health team members d. between nurses and management e. throughout the organization f. between the organizations and the community 3. increased satisfaction with work, including less stress and lower levels of burnout 4. Improvement in peoples a. Level of self-esteem b. Ability to function with autonomy c. Levels of accountability and responsibility

d. Rules for Using Power Use the least amount of power you can to be effective in your interaction with others. Use power appropriate with the situation. Learn when not to use power. Make polite requests, never arrogant demands. Focus on the problem, not the person. Use coercion only when methods dont work. Keep informed to retain your credibility when using your expert power. Understand you may owe a return favor when you use your connection power.

E. ACCOUNTABILITY IN NURSING LEADERSHIP I. Definitions Accountability means being responsible and liable for ones decisions and actions o Accountability is regarded as the hallmark of professionalism. Responsibility involves being reliable and dependable, and obliged to accomplish work and to perform at an acceptable level based on education and training Accountability of the Nurse Leader a) To the patient b) To the nurse himself/herself c) To the people the nurse works with d) To the health care organization the nurse works for e) To the community f) To the professional organizations with which the nurse is an affiliate g) To the government Accountability Shared Leadership a) According to Sullivan and Decker (1991), shared leadership is an organizational structure in which several individuals jointly hold responsibility for achieving the organizations goals. b) Shared leadership depends on: i. Strong relationships and communication ii. Workforce that is highly educated, competent and capable of taking leadership roles iii. Abilities and knowledge that emerge in relation to te current needs of the organization PART II: PRIMARY SKILLS OF THE NURSE LEADER A. COMMUNICATION

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Communication The interactive process that occurs when a person (the sender) sends a verbal or nonverbal message to another person (receiver) and receives feedback. The communication process may be influenced by emotions, needs, perceptions, values, education, culture, goals, literacy, cognitive ability, and the communication mode. Communication in health is essential to coordinate care. Six Principles of Communication 1. Giving information is not the same as communication, which requires interaction, understanding and response. 2. Sender is responsible for clarity 3. Use simple, exact language 4. Communication encourages feedback 5. Sender must have credibility 6. Use direct communication channels if possible. Leadership Roles 1. Understands and appropriately uses the informal communication network in the organization. 2. Communicates clearly and precisely in language others will understand. 3. Is sensitive to the internal and external climate of the sender or receiver and uses that awareness in interpreting messages. 4. Appropriately observes and interprets the verbal and non-verbal communication of followers. 5. Recognizes status, power, and authority as barriers to manager-subordinate communication. Uses communication strategies to overcome those barriers. 6. Maximizes group functioning by keeping group members on course, encouraging the shy, controlling the garrulous, and protecting the weak. 7. Seeks a balance between technological communication options and the need for human touch, caring, and one-on-one, face to face interaction. Management Functions 1. Understands and formally uses the organizations formal communication network. 2. Determines the appropriate communication mode or combination of modes for optimal distribution of informal distribution of information in the organizational hierarchy. 3. Prepares written communications that are clear and uses language that is appropriate for the message and receiver. 4. Consults with other departments or disciplines in coordinating overlapping roles and group efforts. 5. Differentiates between information and communication and appropriately assesses the need for subordinates to have both. 6. Prioritizes and protects client and subordinates confidentiality. 7. Ensures that staff and self trained appropriately and fully utilize technological communication tools. 8. Uses knowledge of group dynamics for goal attainment and maximizing organizational communication. Modes f. Levels 1. 2. 3. Verbal non-verbal telephone pagers text messages e-mail written documents of Communication Public Communication the receiver of the message is an audience of common interest Intrapersonal communication may also be termed as self-talk Interpersonal communication involves communication between individuals, person-to person or in small groups.

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Directions / Channels of Communication DIRECTION Downward communication Upward Communication Lateral / Horizontal Communication Diagonal communication Outward Communication DESCRIPTION Generally directive, given from an authority figure or manager to staff Communication that occurs from staff to management Communication that occurs between individuals as the same hierarchical level Involves individuals at different hierarchical level Communication outside the organization

h.

Barriers to Communication Barrier Use of language Gender

Description Meaning of different gestures vary from one culture to another Some men are more interested in reason, where some women want to be heard and validated through communication.

Culture General Differences Illiteracy Anger Offering false reassurance Being defensive Stereotyping Interrupting Inattention Stress Unclear expectations Incongruent responses h.

