Organizational Communication

Effective communication is essential to the wellbeing of an organization. Communication is critical to the strategic planning process of any organization, and it is crucial for attainment of short- and long-term organizational goals. Likewise, good communication is pivotal to the day-to-day operation of any organization, affecting patient safety and quality care, employee satisfaction, and customer relations and satisfaction. Adamson, Emswiller, and Ollier (1991) recognize the importance of organizational communication and point out that if something cannot be communicated in a consistent and inspiring way, it cannot be done, no matter how well it is planned and financed.

Communication can be considered as occurring along a continuum, from interpersonal communication to small-group communication to organizational communication. Interpersonal communication occurs when the participants are face to face. Although there is disagreement in the literature as to how many people can be involved in interpersonal communication, it is generally agreed that it involves only two or three people. According to Trenhom (1991), because the interaction is face to face, there is spontaneity to the communication, and although the communication is focused, there is no need for messages to be “prepackaged.” Smallgroup communication becomes more complex than interpersonal communication primarily because the number of participants increases. Again, although the exact number of participants in small-group communication is not definite, the literature suggests that it may range from two to seven or so participants. Whereas small-group communication can provide the same sensory impact and immediacy of feedback as interpersonal communication, with participants knowing and reacting to one another, the possible combinations of relationships increase dramatically, and messages may be sent via a variety of networks (Trenholm, 1991). Organizational communication is different from the other two in that the number of participants is greater, and the communication occurs within the context of an organizational hierarchy. Trenholm notes that organizational communication is usually highly structured and goal-oriented and that roles in the communication process may correspond to roles within the organizational hierarchy. Therefore, because messages may be sent by a variety of people in a variety of formats, the immediate feedback of interpersonal and small-group communication is not possible. In organizational communication, messages are, by necessity, carefully planned and structured. Trenholm states that “communication within the organization involves a higher degree of strategic planning than it does with a dyad or small group” (p. 24).

This chapter focuses on organizational communication, although interpersonal and small-group communication may also be used as part of the overall communication strategy. This chapter presents an overview of the communication process, a discussion of three theoretical perspectives relevant to organizational communication, and other information relevant to the understanding of effective communication in organizations.

Communication Theories

Communication between humans is of critical importance whether occurring between two individuals or between multiple people in an organization, but communication is often difficult. Communication is usually taken for granted; that is, someone sends a message to another person, either verbally or in writing, and assumes that the person receiving the message understood the message exactly as it was intended. When communicating with a few people, it is fairly easy to validate whether the message was understood as intended. When communicating with many people in organizations, it becomes more difficult to ascertain whether a message was understood correctly. Because communication is basic and constant in the lives of humans, it has been studied for centuries. If communication within organizations is to be effective, it is important to have an understanding of the underlying precepts of communication.

For example, in order for nurse managers to be effective communicators, they should practice communication founded on sound theoretical perspectives. The following theories are summarized here: the mechanistic perspective, the psychological perspective, and the interactionist perspective.


According to Trenholm (1991), the mechanistic perspective of communication is a linear, one directional, sequential model of communication. Trenholm explains the model by applying it to a face-to-face spoken communication between two people: “The two people become sender and receiver. The sender encodes the message into units of spoken language that are conveyed by sound waves to the receiver, who decodes the message. Any feature not intended by the sender but inadvertently included in the message is called noise” (p. 33). Noise may interfere with the message so that it is not received as intended. Whether communicating between two people or between groups of people, it is important to consider the factors that may hinder the clear transmission of a message: environmental noise, the emotional content of the message, and tone of voice as well as the nonverbal behavior of the sender.


The psychological perspective builds on the mechanistic perspective, acknowledging the sender, receiver, and the message, but goes beyond the linear approach. The psychological perspective is based, in large part, on learned behavior. It suggests that when a message is received, it serves as a stimulus to the receiver to respond to the message. This process of give and take, in which (1) a message is sent, (2) it stimulates the receiver to respond, (3) a response is sent, which then (4) stimulates the receiver to respond, is a learned behavior. Children learn from an early age, as they develop their ability to communicate, that when they are spoken to, they are expected to respond either behaviorally or verbally. This perspective recognizes that people constantly receive and respond to stimuli. “All responses are elicited by stimuli, and all stimuli lead to responses. Human beings are both senders and receivers because we simultaneously react to and produce stimuli” (Trenholm, p. 34). Trenholm further theorizes that humans both seek out and process stimuli according to learned responses. As children are socialized, for example, they learn which behaviors and actions are met with approval, including their communication. Trenholm asserts, “As communicators, we actively choose to attend to certain stimuli, interpret them by means of our own unique mental structures, and respond by emitting certain behaviors capable of stimulating others” (p.37). According to this perspective, a message is sent by some means, and the potential for noise exists, but the sender and receiver become joint senders and receivers. For example, a person sends a message to a receiver either verbally or by some other means. When the message is received, it stimulates the receiver to respond, and the receiver then becomes the sender of a message, and so on.


The interactionist perspective is based on the body of work known as symbolic interactionism. This perspective developed as a way to understand the development of self as learned through a process of interaction within the larger society/environment. According to symbolic interaction, the self emerges during interaction between an individual and the environment beginning in infancy. The self emerges as that which makes each person unique and comprises a set of ideas, values, and experiences, all arrived at through social interaction. Trenholm (1991) notes that the concept of symbols is foundational to this perspective and that symbols are generally agreed upon by members of a group and become socially significant because of this agreement. She summarizes by stating, “Humans exist in and through communication; human action can be understood through the shared symbol systems that make action possible” (p. 39). Given that people have different experiences, ideas, and values, they are likely to interpret messages differently based on their own unique socialization. This theoretical perspective has provided the basis for continuing research in the field of communication and other disciplines. It provides the basis for managers and others involved in organizational communication to understand that people will engage in the communication process based, in part at least, on their own experiences.

Symbols in Communication

Trenholm (1991) believes that “words are symbols, and human language is a symbolic code, just as the Morse Code, sign language, semaphore codes and traffic lights are symbolic systems. The meanings of these codes are established through convention; their use is generally intentional” (p. 12). Dahnke and Clatterbuck (1990) state that “one common view of communication holds that it is a process in which a message producer puts thoughts or feelings into words and transmits those words to a hearer who then gets the information from them” (p. 24).

They further state that the notion of a code is essential to this viewpoint, with language being representative of a code. Barnum and Kerfoot (1995) state, “The act of putting meaning into symbolic form is called encoding, and the act of extracting meaning from symbols is termed decoding. The degree of agreement between the message sent and the message received will depend on the degree to which the symbols have the same meaning for the two parties” (pp. 296–297).

It is clear that in organizations messages are sent through a variety of means to many categories of workers, using words as symbols. Words and other symbols often bear many different meanings. In order for people to derive a common meaning from a message, they must have a common understanding of the symbols, in this case the words. For example, assume a top governing body of a health-care system is composed of both health-care professionals and a mix of lay people. When the administration of the health-care system brings proposals to the group seeking approval for programs or equipment, the proposals must not be filled with technical jargon that the lay members of the group cannot understand. The administrative team presenting the reports or proposals should present them in easily understandable terms or at least interpret the technical language for the audience. This holds true for messages sent throughout the organization.

Many people who work in health-care settings do not have a clinical background and therefore cannot interpret messages about clinical issues accurately. By the same token, clinical people often lack a background in business or finance, so issues of budget may pose difficulty if not presented in easily understandable terms. But executives and clinicians who live with technical terms on a daily basis often forget that the audience does not share that same language. Therefore, messages must be worded appropriately for varied audiences and categories of workers throughout an organization.

Organizational Structure as It Influences Communication

In order to understand how communication can occur in organizations, it is necessary to understand what constitutes an organization and the impact of the chain of command on communication in organizations. (See Chapter 4 for a complete discussion of organizations and their characteristics.) “An organization is a systematic arrangement of two or more people or entities who fulfill formal roles and share a common purpose” (Wolper, 2004 p. 653). All health-care systems fulfill this definition of an organization, regardless of their size or purpose.

Even though a public health agency has a different purpose than a long-term care facility, each has its own purpose and people who fulfill the roles necessary to achieve the goals of the organization. Wolper observes that hospitals usually have pyramidal, or hierarchical, forms of structure in which people at the top levels have a span of control and authority that is passed down to other employees in the chain of command. In such a structure, a manager may delegate to two or three supervisors, who delegate to several charge nurses, and so on. This hierarchical structure is common in most health-care organizations and becomes more pronounced in larger organizations. This structure usually dictates how communication flows within an organization. For example, the nurse administrator may communicate with nurse managers, who then pass the message along to staff nurses. The notion of the chain of command has to do with the lines of authority throughout the organization. Employees are expected to respect the chain of command; a break in the chain suggests a violation of authority, according to Wolper (2004). For example, if an employee has an issue or concern, the employee is expected to communicate the concern to his or her immediate supervisor, who then takes the message through the organizational hierarchy. The manager should return to the employee with an answer to the employee’s concern. Employees often get frustrated as it takes time for an issue to be taken up through the hierarchy and then back down through the channels to the employee. The larger the organization, the more time required for communication to travel through the levels.