Values and beliefs differentiates one from the other Different generations can have different values about work, motivation, lifestyle, and communication Patients, families, and even subordinates do not understand what nurses are trying to imply. A universal, strong feeling of displeasure that is often precipitated by a situation that frustrates or prevents a person from attaining a goal or setting what is wanted from life. Promising something that cannot be delivered. Acting as though one has been attacked Unfairly categorizing someone based on his traits Speaking before the other has completed his message Not paying attention A state of tension that gets in the way of reasoning Ill-defined direction to perform tasks or duties that make successful completion of them unlikely. When words and actions in a communication dont match the inner experience of self and/or are inappropriate to the context.

How to overcome barriers to Communication Understand the receiver Communicate assertively Use two-way communication Unite with a common vocabulary Elicit verbal and non-verbal feedback Enhance listening skills Be sensitive to cultural differences Be sensitive to gender differences Engage in metacognition Communicating with Different Population 1. Subordinates Know the context of the instruction. Get positive attention Give clear, concise instructions Verify through feedback Give follow-up communication 2. Supervisor As a manager, you are charged with supporting your supervisor. Find an appropriate time to discuss a problem, scheduling an appointment if necessary State the problem succinctly and explain why it is interfering with work Listen to your supervisors response and provide more information, if needed. If you agree on a solution, offer to do your part to solve it. If you cannot agree on a solution, schedule a follow-up meeting or decide to gather more information. Schedule a follow-up appointment. 3. Peers Peers may provide camaraderie, and allow exchange of ideas. There may also be competition or conflicts. Peers should interact on a professional level. 4. Medical Staff Respect physicians as persons, and expect them to respect you. Consider yourself and your staff equal partners with physicians in health care. Build your staffs clinical competence and credibility. Actively listen to physician complaints as customer complaints. Remember that limited interaction contribute to poor communication. Serve s a role model to your staff in nurse-physician communication. 5. Other Health care Personnel In interacting with personnel from other departments, the nurse manager must recognize and respond to differences between the goals of their departments and the nursing units. 6. Patient and Families Remember that the patients (and family) are the principal customers of the organization. Treat them with respect; keep communication open and honest. Most individuals are unfamiliar with medical jargon. Use words that may be easily understood. Maintain privacy and identify a neutral location for dealing with different interactions. Make special efforts to find interpreters if the patient or family cannot understand the local language. Recognize cultural differences in communicating with parents and their families.

i.

j.

Comunication Barriers o Culture o Emotions o Gender o Conflict

Others

Stress Stereotyping Interrupting Inattention

DECISION-MAKING a. Decision making The process of establishing criteria by which a nurse leader can develop and select a course of action from a group of alternatives o Decision may or not be the result of problems o Decision-making is considered a critical thinking process, just like problem-solving b. Characteristics of decision-making Not a linear or totally logical process; may involve intuition as well Is often a result of many incremental steps rather than one large steps Smaller choices may be impacted by many factors other than rationality and analytical thought

c. Characteristics of Successful decision-makers Learn to emphasize the tools and techniques that help make decision-making effective and efficient Minimize the techniques or events that can sidetrack the critical thinking and decision-making process Ability to engage in critical thinking is the foundation for decision-making and problem-solving success d. Strategic Steps in Decision-Making 1. Identify the need for a decision. This step considers: What needs to be determined Why a decision is needed All the available information Try to state issues in broader terms rather than narrower terms 2. Determine the desired goal or outcome. The goal should be: a.Clear and specific b.Stated in a sentence or two 3. Identify any other action that exists. For each alternative action, identify: a.Its possible consequences b.Possible benefits c. Evaluating the quality of evidence and existing arguments for or against an alternative action. 4. Decide which action to implement, based on each actions benefits and consequences. a.It may be helpful to prioritize benefits and consequences 5. Evaluate the action by answering these questions: a.Was the goal achieved completely? b.Was the goal achieved partially? c. Was the goal not achieved at all? .Conditions for Changes in Decision-Making 1. Under conditions of certainty Alternative and existing conditions are well-known Decision-making can be based with full knowledge of what outcome will be 2. Under conditions of risk Decision outcome can only be expressed as probability rather than certainty 3. Under conditions of uncertainty Alternatives and functions are complex and variable; the person making the decision may not be even aware of the possibilities or the decision-making may be occurring in a rapidly changing environment Example, when anthrax was used as a bioweapon, decisions about treatment and protection of the public were made under conditions of uncertainty with not precedent and only retical models to guide public health officials. f. Critical Thinking Purposeful, outcome-directed thinking that is based on a body of scientific knowledge derived from research and other courses of evidence A good critical thinker Examines decisions from all sides and takes into account varying points of view Generates new ideas and alternatives when making decisions Asks why questions about a situation in order to arrive at the best decision g.Problem Solving and Decision Making: Tools for Viewing Choices Decision grid

i. Useful when making a decision between two choices PERT chart i. Program evaluation and review technique ii. Useful in making time line decisions Decision tree i. Allow all the outcomes and benefits of a particular decision ii. Useful in making the alternatives visible Gantt chart i. Graphically illustrates a project from start to finish ii. Useful for illustrating a project from beginning to end h.Benners (1994) Novice to Experts Model Facilitates professional staff development by building on the skill sets and experience of each practitioner Acknowledges that there are tasks, competencies, and outcomes that practitioners can be expected to have acquired based on five levels of experience There are five progressive stages of Benners model of nursing practice: 1. Novice (task-oriented and focused) 2. Advanced beginner (demonstrates marginally acceptable independent performance) 3. Competent (has been in the same role for one to three years; demonstrates conscious, deliberative planning) 4. Proficient (perceives the whole situation rather than a series of tasks) 5. Expert (intuitively knows what is going on with patients) i. Group Decision Making Considerations i. Group decision making may be necessary in some situations ii. People affected by a decision often will be involved in the decision iii. Involve people with information or resources that contribute to the decision iv. Consider the size of the group and the personalities of group members Group Decision Making: Advantages i. A group can generate more ideas, thus allowing for more choices and an increased chance of higher quality outcomes ii. When members participate in the decision-making process, the decision is more likely to be accepted iii. Groups may be used as a medium for communication Group Decision Making: Disadvantages i. Time consuming ii. Can be wasteful and unproductive if not managed effectively iii. Can be costly iv. Can generate conflict Techniques for Group Decision Making i. Nominal group technique Group members write ideas, without discussion Each idea is presented with advantages and disadvantages Group discusses, clarifies, and evaluates ideas Group votes privately on ideas ii. Delphi technique Group members do not meet face to face Questionnaires are distributed seeking opinions from group members Summaries are disseminated to group members Process continues until group members reach a consensus iii. Consensus building Means that all group members can live with and fully support the decision regardless of whether they totally agree Useful because all group members participate and realize the contributions of each member to the group Requires more time Should be reserved for important decisions that need strong support iv. Groupthink Different from consensus building Goal is for everyone to be in 100 percent agreement Discourages questions and divergent thinking Hinders creativity Groups can reach a decision early without exploring all options Can cause stereotyping and challenges of disagreement v. Strategies to Strengthen Patient Decision Making Consumers of health care are more knowledgeable and cost conscious Nurses must be aware of patients rights in making decisions about their treatments and must assist patients in their decision making Ask why, what else, and what if questions Anticipate questions and outcomes

C.