Because of the complexities of health-care organizations, it is necessary that all functions are well coordinated. Much of the coordination in hospitals occurs at the level of middle managers. Effective communication between people, units, and departments facilitates coordination of decision making and the quality of the day-to-day operations.

Ruthman (Kelly-Heidenthal, 2003) states, “Avenues of communication are often defined by an organization’s formal structure. The formal structure of the organization establishes who is in charge and identifies how different levels of personnel and various departments relate within the organization” (p. 126). For example, nurses on a unit may have concerns about the transportation of clients to surgery. They tell their concerns to the nurse manager, who in turn discusses the issue with the nurse manager of the surgery department or others within the organization who could solve the problem. The formal structure of the organization dictates who has the authority to deal with certain issues and to speak to others within the organization to resolve problems. Marquis and Huston (2003) note the impact the formal organizational structure has on communication and observe that people in lower levels are more likely to have inadequate communication from higher levels. They state, “This occurs because of the number of levels communication must filter through in large organizations. As the number of employees increases (particularly more than 1000 employees), the quantity of communication generally increases; however, employees may perceive it as increasingly closed” (p. 337).

Often, employees see a great deal of communication coming down through the levels of the hierarchy and perceive that there is very little opportunity for them to respond or to initiate communication from their level. They are bound by the formal lines of the organizational structure and must rely on their immediate supervisor to relay their concerns or input upward. Much communication in organizations is designed to inform employees, but little communication invites employee input. This may be especially true in larger organizations where there are many layers in the hierarchy.

Communication within organizations has become more challenging as health systems have grown in size and complexity. Advances in technology, greater acuity of patients, managed care, diagnosis-related groups, and regulatory requirements have changed the way health-care organizations function. The pace of most health-care organizations is faster than in the past, with many regulatory requirements dictating organizational performance. Effective communication is required for the coordination, cooperation, and collaboration

necessary to achieve unit and organizational goals. The complexities of the health-care environment require effective communication for keeping employees informed of the status and challenges of the unit and organization, the organizational goals, and the unit expectations and responsibilities in meeting those goals. Communication serves to give employees the knowledge and guidance necessary to do their jobs, build commitment to unit and organizational goals, and make them feel that they are an integral part of the organization Nurse executives and managers must be able to ascertain what and how many details need to be provided to employees and make considered judgments about the best means by which to provide that information. Nurse executives in particular may need to deliver the messages on the same topic to several audiences and will need to tailor the message to the audience. If seeking approval for funding for a program from the governing board of the agency, the nurse executive would provide enough information for the board to make an informed decision, usually in a formal presentation. When presenting the program to employees who will be responsible for implementing the program, the level of specificity would increase and might be communicated personally, through nurse managers, in educational session, or by memo. Employees must also understand their responsibility to be proactive in bringing nursing issues—including problems and solution suggestions—to the attention of management, using the proper chain of command.

Types of Organizational Communication

Organizational communication includes  verbal and nonverbal means of communication throughout the organization. Large, complex organizations use a variety of channels of communication, including vertical, horizontal, diagonal, and the grapevine (Marquis and Huston, 2003).

Managers have to determine the best mode of communication to be used to convey a particular message. For example, layoffs or some other change in the organization with strong, potentially negative consequences for employees warrant a face-to-face meeting so that management can provide immediate clarification and can receive feedback. The immediate feedback and clarification may prevent misunderstandings and rumors that misconstrue the intent of the message. Other more routine information may be communicated successfully by memo or e-mail. Marquis and Huston (2003) note that “a message’s clarity is greatly affected by the mode of communication used” (p. 341).


Both face-to-face and written messages constitute verbal communication. Written messages, including e-mail, provide documentation of the message but may be misinterpreted by the recipients and are time-consuming for managers. People will likely interpret written messages from their own perspectives, experiences, and position in the organization, making unlikely a common understanding of written messages by all who receive them. Efficient and effective writing skills are important for nurse managers. Spears (1997) interviewed nurse managers concerning their feelings about writing business communications. Nurse managers reported that on average they spent between 12.4 and 16 hours of a 40-hour work week writing. They noted the need for good writing skills, and many expressed the need for more education in developing writing skills. They reported that often written requests and recommendations garnered more attention from top managers than oral messages. Written requests, recommendations, and proposals also provide a record of the communication.

Marquis and Huston (2003) observe that face-to-face communication is rapid but that fewer people may receive the information. Common strategies used by managers and nurse executives are to have open meetings with staff on all shifts. However, it would be rare if 100% of the staff members were able to attend these meetings at the times scheduled. Therefore, other means of conveying information might be necessary, such as memos or written summaries of the content of the meetings. Nonetheless, nurse managers communicate face-to-face in a variety of formats, including formal meetings, presentations, and work groups. Top-level managers typically spend many hours in meetings. Barnum and Kerfoot (1995) state, “Person-to-person communication has advantages such as forc-ing the receiver’s attention to the issue, providing immediate feedback and clarification, and allowing the message to be adapted to a specific audience” (p.300). Crow (2002) suggests that personal interaction may build more trust than written communication, such as memos, and that it provides people the opportunity to question each other. Whatever mode of verbal communication is used, several points are important. Messages should be checked carefully for accuracy, completeness of detail, and clarity. Some managers ask others to read a message to evaluate these points before the message is sent to the target audience. This review becomes more important in light of a survey of 1000 “average” workers in the United States (Schumann, 2004). The study found that employees want truthful information from their employer and that only about half were satisfied with the information they received. The researcher found that employees want plain talk that is easy to evaluate on items that are important to them. The tone of a message is also of utmost importance. The message should convey respect for the intended audience. Barnum and Kerfoot (1995) state that it is a mistake for a manager to write a message in anger. A communication written or spoken in an angry, confrontational tone almost always engenders a negative response from employees. A message that conveys respect and invites cooperation and collaboration is likely to be well received. The tone must be appropriate for the topic and the targeted audience, and both the short-and long-term effects of the message must be considered.


In face-to-face communication, the spoken word is accompanied by nonverbal behaviors. Sometimes the nonverbal behavior is planned and calculated, and other times it is unconscious on the part of all parties involved in the communication process. Communication is commonly considered a process, with words as symbols and language representing a code. When a person assumes a rigid posture and shakes a fist at someone else, words are not necessary to understand the meaning of the message. In a work setting, an angry, frowning face may convey a louder message than the words spoken or the tone of voice used. Gillies (1994) states, “To compensate for the inadequacy of verbal message information, people unconsciously use facial expression, gesture, touch, and vocal tone to amplify the meaning of spoken communication” (p. 184). Nonverbal communication includes appearance, tone of voice, gestures, body movements, glances, facial expressions, dress, smell, proximity, and gait (Dahnke and Clatterbuck, 1990; Ruthman in Kelly-Heidenthal, 2003). Tone may be more important than the words in a message, and facial expression may be more important than either. Even if the content of a message is fairly neutral and informative, if it is delivered by someone with an angry facial expression using a sharp tone of voice, the content of the message will most likely be overshadowed by the nonverbal behavior of the sender. Because nonverbal communication is usually unconscious, it is hard to control. It is important for the nonverbal message to be consistent with the verbal message. For example, it would be inappropriate to deliver a serious message of a planned layoff while smiling. Managers and employees should be aware of their nonverbal behavior and recognize its impact on all communication. Both managers and employees should monitor their nonverbal behaviors. They may also find it useful to seek feedback from others to determine if their nonverbal behaviors are consistent with their verbal messages and to determine the impact of their nonverbal behavior on the overall impression generated by their communication.


In complex organizations, it is necessary for communication to flow in a variety of directions in order to attain organizational goals. Vertical, horizontal, and diagonal communications are used to communicate effectively.

Vertical Communication

Vertical communication is communication that occurs between superiors and subordinates. Vertical communication includes downward communication, in which information and other types of communication are sent by superiors to subordinates. Downward communication reflects the hierarchical structure of the organization. Downward communication can occur in a variety of ways depending, in part, on the content of the message.

For example, news that will please subordinates, such as a bonus, would be delivered differently than news that might be distressing to them, such as upcoming layoffs (Barnum and Kerfoot, 1995).Some messages may need to be delivered by a variety of modes, such as face-to-face, mediated forms like video or audio, and written. For example, if a procedure is being changed, it may be announced in a unit meeting, reinforced by a memo to all employees affected by the change, and shown in a video detailing the proposed change. The revised procedure would then be written and placed on the nursing unit. The mediated and written messages also serve to provide a record of the communication. If employees do not adhere to the new procedure, they cannot say they were not informed of the changes if it is clear that they received a written notification or were present for a video detailing the procedure.

Mantone (2004) reports the case of a chief executive officer (CEO) who was nearly removed from office because of great unrest in the medical staff due to poor communication. Although the organization was providing information to and communicating with the elected leaders of the medical staff, the information was not reaching the actual medical staff. The CEO learned that reinforcing the message is as important as delivering it initially. It is clear that the CEO should have communicated not only with the leadership of the medical staff but also with the medical staff as a whole, either in faceto-face meetings or in written format.