TIME MANAGEMENT i. Time management A set of related commonsense skills that helps you use your time in the most effective and productive way possible ii. Three time management concepts 1. The relative effectiveness of the effort 2. The importance of outcome versus process orientation 3. The value of organizing how time is currently being used The Pareto Principle States that 20 percent of focused effort results in 80 percent outcome results, or conversely 80 percent of unfocused efforts results in 20 percent results A strategy for balancing life and work through prioritization of effort Outcome Orientation More is achieved through an outcome orientation than an emphasis on task completion Determine long-term goals, then break them down into achievable outcomes that are the steps toward those goals Write down long-term goals and outcomes Flexibility should be part of outcome orientation Time Analysis Analyze how time is currently used Understand the value of nursing time Consider what tasks can be delegated to personnel who receive less compensation than nurses Environment If possible, arrange the environment to provide nurses with efficient access to supplies, equipment, and patient areas Stock supplies to make them available Have specialty carts available Shift Report The shift handoff report can best lead to an efficient, effective, and safe start to the shift Shift report can be accomplished by a face-to-face meeting, audiotaping, or walking rounds Formulating the Shift Action Plan o A written plan that sets the priorities for the accomplishment of shift outcomes that are both optimal and reasonable o Should be written so that all team members are aware of it o Must be based clearly on priorities set at the beginning of the shift with built-in flexibility Strategies to Enhance Personal Productivity 1. Schedule activities that take focus and creativity at high-energy times and dull, repetitive tasks at low-energy times 2. Create more personal time 3. Delegate work to others 4. Eliminate chores or tasks that have no value 5. Get up earlier in the day 6. Use downtime 7. Control unwanted distractions 8. Find personal time for life-long learning Strategies for Avoiding Personal Time Distraction 1. Clear your work area of clutter and keep it clean 2. Organize your work area 3. Open your mail over your garbage can; respond, delegate, or throw it out 4. Break a task down into manageable segments; return to it again and again until it is complete 5. Become a pursuer of excellence, not a perfectionist Prioritizing Use of Time a. Understand the big picture Examine the best picture. Nurses should know what is expected of their co-workers, what is happening on other shifts, and what is happening beyond the unit. b. Decide on Optimal Desired Outcomes These are the best possible objectives to be achieved given the resources at hand. c. Do First Things First 1. First Priority : Life threatening or potentially life-threatening conditions. Life threatening conditions include patients at risk to themselves or others and patients whose vital signs and level of consciousness indicates potential circulatory or respiratory collapse.

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2. Second Priority : Activities Essential to safety Includes those responsibilities that ensure the availability of life-saving, monitoring, medications, and equipment, and that protect patients from infections and falls. 3. Third Priority : Activities essential to the plan of care Includes plan of care that relieve symptoms or lead to healing. These activities include relieving symptoms pain and nausea, and those that promote healing like nutrition, positioning, medication administration.

D.

i.

CHANGE MANAGEMENT SKILLS Change 1. Change means making something different from what it was. 2. Change is inevitable, exciting and anxiety provoking.

ii. The Changing Health Care Environment 1. Access to information has transformed the relationship between the patient and health care providers 2. Evidence-based practice is changing the way decisions are made regarding health care treatment and how nursing care is delivered 3. Changing demographics within the population have resulted in a diversity of cultures and languages iii. Types of Change 1. Personal change a. Voluntary change with the goal of self-improvement 2. Professional change a. Deliberate change with the goal of improving professional ability/status 3. Organizational change a. A planned change in an organization to improve efficiency Traditional Change Theories

iv.

i.

Lewins force-field model b. Unfreezing i. The current or old way of doing something is flawed c. Moving i. The intervention or change is introduced and explained d. Refreezing i. The new way of doing is incorporated into the routines or habits of the people affected ii. Lippitts phases of change a. Diagnosis of the problem b. Assessment of the motivation and capacity for change c. Assessment of the change agents motivation and resources d. The selection of progressive change objectives e. Choosing an appropriate role for the change agent f. Maintenance of the change once it has been started g. Termination of the helping relationship Havelocks Six-Step Change Model Planning stage o Build a relationship, diagnose the problem, and acquire resources Moving stage o Choose the solution and gain acceptance Refreezing stage o Stabilization and self-renewal Rogers diffusion of innovations theory Five-step innovation/decision-making process o Awareness, interest, evaluation, trial, adoption Believes change can be rejected initially and adopted at a later time Believes change is reversible and initial rejection does not mean the change will never be adopted

iii.

iv.

v. The Change process a. Assessment b. Planning c. Implementation d. Evaluation vi. Change Strategies Strategy Power-coercive approach Description Uses authority and threat of job loss to gain compliance with

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Normative-reeducative approach Rational-empirical approach

change. Uses social orientation and the individuals need for satisfactory relationships in the workplace as a method of inducing support for change. Focuses on the majority rule to induce change. Uses knowledge as power base. Once workers understand the organizational need for change or understand the meaning of the change to them as individuals and the organization as a whole, they will change.