Upward communication occurs when employees or managers who are subordinate to top level management send messages up through the chain of command (Marquis and Huston, 2003). Each employee is expected to respect the chain of command and submit the communication to an immediate manager. Organizations should establish a culture that supports upward communication from employees. Subordinates should be educated as to how to use the chain of command to elicit information, provide input, and express concerns. If the immediate manager is unable to address the issue, it must be clear how that manager should move the message through the organization in order to respond to the person who submitted the message.

Employees often feel that their input and questions are not welcomed and complain that they do not receive satisfactory responses, which may have a negative impact on employee satisfaction and productivity. It is generally easier to filter information down through the layers than to filter information upward (Keefe, 2004). For example, nursing staff members may be concerned about inadequate staffing on a unit. They bring their concerns to their nurse manager, who listens to them and assures them that their concerns are viable and will be addressed. Several weeks pass, and the staff nurses have had no further communication regarding staffing from the nurse manager. They again pose their concerns to the nurse manager, who assures them again that the administration is aware of the staffing difficulties and is working toward a solution. Nurses are likely to become increasingly frustrated when more time elapses with no definitive communication from the nurse manager and with no changes in the staffing patterns.

Horizontal Communication

Horizontal communication occurs when managers and others communicate with people on the same level in the organizational structure. Staff nurses communicate with other staff nurses, or nurse managers communicate with other managers.

Communicating with others at the same level in the hierarchy is often more efficient than moving a communication up and down through the chain. Effective horizontal communication can facilitate coordination between departments as well as problem solving and decision making. Horizontal communication provides a direct, often expedient, way of solving problems and addressing issues critical to the effective functioning of the organization.

Diagonal Communication

In diagonal communication, managers interact with managers, physicians, and groups of people in other departments in the organization who are not on the same level in the hierarchy (Marquis and Huston, 2003). This type of interaction is important to the functioning of the organization and usually does not occur through formal means. Diagonal communication serves much the same function of being an expedient, direct route of decision making and problem solving as horizontal communication but encompasses a wider range of people throughout the organization. Diagonal communication allows managers to go directly to a person at a different level in the bureaucratic structure to resolve issues.

For example, a nurse executive might work with the leadership of the medical staff to address a clinical issue.


Organizations have both formal and informal communication networks. “Formal communication networks follow the formal line of authority in the organization’s hierarchy. Informal communication networks occur between people at the same or different levels of the organizational hierarchy but do not represent formal lines of authority or responsibility” (Marquis & Huston, 2003, p. 339). Formal communication occurs when a nurse manager takesa unit problem to an  immediate superior. Much communication occurs informally between employees who are not formally connected within the hier archy. For example, nurses may have lunch with employees from the laboratory and discuss a process or procedure. Informal communication can occur in chance encounters within the organization but may be useful in accomplishing goals. Duemer and Mendez-Morse (2002) believe that people who hold higher positions in the organization have access to more formal communication, and those lower in the organization participate more easily in informal communication. The higher positions in the organizational hierarchy provide more access to key people in the organization, so formal communication can occur fairly easily. Further, managerial and administrative people often conduct business in regularly scheduled meetings. People who hold lower positions in the organization do not have the same access to key people. Given the difficulty in upward communication, employees may find it more expedient and convenient to engage in informal communication networks. Informal communication may be facilitated by proximity of employees to one another, making communication convenient. Baker (2002) observes that, traditionally, formal communication was considered to be the more effective type of communication in large bureaucratic organizations. Informal communication, traditionally considered as interpersonal or horizontal, was thought to hinder effective communication. Today, however, both formal and informal communication may be necessary for effectively conducting the work of modern organizations. Astute nurse executives recognize the need to incorporate informal communication into the communication network.

The nurse executive may use informal communication, however, to clarify a formal communication, to provide or seek additional information on an issue, or as a vehicle for negotiation and persuasion.


A common vehicle for informal communication in organizations is the grapevine. “The grapevine is the informal and unsanctioned information network within every organization” (Mishra, 1990, p. 213). The grapevine is essentially the rumor mill in an organization. Word is spread from one person to another outside the formal communication network. The grapevine is the spread of information without regard for the traditional networks of communication. Because management does not control the grapevine, it moves in every direction within the organization. Dowd, Davidhizar, and Dowd (1997) believe that in the absence of factual information, employees will fill in the lack of information with rumors. Grapevines carry both positive and negative messages. Rosnow (1983) suggests that productivity and morale are decreased when the grapevine consistently carries negative messages. In those situations, Crampton, Hodge, and Mishra (1998) believe management should focus more on the conditions in the organization that lead to the rumor rather than on the rumor itself. They observe that rumors usually develop when formal communication has been absent or unclear. Rosnow suggests that the more anxious people are, the more likely they are to participate in rumors. When focusing on the conditions that lead to rumors, managers should be aware of employee satisfaction and employee concerns.

When employees believe they are being kept well informed of issues important to them, they may decrease the use of the grapevine. However, the grapevine is not all negative. Rosnow uses the example that if an employee is disciplined by a manager for tardiness, word will spread rapidly, and tardiness across the organization or department is likely to decrease. The grapevine is faster than memos or distributing policy or other more formal means of communication because the rumors are spread without regard for the conventional networks of communication dictated by the organizational structure.

Dowd, Davidhizar, and Dowd (1997) also believe that rumors may have the positive effect of relieving tension and helping employees adapt to change. If employees are concerned about a proposed change in policy or procedure, hearing others talk about the change may provide employees the opportunity to become accustomed to the idea. Further, if employees are worried about an issue or do not have complete official information about an impending change, listening to and passing along what others are saying or believing about the situation may relieve some stress and tension.

It is clear that managers need both to monitor and manage the grapevine as appropriate. If misinformation is rampant and is causing unrest, managers must intervene and provide factual information quickly. The most astute managers not only manage the grapevine but use it advantageously. Leftridge et al. (1999) report a technique used for managing the grapevine at one hospital. Members of management hung a grapevine wreath in the corridor of the nursing service and announced their plan at a staff meeting. They encouraged staff to write down any questions or rumors they wanted addressed and post them anonymously to the “grapevine.” Managers’ answers were written on purple paper, posted by e-mail, answered in staff meetings. and posted on the grapevine. This method allowed employees to ask questions they might not have asked in a formal setting. This exchange of ideas and information between employees and managers can be highly advantageous to the organization. It serves as a means of providing factual information and may serve to build trust between employees and management. The grapevine is a fact of life in every organization. The challenge becomes finding the best ways to use it to the organization’s advantage.

Gender and Generational Differences in Communication

Many factors can affect communication in organizations where many people are involved in the communication process. Two such variablesinclude gender and generational differences.


It has long been recognized that men and women differ in their communication styles and preferences.

Tripp (2002) cites research by Nicotera and Rancer in 1994, which suggests that males are expected to and actually do exhibit more verbal aggressiveness and are more argumentative than females, which may place men in more credible positions in the hierarchy. Vanfosson (1996) reviewed the research on gender and communication and observed that men are more likely than women to initiate interaction and are more likely to interrupt other people than women. She ascertained that in meetings men obtain the “floor” more often and hold it longer than women. Vanfossen notes that the significance of the findings is that those who talk more in decision-making groups tend to become leaders. People in more powerful positions spend more time talking than people in less powerful positions. Tripp suggests that socialization and acculturation account for the vast majority of the differences in male and female communication behavior. He further notes that these findings in basic research are important to those involved in organizational communication. It is important for nurse administrators and managers to be aware of the general differences in communication patterns between males and females. This is particularly important because nursing is a discipline consisting primarily of females functioning in bureaucratic organizations potentially led by males. Nurses need to be aware of their own and others’ communication styles so they can be equally effective within the organization as others. For example, female nurses may be less willing to speak out in meetings than their male counterparts but may find it necessary to do so in order to have equal input into important issues. When males are interacting within groups composed primarily of females, they may find it advantageous to modify their communication style to foster input from all members of the group.


An organization comprises people of many ages, which can pose challenges for communicating throughout the organization. People across generations have different socialization and experiences that necessarily affect communication styles and preferences. Generalizations about younger people and older people and their attitudes about communication should be made cautiously, but some broad generalizations may apply. Many older people complain that younger people are too casual, do not value face-to-face communication, and are too technology-dependent. Many younger people complain that older people are set in their ways and are not computer-savvy (Lieberman and Berardo, 2005).

Even though all members of a generation may not share the same values and traits, most people are shaped by the important events in their early to middle years (Executive Update, 2000). People of different generations prefer different methods of communicating and have different comfort levels with technology (Burke, 2004). According to this author, providing important information in a variety of formats increases the likelihood of people receiving the information in a format that they prefer. Because people of different generations hold different goals, beliefs, and experiential backgrounds, misunderstandings occur in the workplace. These intergenerational misunderstandings can create tensions and strife, which results in unproductive use of time and energy (Executive Update, 2000). To decrease such tensions, managers may engage employees in team-building activities that draw on the strengths of each generation and provide learning opportunities for all members of the team. Having employees of several generations in an organization can bring a richness of experience and perspectives to the organization. Managers should strive to create a positive, empowering work environment that is valued by all generations in the workforce. Such a work environment can be created by using team- and camaraderie-building strategies and emphasizing communication. Management should provide information to employees in a variety of formats and facilitate interaction between people of all ages to foster mutual understanding and collaboration.

Information Technology and Electronic Communication

Technology has transformed clinical practice and  has changed organizational communication itself. Clinical information systems allow nurses to chart at the bedside, eliminating duplicate documentation. Wireless technology allows nurses, for example, to access patient records, answer call lights from remote locations, and access databases for clinical practice. Technology also allows caregivers to have access to data when needed (Newbold, 2003). As new clinical or administrative technology is being introduced, communication concerning resulting changes may be an important determinant of success. Simpson (1996) observes that when implementing an information technology system, organizational communication about the technology must be tailored to the specific audience. Employees should be kept well informed of the new systems throughout the change process. If employees believe they have been a part of the change process, they are more likely to accept the proposed change.


It has been widely recognized that information technology systems have the potential to improve safety and quality of patient care. Electronic health record (EHRs) are an integral part of the information technology system that can positively affect patient care. Kauka (2005) recognizes several benefits of EHRs, including facilitating faster and better communication among providers, allowing for faster and simultaneous access to patient data by authorized providers, reducing errors resulting in better outcomes and lower costs, and improving patient confidentiality. The Institute of Medicine of the National Academies has identified a set of core functions that EHRs should fulfill in order to promote patient safety and increase quality and efficiency in healthcare delivery (The National Academies, 2003). The eight functions fall into the categories of: (1) health information and data, (2) results management, (3) order entry/management, (4) decision support, (5) electronic communication and connectivity, (6) patient support, (7) administrative processes, and (8) reporting and population health management (Institute of Medicine, 2003). The National Academies (2003) note that immediate access to health information and data regarding patients’ diagnoses, allergies, medications, laboratory test results, etc., is useful in timely decision making. Results management speaks to the ability of providers of care in multiple settings to have quick access to new and past data, such as laboratory test results, thereby increasing patient safety and quality of care. Decision support includes computerized decision support systems to facilitate compliance with best practices. It uses reminders, prompts, and alerts; identifies possible drug interactions; facilitates screenings and preventive practices; and facilitates diagnoses and treatments. The National Academies go on to observe that electronic communication and connectivity include readily accessible communication among providers and patients that is secure, efficient, and readily accessible, which reduces the frequency of adverse events through timely diagnoses and treatment. Patient support includes tools that assist patients in controlling chronic conditions through home monitoring and self-testing, having access to their health records, and providing interactive patient education. Administrative processes include computerized tools that improve provider efficiency. Reporting includes data storage using uniform data standards, which help health-care organizations fulfill reporting requirements. These functional categories will serve as a basis for development of industry standards for EHRs and will guide the development of software that includes those functional areas (The National Academies, 2003). Ideal EHRs are still in development, and health systems and vendors alike continue to work toward refining them.

EHRs have the potential to alter the way patient information is managed throughout the system with positive effects on patient safety and quality of care. Patients may view their medical records through secure access using the Internet. Ross, Moore, Earnest, Wittenvrongel, and Lin (2004) state that such access to their medical records may help patients in the management of chronic diseases. They conducted a study to ascertain the effects on patient care and clinic operations of patient-accessible online medical records concerning patients with congestive heart failure. They used software that included an educational guide and messaging system between patients and staff. The sample included 107 patients, 54 of whom were in the intervention group and 53 in the control group. The researchers found that providing these patients with an online medical record was not only feasible but also improved treatment adherence (Ross, et al., 2004). The use of computerized systems has altered not only methods of patient care delivery but also the way people communicate in organizations. Norton and Lester (1996) observed that electronic communication breaks down rigid organizational structure and actually circumvents hierarchy because information

Practice Proof

flows around rather than through the traditional organizational hierarchy. They note that organizational culture and common sense can control such communication fairly well and that there should be rules and procedures to govern use of information technology. For example, if a communication is sent to staff from the chief nurse executive, it should be made clear whether the staff members can respond to the communication directly or if they should go through their supervisor. In health care, there is always the overriding issue of privacy, so each organization will have policies governing what information is accessible to categories of staff and under what circumstances.


One way that organization-wide communication has changed through technology is the establishment of intranets using Web technology. Intranets are private, in-house systems that allow people to communicate and share information easily and efficiently (Cupito, 1997). Use of intranets varies, but the commonality is that they improve communication. Notices that keep employees informed on a given topic can be posted; information that is specific to the organization becomes accessible to staff, such as policies, announcements, events, and so on. White (2004) believes that in order to get the most from an intranet, the intranet has to be a part of the overall communication strategy of the organization. He stresses the importance of people being able to trust the information they obtain and being able to find current and correct information on the system. Sinickas (2004) reports on research from 20 organizations over 4 years. Of the employees surveyed, only about 33% said they would like to rely on the intranet exclusively for communication in the workplace, and about 50% said they would like it to be a component of the communication system in the organization. Only about 10% of the employees stated that they did not wish to receive any information through the intranet. These findings point out the necessity for managers to use a variety of techniques when communicating to a diverse population.


Electronic mail (e-mail) is a widely accepted communication technique. Organizations have come to rely on e-mail as a fast, efficient means of communicating with large numbers of people or a single person. Although e-mail allows the recipient to answer when time allows, it is expected that e-mail will be answered in a timely manner. A recent cartoon depicted a manager standing at the desk of an employee, stating that the employee should have checked his e-mail more often as he was fired weeks ago. This exemplifies two important points. E-mail would be an inappropriate means of informing an employee of something as serious as termination of employment. It also points out the need for employees to read e-mails in a timely manner to stay informed and receive current information.

E-mail allows large numbers of employees to receive the same message at the same time. However, e-mail is not a perfect way to communicate and should only be part of an overall communication strategy. Simpson (1996) notes that an e-mail cannot be sent to 100 people with an expectation that the message will be commonly understood and interpreted correctly by all of the recipients. Managers must understand that employees may not all interpret an e-mail in exactly the same way. Interpretation will vary, depending on the topic, complexity of the message, position of the employee in the organization, and personal perception. Sinickas (2004) notes that electronic communication seems to reduce employees’ need for or expectation of face-to-face communication more than it decreases their desire for printed communication. With the use of e-mail, employees seem to have fewer expectations that communications in the organization will occur face-to-face. Many people may still wish to have notices written and posted or provided to them by some means other than e-mail, however.

E-mail is an expedient way to communicate within organizations but less confidential and secure than some other forms of communication. When using this mode of communication, there is need for security to avoid unauthorized disclosure of patient information or other privileged information. Because the very nature of e-mail encourages spontaneous communication, and because much information in a health-care organization warrants confidentiality, organizations should have an e-mail usage policy. The policy should be designed to protect confidential information, ensure that the organization is in compliance with all relevant national and state laws, and inform employees of the rules that apply to their appropriate use of e-mail. Organizations may establish rules that deal with personal use of e-mail, including the kinds of messages and material that are suitable for transmission in the workplace. Van Doren (1996) notes that while employers consider monitoring of e-mail as their responsibility to protect confidential information, employees may view the monitoring as an invasion of their privacy. Van Doren further observes that e-mail communication of employees in hospitals and long-term care facilities is being obtained by the legal system and used as evidence against them in lawsuits. The issue of liability points out the importance of policies to govern use of e-mail within an organization.

One major advantage of e-mail is that managers can provide immediate information to many people within the organization, for example, to counter the rumors spread through the grapevine. Managers should proofread their messages before they are sent to be sure they are accurate and carry the intended message. E-mail is a convenient way for managers to keep employees feeling that they are well informed of issues of importance to them.

Importance of Organizational Communication

Effective communication is an essential component of organizational functioning. It is generally accepted that communication directly affects patient safety and quality of care. “According to findings from a study released in a national briefing of healthcare stakeholders, the prevalent culture of poor communication and collaboration among health professionals relates significantly to continued medical errors and staff turnovers” (Kohn & Henderson, 2005). Adubato (2004) observes that many thousands of people die each year from medical errors during their hospital stay. He states, “These are not caused by high-tech medical equipment breakdown, but by sloppy, downright poor communication by health-care professionals who should know better” (p. 33). Amatayakul and Cohen (2004) believe that optimal communication is as important in reducing medication errors as computerized physician order entry and other efforts to improve patient safety. Hanlon (1996) says that poor communication is often cited as a source of stress for nurses. He believes that when nurses have repeated unsatisfactory communication experiences, there is a cumulative effect that creates stress. This stress, according to Hanlon, may contribute to burnout, job dissatisfaction, and increased turnover, all of which serve to decrease the quality of care received by patients. Similarly, Breisch (1999) believes that effective communication, as well as accountability and recognition, is necessary for motivating employees. She explains that nurses’ responsibilities have become more complex with greater patient acuity, more rigorous documentation requirements, and technological advances. These factors support the need for nurse managers to create a work environment that supports the needs of the work group. In fact, the importance of effective communication in the organization is reflected in The Scope and Standards for Nurse Administrators, which states that the nurse administrator “creates a climate of effective communication” (American Nurses Association, p. 26).


Adena Health System in Chillicothe, Ohio, developed an innovative way to meet the accreditation requirements of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Effective organizational communication was key to Adena’s innovative approach to the accreditation process.