vii. Roles and Characteristics of the Change Agent Leads the change process Manages the change process and group dynamics Understands feelings of the group experiencing change Maintains momentum and enthusiasm Maintains vision of change Communicates change, process and feelings Knowledgeable about the organization Trustworthy Respected Intuitive viii. Responses to Change Innovator o Change embracer; enjoys the challenge; often leads change Early adopter o Open and receptive, but not obsessed with change Early majority o Enjoy and prefer the status quo, but do not want to be left behind Late majority o Followers; often skeptics Laggards o Last group to adopt change; prefer tradition Rejectors o Openly oppose and reject the change E.CONFLICT RESOLUTION i. Conflict Consequence of real or perceived differences in mutually exclusive goals, values, ideas, attitudes, beliefs, feelings or actions Important part of the change process, and is not automatically negative ii. Sources of Conflict Allocation/availability of resources Personality differences Sources of Conflict Differences in values Internal/external pressures Cultural differences Competition Differences in goals Issues of personal/professional control iii. Types of Conflict Intrapersonal o Disagreement in philosophy or values, policy or procedure Interpersonal o Personality conflict Organizational o Competition for resources iv. Conflict Management Avoiding o Ignoring the conflict Accommodating o Smoothing or cooperating o One side gives in to the other side Competing o Forcing o The two or three sides are forced to compete for the goal Compromising o Each side gives up something and gains something Negotiating o High-level discussion that seeks agreement o Not necessarily consensus Collaborating o Both sides work together to develop optimal outcome

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Confronting o

Immediate and obvious movement to stop conflict at the very start

Leadership and Management Roles Model conflict resolution behaviors Lessen perceptual differences of parties Assist parties to identify resolution techniques Create environment conducive to conflict resolution If conflict cannot be resolved, minimize or lessen perceptions of conflicting parties

F.TEAM BUILDING SKILLS

i.Team

A small number of people with complementary skills who are committed to a common purpose, performance goals, and approach for which they are mutually accountable Teams exist for specific purposes

ii.Advantages of Teamwork

Promotes safe and efficient patient care delivery Creates effective interprofessional communication Equalizes power through shared governance Improves interpersonal relationships and job satisfaction Promotes free exchange of ideas, team cohesion, trust, and mutual respect Improves stability in employee satisfaction

iii.Stages of Group and Team Process

Forming stage o Occurs when the group is created and they meet as a team for the first time o They explore the purpose of the team, why they are called to be part of a team, and what contribution they can bring to the table o Proceed to establishing team goals and expectations Storming phase o As the group relaxes into a more comfortable team setting, interpersonal issues or opposing opinions may arise to cause conflict between the members o Conflict is healthy and a natural process o Must openly confront issues and conflict o Real teams dont emerge unless individuals on them take risks involving conflict, trust, interdependence, and hard work Norming phase o A feeling of group cohesion develops o Team members master the ability to resolve conflict o Team members learn to respect differences of opinion and work together o Overcoming barriers to performance is how groups become teams Performing stage o Group cohesion, collaboration, and solidarity are evident o Personal opinions are set aside in order to achieve group goals o Team members are openly communicating, know each others roles and responsibilities, are taking risks, and trusting and relying on each other Adjourning phase o Termination and consolidation occur in this stage o The team reviews their activities and evaluates their progress o The team leader summarizes the groups accomplishments and the roles each member played in achieving these goals o It is important to provide closure so each member leaves with a sense of accomplishment Proactive Motivated Take responsibility for ones actions, decisions, and behavior Seize initiatives to do whatever is necessary to get the job done consistent with correct principles

iv.Qualities of Effective Team Members

v.Qualities of Effective Team Leaders

Will organize, facilitate, and manage the entire team Must understand how various learning styles, cultural diversity, and personality differences play into the dynamics of teamwork Have good communication skills, conflict resolution skills, and leadership skills Focus the team on outcome improvement Track reports

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Recognize contributing members

vi.Avoiding Groupthink

Occurs when the desire for harmony and consensus overrides members rational efforts to appraise the situation The consequences of groupthink are that teams may limit themselves to one possible solution and fail to conduct a comprehensive analysis of a problem Team leaders can help avoid groupthink

vii.Symptoms of Groupthink

The illusion of invulnerability Collective rationalization Belief in the inherent morality of the team Stereotyping others Pressures to conform The use of mindguards Self-censorship Illusion of unanimity