JCAHO instituted a new process whereby surveyors selected approximately 11 active patients and retraced their care through different departments. The surveyors observed care given, reviewed policies and procedures, and questioned staff and patients in different areas of the hospital. Because of the uniqueness of each patient and the differences in each area of the hospital, preparing the facility for a survey was challenging. The unpredictable nature of tracer activities proved to be difficult for even the most experienced managers and survey coordinators. Historically, Adena had used mock surveys and electronic communication to prepare the staff for the JCAHO visit, but these methodologies had failed to generate any enthusiasm among the staff. Further, following the accreditation visit, most practices returned to the way they had been prior to the visit.

The “Survivor Adena” concept was developed based on the popular Survivor television series. The objectives of Survivor Adena were to provide a framework to motivate and engage the organization in survey readiness to sustain the results of the preparation. A tribal council was developed to lay the groundwork for Survivor Adena, which focused on innovative ways to communicate effectively with staff to engage them in the accreditation process, empower staff to make changes, and provide ongoing education needed to make the required organizational changes. Adena’s staff was given the task of developing over 120 “tribes.” Each tribe had the challenge of picking an area of focus that combined the concepts of JCAHO’s “Shared Visions” tracer methodology and any “hot button” areas such as patient safety, medication management, and infection control. Tribes were encouraged to collaborate with other departments and collaborate on a common goal.

Weekly, mini-challenges were electronically mailed to Adena’s staff. The mini-challenges were quizzes that focused on specific topics or standards of care. It was mandatory for staff to complete the weekly quizzes. A Survivor Adena Fair was held to bring various departments together to provide educational booths and fun activities to promote sustained excitement and motivation concerning the upcoming survey. Complete participation was expected from the staff, and 99% indicated on a survey that the fair was beneficial and provided a good learning opportunity. Incentives were built into the plan, with people and tribes earning tickets that were cashed for various prizes at the end of the 18-month Survivor Adena project.

Adena had a successful survey and received very few requirements for improvement. Dawn Allen, Director of Quality Management and Medical Staff Services at Adena, stated that the participation, enthusiasm, and activity from the staff in preparing for the JCAHO survey were unprecedented in this system. She further noted that traditional methods of a unilaterally driven project will no longer meet the expectations of JCAHO’s Shared Vision framework and that creating a culture of continuous survey readiness is crucial. The system believes that the shared vision at Adena of communicating effectively with employees and encouraging communication between departments was instrumental in developing ownership of the concept of continuous survey readiness. The outcome of their efforts is a system with a culture of safety and quality that is imbedded within the organization.

All Good Things…

Communication is essential to the goal attainment and overall success of an organization. Effective organizational communication is challenging in many ways, given the complexity of health-care systems. Because good communication is such an important component of successful operation, it is well worth the time and effort it takes to develop effective communication strategies. Nurse administrators and managers responsible for internal communication must recognize that people interpret messages differently, depending on several factors, including their experiential background and position in the organization. Further, there are gender and generational differences that must be recognized and accommodated when communicating with many people in an organization. Managers must choose the correct mode of communicating messages depending on the intent of the message. Some messages may need to be delivered face to face, and others may be sent by memo, e-mail, in a group setting in meetings, or some combination of modes. Managers also have the obligation to ascertain whether important information has been understood correctly by diverse employee groups.

Employees must understand their responsibility in the communication process and how the flow of information is to occur from the level of the employee to those at higher levels of the hierarchy. Management is then obligated to address employee concerns in a timely and effective manner. Communication has been shown to require a time commitment by managers in order for it to be effective throughout the organization. This commitment is well worth the effort as effective communication influences employee satisfaction, quality care, and customer satisfaction. Effective communication within an organization improves the coordination of decision making and may decrease the use of the grapevine. Excellent organizational communication facilitates the attainment of organizational goals and is necessary for almost every aspect of operations. Effective communication within the organization should be a priority of every nurse manager and is an essential component of effective leadership.


Nursing informatics is a relatively new specialty, which has been marked by rapid growth in terms of numbers of practitioners as well in the explosion of domain knowledge. Beginning with the Social Security Act amendment of 1965, which established Medicare and Medicaid, the growth in the use of computers in health care was assured. This act required documentation of care, most notably nursing care, and the progression of nursing documentation in the medical record received a significant boost (Thede, 2003).

The first nursing informatics specialists emerged in 1981, when approximately 15 nurses identified nursing informaticists as their practice specialty (Saba & McCormick, 2006). Nursing informatics was recognized as a specialty by the American Nurses Association (ANA) in 1992, thereby denoting it as a distinct nursing practice specialty with a unique scope of practice. In 1994, ANA published the first Scope of Practice for Nursing Informatics, followed by the Standards of Practice for Nursing Informatics in 1995. Once the scope and standards of practice were clearly articulated, the American Nurses Credentialing Center (ANCC) offered the first certification examination in December 1995. As of December 31, 2005, 566 nurses were certified across the United States as Nurse Informaticists (T. Norris, ANCC, personal communication, April 20, 2006). Throughout the last two decades of the 20th century, informatics grew as a specialty in health care as well as within the nursing profession. As the use of electronic documentation systems grew from small, isolated demonstration projects to a mainstream reality, it became clear to nursing leaders that the profession needed to define taxonomies and classification models and minimum data sets that could be coded for documentation, storage, and retrieval in electronic medical record systems. Additionally, demand was growing for nursing protocols, innovative methods to support nursing and patient education, and expert systems incorporating knowledge representation and decision support and evidence-based practice. With these compelling objectives, nursing informatics has a practice agenda on which to focus for the foreseeable future (Saba, 2001).

Definition of Nursing Informatics

Graves and Corcoran provided the first definition of nursing informatics in 1989: “A combination of computer science, information science, and nursing science designed to assist in the management and processing of nursing data, information, and knowledge to support the practice of nursing and the delivery of nursing care” (Graves & Corcoran, 1989, p. 227). These two scholars also clarified that professional information systems serve as a foundation for the dimensions of supporting decisions and advancing the knowledge of the discipline. The Graves and Corcoran definition has been expanded by the ANA: “Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in their decision making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology” (American Nurses Association, 2001, p. 17). Several important factors are inherent in these definitions. First, the definitions illustrate that nursing informatics is a multidisciplinary science practice. Second, the definitions clarify that nursing informatics is not to be equated with the generic term informatics; it is specific to nursing and nursing practice because of the inclusion of the nursing science domain. Nurses specializing in nursing informatics employ their nursing science knowledge to mold, provide direction to, and influence the design of nursing information systems. Another core component is computer science. Nursing informatics is not about computers but rather the core elements derived from computers—data, information, and knowledge—and how best to structure nursing documentation systems to ensure that the output will meet the needs of patient care and nursing science. We will discuss these three concepts later, but it is important to note that computer technology is the tool by which the outputs of information science are derived and which are an important facet of nursing informatics.

Dr. James Turley suggested the addition of cognitive science to the definition of nursing informatics. Understanding the processes employed in structuring knowledge; representing knowledge; and employing knowledge in decision making, recall, and perception are important dimensions in the practice and application of informatics. Ongoing research in the cognitive domain provides important understanding to guide the design of information system software, helping to create systems that are increasingly more useful and more effective in supporting decision making by clinicians.

Turley suggests a model that incorporates the elements of Graves and Corcoran’s model—nursing, information, and computer science—and adds the domain of cognitive science. Furthermore, Turley suggests that the nursing science is the foundation on which the other three sciences rest. Turley’s model also suggests that it is the  intersection of the cognitive, information, and computer sciences that constitutes nursing informatics (Turley, 1996). Nursing science is the raison d’être of nursing informatics, and without the needs and context of nursing science nursing informatics would have no purpose. Turley’s model has the further advantage of flexibility: the model can be translated to other health-care science disciplines by changing the foundational domain.

Nursing informatics has the purpose and the potential to support and improve the care of patients and communities through the collection, management, and communication of information about and for the patient. As well, nursing informatics can assist in making the contributions of nursing visible in the medical record and assist thnurse by providing decision support tools. Nurses are presented with an increasing array and complexity of information that they are expected to synthesize and incorporate into their patient care decisions. More information does not necessarily result in better care unless it is thoughtfully analyzed, organized, and presented in ways that are meaningful to nurses and their practice. The timing, content, and format of the information can vary with the recipient; the information needs of clinicians at the point of care are different from the needs of the manager or administrator, and those needs differ from the needs of the policy maker.

Turley’s suggested model for nursing informatics.


Consequently, a pivotal role of the informaticist is to collaborate with those individuals and groups to discover their information needs and the decisions that will result and translate those needs into creation of appropriate data collection, analysis, and presentation formats.

Nursing Informatics Standards of Practice

The standards of nursing informatics practice carefully parallel the nursing process (see Table 9-1). The clinical nurse focuses on assessing the needs of a patient and the individuals in the patient’s support system. The nurse then develops a plan of care based on careful prioritizing of the nursing diagnoses. Then the plan is implemented and assessed and evaluated according to the patient’s responses to the plan. Data collected during evaluation are thoughtfully analyzed, and appropriate modifications are made to the plan of care.

The focus of the nurse informaticist is assessment of systems problems as identified by a group of clinical practitioners; identification of the problems,


Comparing the Nursing Process and Nursing Informatics Standards of Practice

opportunities, and constraints; and description of the outcomes the group desires to achieve. Using the information gathered during the assessment phase, the nurse informaticist prioritizes the problems and constraints; carefully explores alternatives in the context of time, fiscal, and resource constraints; and prepares recommendations for the team to consider.