PART III: STRATEGIC ORGANIZATIONAL ROLES a. Patient Care Management i. First Line Care Management Uses nursing process for patient populations Effective first line care management includes: o A manager who leads and coordinates a team of diverse individuals toward a common goal o Governance structures, patient care delivery process, and measures of care delivery outcomes, all of which are consistent with professional practice philosophy and the organizations mission. o Shared decision-making between nursing leaders and nursing staff o Environment in which patient care delivery, clinical quality, access, service, and cost are accountable and can be evaluated. ii. Nursing Care Delivery System Purpose of the nursing care delivery system is to provide a structure that enables nurses to deliver nursing care to specified groups of clients. Delivery of care includes assessment, planning, implementing and evaluating. Care Delivery Management Tools o In diagnosis-related groups (DRGs) the national average length of stay (LOS) for a specific patient type was used to determine payment for that grouping of patients o Clinical pathways Care management tools that outline the expected clinical course and outcomes for a specific patient type Should be evidence-based Pathways include expected outcomes specified for each day of care Patient progress is measured against the expected outcomes o Case Management A strategy to improve patient care and reduce hospital costs through coordination of care Typically a case manager: Is responsible for coordinating care and establishing goals from preadmission through discharge Evaluates the patients outcomes daily and compares them to the predicted outcomes articulated in the clinical pathway Works with all the disciplines to facilitate care Types of Nursing Care Delivery System a. Functional- also called task nursing where the needs of a group of clients are broken down into tasks.

CHARGE NURSE

MEDICATION NURSE

TREATMENT NURSE

MIDWIFE ASSIGNED IN TAKING VITAL SIGNS

b.

Team Nursing

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The most common delivery system; the team of nursing personnel provides total patient care to a group of clients. The team leaders time is spent in indirect care activities, such as : developing or updating nursing care plans, resolving problems encountered by teams; conducting conferences; communicating with other disciplines of care. A care delivery model that assigns staff to teams that are then responsible for a group of patients A unit is divided into two or more teams, each led by a registered nurse The team leader supervises and coordinates all of the care provided by those on the team Care is divided into the simplest components and then assigned to the care provider with the appropriate level of skills

HEAD NURSE

TEAM LEADER/ RESEARCHER Staff Nurse

TEAM LEADER/ RESEARCHER Staff Nurse

TEAM LEADER/ RESEARCHER Staff Nurse

PATIENT

PATIENT

PATIENT

c.

Total

Patient

Care

the

registered

nurse

is

responsible

for

all

aspects

of

care.

CHARGE NURSE

STAFF NURSE

STAFF NURSE

STAFF NURSE

PATIENT

PATIENT

PATIENT

d.

Practice Partnership an RN and a less experiences assistant agree to become partners

RN

PARTNER

PATIENT
b. Strategic Planning i. A strategic plan is the sum total or outcome of the processes by which an organization engages in environmental analysis, goal formulation, and strategy development with the purpose of organizational growth and renewal provides unified vision and goals for the organization ii. Helps ensure that the needed resources are available to carry out initiatives iii. Steps in Strategic Planning Process Perform environmental assessment Conduct stakeholder analysis Review literature for evidence-based best practices Determine congruence with organizational mission Identify planning goals and objectives Estimate resources required for the plan Prioritize according to available resources Identify timelines and responsibilities Develop marketing plan Write and communicate business plan/strategic plan Evaluation iv. Organizational Purpose, Mission, Philosophy, Values

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Mission statement o A formal expression of the purpose or reason for existence of the organization Philosophy o value statement of the principles and beliefs that direct the organizations behavior Values o May be formally stated and explicit, or may be implicit and part of the organizational culture

c.

Strategic Thinking to Improve Patient Care (Evidence-Based Care) i. Evidence-based care The process of providing clinically competent care that is based on the best scientific evidence available

d.

Managing Outcomes Utilizing an Organizational Quality Improvement Model i. Quality assurance (QA) Emerged in health care in the 1950s as an inspection approach to ensure that minimum standards of care existed in health care institution ii. Total Quality Management (TQM) Began in the manufacturing industry W. Edwards Deming and Joseph Juran consulted with Japanese corporations in the 1950s Also referred to as quality improvement (QI) and performance improvement (PI) This approach became integrated in the health care industry in the 1980s A proactive approach emphasizing doing the right thing for customers when

iii.

Quality Improvement (QI) A systematic approach of organization-wide participation and partnership in planning and implementing continuous improvement methods to understand and meet customer needs and expectations and improve patient outcomes Focus of Quality Improvement (Doing the Right Thing) Meeting the needs of the customer proactively Building quality performance into the work process Assessing the work process to identify opportunities for improved performance Employing a scientific approach and using data for assessment and problem solving Improving health care performance and changing the health care system continuously as a management strategy, not just when standards are not met Methodologies for Quality Improvement 1. Plan-do-study-act (PDSA) cycle Asks three questions:

iv. v.

2.

1. 2. 3.

What are we trying to accomplish? How will we know that a change is an improvement?

What changes can we make that will result in improvement? The goal is to increase the ability to predict the effect that one or more changes would have if they were implemented

FOCUS Methodology Describes a stepwise process how to move through the improvement process o F: focus on an improvement idea o O: organize a team that knows the work process o C: clarify what is happening in the current work process o U: understand the degree of change needed o S: select a solution for improvement Other Improvement Strategies Benchmarking o A continual and collaborative discipline of measuring and comparing the work of key work processes with those of the best performers Focuses on key services or work processes Regulatory requirements o Joint Commission on Accreditation of Health Care Organizations (JCAHO) Sentinel event review o An unexpected occurrence involving death or serious physical or psychological harm Measurements o Dashboard o Balanced scorecard o Report cards o Clinical value compass Storyboard o Placed in a high traffic area o Outlines the progress of the quality improvement process

3.

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 4.

Patient satisfaction data

Principles in Action in an Organization i. Organizational structure 1. Encourage accountability 2. Maximize communication 3. Communicate and focus priorities at all levels ii.Outcomes Monitoring 1. Outcomes o A measurement of the patient response to structure and process o Measure actual clinical process o Can be short term or long term 2. Outcome data can be helpful in identifying opportunities for improvement by determining root causes

e.

Managing and Supporting Excellence in Staff Performance i. Staff Performance includes the following: Daily job performance according to requirements of job description Attendance Punctuality Adherence to organization policies and procedures Absence of errors, incidents or accidents Honesty and trustworthiness ii. Three levels of staff performance development Clinical skills Technical skills Interpersonal skills iii. Strategies for Developing Staff Excellence Mentoring o A mentor is a more experienced role model who guides, coaches and advises the less experienced. o Gives professional advise and helps avoid pitfalls Understanding needs of adult learners. o stages of adult learning Have an experience Reflect on experience Relate the experience to a mental model or theory Staffing Needs i. Meeting staffing needs in an organization. The nurse manager considers the following: Staff knowledge and performance The severity of patients illness Amount of nursing time available The care delivery model the organization follows What the health care organization provides to support and facilitate patient care. ii. Determination of Staffing Needs Patient census was historically used to determine staffing needs Has proven to be inaccurate, since patient care needs vary greatly Better matching of patient needs to nursing resources is now an important financial quest in health care institutions iii. Core Concepts Full-time equivalent (FTE) is a measure of the work commitment of an employee who works 5 days a week or 40 hours per week for 52 weeks per year; some agencies consider 36 hours (three 12-hour shifts) full time FTE hours are a total of all paid time Productive hours o Hours worked and available for patient care Nonproductive hours o Benefit time such as vacation, sick time, and education time Direct care o Time spent with hands-on care to patients Indirect care o Time spent with activities that support patient care Patient Classification Systems o Nurse intensity A measure of the amount and complexity of nursing care needed by a patient o Patient turnover A measure reflecting patient admission, transfer, and discharge Considerations in Developing a Staffing Plan Benchmarking o A tool used to compare productivity across facilities to establish performance goals o Does not always reflect quality of care indicators that can link quality patient care outcomes to productivity measures

f.

iv.

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o Can be helpful in establishing a starting point for a staffing pattern Regulatory requirements o One controversial issue is nurse staffing levels o Mandated nurse staffing plans are enacted by law Skill mix o The percentage of RN staff to other direct care staff Should vary according to the care that is required and the care delivery model utilized Staff support o The supports in place for the operation of the unit or department (a systematic process to deliver medications, patient transport services, secretarial services, etc.) v. Considerations for Staffing The patient type and acuity The higher the patient acuity, the more consistent the staffing needs are across shifts The experience of the staff o Novice nurses take longer to accomplish the same task than an experienced nurse o An experienced RN can handle more workload and higher acuity patients Good staffing requires putting the patient first Supporting Staff excellence through performance assessment a. Purposes of performance assessment Provide feedback Justify merit increases and other compensation adjustments Identify candidates for promotion Confirm hiring decisions Counsel and terminate b. Principles of Evaluation The evaluation must be based on the behavioral standards of performance which the position requires. There should be enough time to observe an employees behavior. The employee should be given a copy of the job description, performance standards, and evaluation form before the scheduled evaluation conference. Areas needing improvement must be prioritized to help worker upgrade his performance. Evaluation should be structured in such a way that it is perceived and accepted positively as a means of improving job performance. c.

vi.