Working closely with the clinicians, the nurse informaticist facilitates and supports the clinical team in selecting a solution from the options presented, ensuring that the advantages and limitations of each solution are explored carefully. Once the clinical team has chosen the most appropriate solution, the nurse informaticist works with the system programmers during design of the software solution, reviewing the progress of the plan with the clinical team at key junctures. Upon completion of the programming process, the system is implemented, and the evaluation phase begins. Employing evaluation measures defined during the planning phase, the nurse informaticist gathers the evaluation data, analyzes them, and works with the programmers and the clinical team to define the nature of system modifications necessary to resolve identified system issues. The evaluation process and subsequent system modification are iterative.

It is important to recognize that the above summary is just that—a very high-level summary. Just as the brief description of the nursing process does not begin to describe the details of interventions and decisions a nurse makes during an episode of patient care, the same can be said for the processes, interventions, and decisions of the nursing informaticist. It is also important to point out that the process of identifying and implementing systems solutions necessitates development of detailed workflow information, and the solutions often include changes in workflow that are not related to the software solution. Nonetheless, there is value in identifying and comparing the parallels between the nursing processes of patient care and the analysis processes of information system design and informatics.

Health-Care Data Standards

Data standards are intended to minimize confusion and assure that data are collected, stored, transmitted, and retrieved in a manner that ensures that the original meaning is intact and that actions taken in response to the data are consistent with the original meaning of the data (Sensmeier, 2006, p. 218). A discussion of data standards should begin with a clear understanding of what constitutes a standard. A standard is an agreed-upon reference point, criterion, or value against which something can be measured. To be effective, data standards includdiscrete, precise definitions, adherence to which is not optional (Thede, 2003, p. 205). Dr. Thede used an apt analogy from the 19th century U.S. railroad industry in discussing her vision of standards. In the railroad’s early days, standards for track width, or gauge, had not been established, and each railroad company was free to create its own gauge. The problems associated with multiple widths quickly became apparent when trains from different railroad companies could not travel beyond their own territory. The problems this created for passenger and product movement quickly became apparent and necessitated that the competing companies come to agreement on a standard gauge. In the health-care industry, much work is focused on standard development. Some standards are widely accepted, and others are evolving. The following discussion will briefly describe some of the collaborative work currently being conducted in the United States and globally.

Interoperability is another term that is frequently used in discussions regarding health-care information systems standards. Systems that can effectively exchange data and effectively and efficiently use the data that have been exchanged have interoperability. Health-care data standards are designed to support and enable interoperability. Data standards include “methods, protocols, terminologies, and specifications for the collection, exchange, storage, and retrieval of information associated with health care applications, including medical records, medications, radiological images, payment and reimbursement, medical devices and monitoring systems, and administrative processes” (Washington Publishing Company, 1998). Data standards encompass four primary areas:

1. Definition of data elements.

2. Determining data interchange formats to establish how data elements are to be encoded as well as to assure relationships between data elements through defining how documents and information models should be structured.

3. Terminologies, which identify and define the terms and concepts used to classify and code data elements and establish relationships between the concepts and terms.

4. Knowledge representation, as provided by electronic medical literature, guidelines, evidence-based practice protocols, and clinical decision support (Institute of Medicine, 2004, pp. 128-129).

Data Elements

Data elements are the most basic pieces of information collected, and in order to be able to use the collected data they must be defined clearly, discretely, and unambiguously. Definition includes determining how the data are to be collected, by what software application, by what hardware, and when they are to be collected. It is also important to establish how the data will be entered into the software system, e.g., as free text or by selection of predefined responses using coded values. Without clearly defined, consistently entered, unambiguous data, the ability to recover data with assurance of content is greatly diminished, as is the potential of the use of the data in future research.

The question of what data should be collected was answered in part through the development of minimum data sets, an example of which is the Nursing Minimum Data Set (NMDS) (Table 9-2).

ANA-Approved Terminology Standards (February 24, 2006)

The NMDS identifies a limited set of data elements that should be collected  or every patient. These elements are clearly defined and serve as a foundation for further data collection. Fortunately, these data elements are generally collected by most electronic medical record systems.

Data elements are the most basic pieces of information to be collected, and each element must have a unique definition in order to ensure clear and consistent meaning. This process is not inconsequential. For example, “blood pressure” is a term often assumed to be understood. The term, taken alone, can have various meanings relative to the context of the user: a physical therapist may think of blood pressure in terms of pre- or postexercise; a neuronscience practitioner may think in terms of the position of the client at the time of measurement; the nurse clinician may evaluate blood pressure in the context of pre- or postprocedure. It becomes obvious just how critical it is to have a clear, discrete,nonambiguous definition of each data element: “Common data standards are essential to simplify and streamline data requirements and allow the information systems that carry the data to function as an integrated whole” (Institute of Medicine, 2004, p. 132).

Data can be appreciated best in the datainformation-knowledge continuum. Data are fundamental building blocks; they combine into a clear, objective definition of a specific fact, without attached meaning. Data are transformed into information when they are interpreted or analyzed and when a structure or organization has been applied.

Information becomes knowledge when it is incorporated into the creation of thoughtful relationships and used to support decision processes meaningfully (American Nurses Association, 2001). For example, assessment of pain at a specific moment in time provides data. The data gathered during that assessment gain meaning when placed in the context of previous pain assessments, and the pain data become information. Finally, when this pain assessment information is evaluated in the context of information regarding recent pain medication administration and other pain alleviation measures, the nurse develops knowledge regarding the effectiveness of the patient’s pain management plan.

Knowledge work uses transformed information in the context of specialized knowledge and expertise (Mayes, 2001). Registered nurses are knowledge workers by the very nature of the work they do and the continual synthesis of information and knowledge they weave throughout the decision processes inherent in patient care. Clinical judgment implies that nurses use their knowledge to interpret information in the context of the individual patient and apply that knowledge to higherlevel clinical plan development. The electronic medical record systems and knowledge representation systems support and enhance the ready access of the clinical nurse to such data, information, and knowledge.


Four types of data interchange standards have been developed in health care. These standards address:

1. Communication between medical devices and between devices and electronic medical records (EMRs)

2. Digital imaging communications

3. Administrative data exchange

4. Clinical data exchange (Mayes, 2001;Sensmeier, 2006)

Transfer of physiological data from a cardiac monitor to the EMR is an example of communication between devices and the EMR. Radiology departments employ digital imaging communication every day as they make x-ray films available to practitioners over the Internet. Administrative data exchange is an integral part of the billing systems of hospitals, enabling information to be shared with payers. Clinical data exchange is woven throughout an EMR system as, for example, data from the laboratory information system are sent to the EMR for integration in the patient record. The National Committee on Vital and Health Statistics, through its accountabilities under the Health Insurance Portability and Accountability Act of 1996, recommended adoption of several standards for data exchange. Table 9-3 is a sample of the more widely known data standards and includes a brief description of the purpose of the standards. Each standard addresses at least one type of data interchange. It is important to know why these standards have been created and that they are necessary for effective and safe patient care. The specifics of the standards will continue to evolve as a result of technological innovations.

Knowledge Representation

Effective data standards are fundamental to knowledge representation, and knowledge representation is a cornerstone of establishing and communicating best practices. As new knowledge is discovered, best practices evolve and change. At this point, the health-care industry does not have effective technological processes for quickly translating new knowledge into best practices. However, information systems, particularly the EMR, offer considerable promise. A major goal of information system developers is design of software systems that can translate up-to-the-moment evidence-based practice guidelines into clinical decision support and provide that information to practitioners when they work with the EMR (Institute of Medicine, 2004).

The promise is there, but the timeline for realization is not clear at this juncture. One means of knowledge representation currently available is electronic linkage to the biomedical literature and other medical knowledge bases. This level of functionality supports practitioner access at the point-of-care, providing information to support clinical decision making. Often the links to literature, formulary, and other knowledge bases

Health-Care Data Standards Organizations

have embedded icons in EMR systems, demonstrating an immediate level of support for practitioners. This type of knowledge representation brings the most recent medical literature to the fingertips of the practitioner, thereby enabling the practitioner to evaluate the information in the literature and appropriately weave it into patient care as the individualized plan of care is developed. An exciting next-generation dimension of clinical practice guidelines is evolving. Generally, implementation of practice guidelines beyond the local setting has been severely limited. One limitation is the lack of standards to support representing guidelines in a machine-readable format. A second limitation is that guidelines are not documented in a language that is nonambiguous, with clear and nonredundant definitions. Third, clinical practice guidelines must have access to stored data of the patient, and that data repository must contain the necessary clinical data that will support decision making. Clinical practice guidelines to date have been created using the relative simplicity of “ifthen” statements. More recent research, devoted to creating software that will enable practitioners to query large databases for best practices, structuring the query to consider information and context specific to the subject patient, offers the promise of a much more dynamic, real-time clinical decision support system (Institute of Medicine, 2004).


Terminology standards are part of health-care data standards. Nursing terminologies have special meaning to nursing practice. A suitable summary for why nursing terminologies are needed is that “if we cannot name it . . . we cannot control it, finance it, research it, teach it or put it into public policy” (Royal College of Nursing [UK], 2004). This quote is an apt distillation of the importance of nursing terminologies and the work that is being conducted in this field. Collectively, nursing does not have standard terminology, and this is readily evidenced within any given hospital or nursing unit that does not have an electronic documentation system. To a significant extent, nursing has followed the medical model, failing to articulate clearly a precise, unique name and definition for much of the work of nursing.

Nursing terminology is another critical standard necessary to the evolving medical record. Nursing terminology is a standard that is generally more functionally apparent to practitioners than other standards because users interact with the terminology throughout the electronic documentation experience. The underlying terminology guides the selection of data elements to be included in the documentation screens, the definition of those elements, and the selection options available to the nurse. Standardized nursing terminologies, or languages, provide important benefits to nursing practice, which include:

■ Consistency in documentation resulting from the ability to trend or evaluate data longitudinally

■ Nursing clinical decision support

■ Significantly enhanced nursing research ability resulting from easier and more comprehensive data retrieval from EMRs and use of data from multiple geographic sites in research studies

■ Evidence-based nursing practice resulting from EMRs that support the process of developing evidence

■ Quality assessment and evaluation of practice resulting from the ease of data retrieval and subsequent analysis

■ Professional billing for nursing services; unambiguous, consistent, comprehensive documentation is a necessary prerequisite to bill for nursing services, and standardized languages are a cornerstone to realization of that documentation

■ Creating visibility for the care provided by nurses; the terms, definitions, and classifications that are inherent in standardized terminologies will ensure that care provided by nurses will be definitively incorporated in the patient medical record

■ A bridge between the different terms used by the various care provider professions as well as a bridge between regional terminology differences across the country; as our society becomes increasingly multicultural, the need for a clearly defined and consistently employed terminology system becomes more urgent to help reduce communication ambiguity and increase patient safety.

Given the benefits that standardized terminologies offer the nursing profession, it may be surprising to learn that consensus on nursing terminologies has not been achieved. Nursing is a very complex and diverse profession, and no single terminology has been created to meet the data collection and documentation needs of the profession. There is some agreement regarding the functional characteristics and structural attributes of terminologies. These features include (Henry & Mead, 1997):

1.                     The system should be  complete and have sufficient in-depth coverage and granularity (depth and level of detail) to depict nursing care processes. For example, the full spectrum of nursing diagnoses needs to be incorporated.

2. The system needs to be  comprehensive, including each facet of the nursing care process. For example, it should include risk factors or the recipient or target of the education that is to be provided.

3. Concepts should be nonredundant, without vagueness or ambiguity, and there should be no overlapping meanings.

4. Concepts should be atomic, or separable into their constituent components. For example, a category should not be “pain” but instead subdivided into chronic pain or acute pain.

Atomic elements must be able to be combined (compositional) to create concepts. For example, an atomic element could be chronic fatigue, which, combined with acute fatigue, would create the larger concept of fatigue.

5. The system needs to be able to support hierarchies of concepts, allowing linking of general and more specific terms, and support multiple “parents” and “children.” For example, incontinence may be due to neurogenic causes or bladder prolapse.

6. Each term and concept must have a clear and concise definition.

7. The above list is a sample of the considerations and criteria employed in evaluating or creating a terminology system. This brief overview provides some insight into a complex process that is highly collaborative, requiring consensus building and continual review.

In 1995, the ANA established the Nursing Information and Data Set Evaluation Center (NIDSEC) to evaluate standardized nursing and other terminologies that have been developed by professional groups or information system vendors. The purpose was to identify and recognize those terminologies that effectively represent nursing practice and support documentation of nursing practice in computer information systems. NIDSEC evaluation criteria incorporate nomenclature, data repository (how data are stored), clinical content, and general characteristics of the system (NIDSEC - Nursing Information and Data Set Evaluation). As of February 24, 2006, NIDSEC recognized two minimum data sets, eight nursing interface terminologies, and three multidisciplinary terminologies. A brief description of each is included in Table 9-2.

Nursing documentation in the paper medical record has traditionally included one or more flow sheets as well as narrative notes. Documentation of patient care in a paper medical record is relatively unstructured, most specifically within the narrative notes. Clearly, many health-care organizations have documentation standards, such as documentation by exception; however, within the defined standard there is generally significant flexibility. Narrative notes have a number of limitations, including:

■ Differences in terminology between care providers, even when the providers are referencing the same topic

■ Use of abbreviations and acronyms, resulting in confusion and misinterpretation

■ Differences in writing style and content that limit the development of continuity and the ability to trend the clinical condition and responses of the patient

■ Illegible handwriting

■ Difficult, very costly, and limited data retrieval ability

Consequently, employing the use of terminologies represents a significant change in documentation practice. Documentation in a well-designed EMR is completed largely by selecting the appropriate option from prepared selection lists that are coded to ensure consistent data storageInformation System Goals for the Early 21st Century

The report of the Institute of Medicine (IOM), Crossing the Quality Chasm, identified six major aims for improving the health-care system of the 21st century. Targeted to all health-care organizations, professional groups, and private and public purchasers of health-care services, the focuses are: safety, effectiveness, becoming patient-centered, timeliness, efficiency, and equitability (Institute of Medicine, 2001). Although not a panacea, the EMR and the work of nurse informaticists in collaboration with clinical nurses can make significant contributions to the agenda set forth by the IOM. Patient safety can be significantly enhanced through the use of EMR systems. Some examples in which EMR systems support these goals include:

■ Legibility of handwriting and ready identification of the authors of documentation are fully supported in an EMR system. Error reduction is achieved because drug dosages are clearly written and documentation standards, such as the use of leading zeros preceding decimals, are ensured

■ Clinical alerts, such as drug-drug and drugallergy interactions, provided to the physician at the time an order is entered in the EMR save pharmacists and nurses time clarifying orders and enable the appropriate medication intervention to reach the patient more quickly

■ Nurses receive allergy interaction information at the time of medication administration

■ Positive patient identification systems, such as bedside bar-code scanning of patient wristbands, medications, and the medication administration record, can support consistent and clear verification of the five patient rights and can help to avoid medication errors.

Effective care can be supported by access to evidence-based practice databases and up-to-date protocols, helping to make sure that patients are receiving care based on the most recent scientific information. Presenting the most recent evidence to practitioners can be achieved by clinical decision support systems that offer recommendations or that suggest treatment modalities based upon the clinical condition and clinical data of the patient. Effectiveness can be further supported through data-mining (retrieval of selected clinical data from the EMR); for example, some systems analyze the response of patients with similar clinical presentations and diagnoses to specific clinical interventions. EMR systems can also offer reminders to clinicians regarding best-practice recommendations for laboratory testing, such as monitoring therapeutic blood levels of an antibiotic or anticoagulant.

Preventive care screening recommendations, such as annual mammograms or initial colonoscopy for patients who have reached the age of 50, are another example of assuring that patients receive timely interventions. Patient-centered care is enhanced as documentation by various practice disciplines, such as physicians, nurses, therapists, and pharmacists, is integrated, and practice silos are diminished or eliminated. For example, EMR sys tems support patient-focused problem lists, interdisciplinary communication through integration of documentation entries, and elimination of redundant documentation through presentation of previously documented data when and where they are needed in data screens.

Computer Hardware

Computer technology is changing rapidly, and the half-life of what is considered to be a sophisticated computer has become very short. Within that context, this section will briefly discuss the components of a computer. Perhaps the place to begin is to clarify that hardware refers to all of the physical

Practice to Strive

components of the computer. This hardware is often classified as processing components, memory, and input and output devices. Familiarity with these terms can diminish some of the mystery of computers for those who are not accustomed to using them or their component parts.


The central processing unit (CPU) is the brain of the computer. Think of the CPU as the control center, directing the flow of information while also interpreting, directing, and monitoring the execution of instructions received from memory. The CPU is also responsible for arithmetic logic, the foundation of computer function.

The motherboard is another key element, providing the connective infrastructure of the computer. The CPU, chips, hard drives, and disk drives are mounted on the motherboard, and the motherboard creates the internal organization and is the location for addition of new components. An important feature of any computer is the speed at which the computer processes information. Speed is usually described as clock speed, or the number of electric pulse cycles that occur in a defined period. Hertz is the term used to measure clock speed, and 1 hertz is 1 cycle per second. Megahertz (MHz) is 1 million cycles per second, and gigahertz (GHz) is 1 billion cycles per second.


In order to work and accomplish tasks using the computer, input devices are necessary. Input devices enable the user to enter data, such as numbers or words, that the computer then uses to perform computations based on commands that are also entered by input devices. Another way of perceiving input devices is that they enable two-way communication between the user and the computer. Commonly used input devices include the keyboard, mouse, and scanner; some computers support the use of light pens or touch-screens and other devices. In most cases, a combination of input devices, such as the keyboard and mouse, is needed for entry of data and commands. A means of extracting data from the computer is also necessary; output devices are required for this purpose. Output devices include disks, CDs, flash drives, electronic transmission to another computer, and printers, to name the more commonly used devices.