Quality and volume of work Work knowledge Work judgment Organization Responsibility and flexibility Interpersonal skills

Key elements of performance assessment

vii.

Roles and responsibilities of the nurse manager in evaluating staff performance a.

Set specific expectations Encourage balance between

Six key activities

performance measurements and standards of care to facilitate setting measurable goals and ensure that employees take personal responsibility for meeting goals Review goals and action plans with staff to facilitate feedback cycle Reassess systems and resources to obtain goals, and work with staff to determine priorities and alternatives Follow work progress Encourage or reinforce achievement Rewarding successful performance i. Incentives ii. Recognition iii. Promotion iv. Choice of preferences v. Professional development vi. Letters of recognition

b.

g.

Nurse Advocacy a. Nursing Values Common to Advocacy Each individual has the right to autonomy in deciding what course of action is most appropriate to meet the healthcare goals. Each individual has the right to hold personal values and to use those values in making their own health care decisions. All individuals should have access to the information they need to make informed decisions and consent. The nurse must act in behalf of patients who are unable to advocate for themselves.

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Empowerment of patients and subordinates to make decisions and take action on their own is the essence of advocacy.

b. Political roles for Nurses ROLE ACTIVITIES Nurse Individual Highlights important role of nurses to prevent nursing-sensitive outcomes Sets goals to strengthen nursing as a profession Highlights the essential dimensions of nursing Participates as a member of health care consumer groups Nurse citizen Votes and writes members of congress and state legislators on issues of interest. Educates patients on how to evaluate sources of health care. Nurse Activist Active member of a professional organization that lobbies and influences legislation Nurse Politician Runs for a political office and serves society as a whole Collaborates with other members of health care professionals to improve care at the local, community and national level.

h.

Delegation of Patient Care i. Delegation The transfer to a competent individual of the authority to perform a selected nursing task in a selected situation The nurse retains accountability for the delegation All delegation involves at least two individuals as well as specifying duties to be accomplished Successful delegation addresses the personal needs of the patient and the nurses professional goals ii. Accountability Being responsible and answerable for actions and inactions of self or others in the context of delegation iii.Supervision The provision of guidance or direction, evaluation, and follow up by the licensed nurse for accomplishment of nursing tasks delegate to the unlicensed assistive personnel (UAP) iv.Considerations for Delegation Potential for harm Complexity of the task Amount of problem solving and innovation required Unpredictability of outcomes Level of patient interaction v. Rights of Delegation Right task Right circumstance Right person Right direction/communication Right supervision vi.Obstacles to Delegation Fear of being disliked Inability to give up control of the situation Inability to determine what to delegate and to whom Past experience with delegation that did not turn out well Lack of confidence to move beyond being a novice nurse Tendency to isolate ones self and choosing to complete all tasks alone Lack of confidence to delegate to staff who was previously ones peers Inability to prioritize using Maslows Hierarchy of Needs and the Nursing Process Thinking of oneself as the only one who can complete a task the way it is supposed to be Inability to communicate effectively Inability to develop working relationships Lack of knowledge of staff capability

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vii. Delegation of the Nursing Process Some professional activities can never be delegated o Patient assessment o Triage o Making a nursing diagnosis o Establishing a nursing plan of care o Teaching or counseling o Telephone advice o Evaluating outcomes o Discharging patients

Delegated tasks:
o o o o o o

Typically those tasks that occur frequently Considered technical Considered standard and unchanging Have predictable results Have minimal potential for risks Delegated tasks fall within the implementation phase of the nursing process

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

PART IV: TEN WAYS OF BECOMING A LEADER Make a commitment to lifelong learning. Learn to write well. Join a professional nursing association. Get involved in the community. Teach. Get politically involved. Get certified. Serve on committees in your organization. Give yourself a break. Be proud to be a nurse.

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