Computer memory consists of read-only memory (ROM), random access memory (RAM), and storage memory. ROM is memory used only by the computer and is protected from alteration, including erasure, by the user. The information stored in ROM supervises the overall function of the computer and enables certain computer functions, such as starting computer operation, often referred to as booting.

RAM is usually called the working memory of the computer, and it is RAM that supports the various applications used, such as spreadsheet and word processing. Another term associated with RAM is volatile memory, a reference to the temporary nature of RAM storage. Instructions needed to operate an application are retrieved from permanent storage, such as the hard drive, CD, or diskette, and used by RAM while the application is in use.Because RAM loses the information stored in it each time the computer is turned off, any work completed using applications must be saved to permanent storage so that it can be retrieved later. The files created and saved while working on the computer are placed in storage memory, sometimes called permanent memory. The term permanent memory should not be misleading; the files stored in permanent memory reside there until such time as they are erased or overwritten by new files. Hard disks, CDs, and diskettes are used to store files. Another, more recent, innovation for file storage is the flash drive, also known as a thumb drive or memory stick. These highly portable devices are available in ever increasing memory capacities (Saba & McCormick, 2006; Thede, 2003).


The way in which the computer works with and stores data is based on the binary system. A bit is the smallest unit of storage in the computer. It has two possible values, zero and one (0 and 1). If you think of the bit as an on-off switch, the “on” position is equal to 1, and the “off” position is equal to 0. Bits are combined in groups or units of eight bits

Computer Memory in Bytes

which are known as a byte. A byte represents a single character, such as an M or the number 4 (Saba & McCormick, 2006).

The number of possible combinations of 0 and 1 in a byte is 255, and in the early days of computer technology 255 was the limit of the number of characters a computer could represent. With the advent of newer technology, computers are able to express increasingly more characters and graphics, greatly expanding the flexibility for image and other visual displays. One expression of power today is to indicate the number of bytes the computer can handle: Table 9-4 is a scale of the actual and theoretical storage capacity of computers; for example, at the time this chapter was written, the yottabyte was theoretical storage capacity.

Privacy and the Protection of Health-Care Data

The Health Insurance Portability and Accountability Act (HIPAA) was enacted by Congress in 1996 to protect workers by limiting employer denial of health insurance coverage to employees with preexisting medical conditions. Interestingly, because the act also directed the Department of Health and Human Services to develop privacy rules for health data contained in EMRs, HIPAA indirectly promoted significant impetus for development of a number of standards to support data transmission.

The privacy portion of this act, often referred to as the Privacy Rule, affects all health-care providers and health plans and specifically indicates that protected health information (PHI) may not be disclosed without the permission of the patient (Flores, 2005).

HIPAA, although referred to as an act or government regulation, is more appropriately characterized as a process. As the years have passed since the law was enacted in 1996, HIPAA has gradually become recognized as a significant source of change in the culture of health care . The accountability for protection of PHI has resulted in a changed organizational focus that extends beyond the tenets of the original act. For example, quality assurance data designed to monitor and improve patient safety often include PHI information to enhance and strengthen data analysis. The need to assure that PHI is appropriately protected and that data are effectively de-identified has resulted from the evolving awareness of the need to respectfully protect information that could be traced back to individual patients.

The future challenge for the health-care industry will be to balance the need to protect the PHI with the contrasting advantages that could be gained for streamlined patient care as a result of access to medical record information. For example, in the event of a widespread health emergency, access to personal medical record information would support creation of aggregate data pools or databases that would greatly speed understanding and insight into the problem and accelerate identification of preventive or treatment solutions.

Nurses have historically advocated for and protected patient privacy. HIPAA supports and increases the accountability of the nurse, as a health-care provider, to protect the privacy of the patient. There are personal measures that are deeply embedded in nurses’ daily practice to protect patient privacy. For example, nurses can make certain that they protect the privacy of personal security passwords to information systems and refuse to share their passwords. Experts advise against writing down passwords due to the risk of discovery by others. All practitioners are responsible for all documentation made under their password, even if they did not make the entry. This sobering fact offers a compelling rationale for not sharing passwords and assuring that they cannot be discovered by others.

Another example of protecting the privacy of the patient occurs when using the EMR. By ensuring that each session is closed and logged out each time one leaves the computer, the nurse is demonstrating respect for this important patient right. Each of these measures is part of the overall strategy present in health-care organizations to honor and respect the trust relationship with patients.

All Good Things...

Nursing informatics is a new and important part of the nursing care arsenal. Working in partnership with the other members of the team, informaticists help the team define the clinical, administrative, and research outcomes and how those outcomes can be supported with comprehensive clinical data. Informaticists assist in creating an infrastructure that supports clear communication through the design of documentation consisting of nonredundant data elements with nonambiguous definitions. Nurse informaticists guide nursing leadership through the selection of a terminology system that meets the clinical and strategic goals of nursing practice and supports patient care. Nurse informaticists actively participate with clinical and information systems leadership in designing the strategic direction of the EMR system, ensuring the practice needs and imperatives of nursing are incorporated.

Nursing informaticists also communicate and interpret the role of nursing informatics to the nursing community. Effective staff training in effective use of information systems is an ongoing focus of nurse informaticists. An important facet of the role is translation of key accountabilities of practicing nurses as they use information systems and assisting the nursing community to perceive and understand the importance of its ongoing engagement and input to the work of nursing informaticists.

Enhancing Your Critical Thinking, Decision Making, and Problem Solving

Decision making is one of the most frequent activities performed by a professional nurse. At the bedside or in the boardroom, nurses must make decisions and solve problems to produce outcomes that enhance patient care. Some decisions, like when to brush your teeth, become habits, so one does not think about them. Other decisions become life-altering events that should be made with structured thought or after utilizing problem-solving techniques. All decisions are not made in response to problems, but all problems were resolved because of decisions made along the way. Driven by critical thinking and using a multidisciplinary knowledge base, nurses need to make decisions that are appropriate to the context of the situation and considerate of the culture where theservices are being provided.  These decisions need to be based on knowledge of the individuals, relationships, ethics, politics, and financial considerations of the situation. Decision making can be simple or complex. The situation may require a quick response or allow for reflection, collaboration with others, and a carefully considered response. Nurses need to develop and enhance ways to see all sides of an issue, find various approaches to solve problems, and make careful, intelligent decisions. Critical thinking is the foundation for examining all possibilities and arriving at reasonable and justified conclusions. This chapter will explore various ways to make good decisions and solve problems effectively by using creative critical thinking skills.

Critical Thinking

Critical thinking is a complex process that has many definitions. Some authors state that it is a reflective and reasonable way of thinking; others see it as an attitude of inquiry. Still others describe it as a disciplined, self-directed thinking process. Most agree that critical thinking does entail an orderly investigation of ideas, assumptions, principles, and conclusions. Critical thinking is the process that guides scientific reasoning, the nursing process, problem solving, and decision making. The cognitive skills attributed to the critical thinking process include divergent thinking, reasoning, reflection, creativity, clarification, and basic support (Green, 2000).

■ Divergent thinking is the ability of an individual to analyze a variety of opinions and judgments.

■ Reasoning involves the use of logic and the ability to discriminate between observation and inference, fact and guessing.

■ Reflection allows one to deliberate about something, whereas creativity enables one to produce ideas and alternatives and consider multiple solutions.

■ Clarification includes identifying similarities, differences, and assumptions and defining terms.

■ Basic support involves the use of known facts and background knowledge.


Critical thinking is a process that entails identifying assumptions, considering context and meaning of issues, and gathering data to consider alternativesand outcomes (Box 10-1).

Identifying Assumptions

The critical thinking process begins by exploring the assumptions underlying a situation. These assumptions may be beliefs that influence how an individual will reason or understand a situation and may reflect a person’s point of view or perspective. These assumptions may not necessarily be grounded in reality. For example, administering medications is a common activity of nurses, and finding strategies to avoid medication errors has become an important concern and problem-solving initiative in many organizations. If a patient assumes the nurse will always administer the correct medication, it is unlikely that the patient will

question any medications the nurse offers. This assumption will have an impact on any efforts to include the patient in a program to decrease medication administration errors.

Considering the Context

The critical thinking process involves considering the context of the present problem or situation. Analysis and interpretation of the meanings of the present issue or situation are essential to developing a conclusion. Returning to the patient taking medication, a context could be when the patient is not responsive or not physically or mentally capable of being involved in taking the medications and cannot be safely included in the process. Another context is the patient taking medications at home without direct nursing supervision. All these situations might involve different strategies to try to avoid medication errors.

Data Collection

Data collection is the next step in the critical thinking process. All too frequently, snap decisions are made based on first impressions. Leaders who use critical thinking skills do consider first impressions, but they are always careful to continue to gather data and carefully evaluate all the alternatives and possible outcomes. Nurses are often faced with clinical situations that require gathering assessment data and considering various alternative interventions

Decision model.

while balancing the needs of the individual patient and predicting potential outcomes. For example, making a patient assignment involves reviewing the acuity of the patients and where the patients are geographically located, reviewing the staff mix based on status of the nurses, the experience of the individual staff members, and the numbers of staff available.

Making Decisions

All nurses make decisions frequently. Making many decisions, however, does not necessarily guarantee that an individual will make good decisions. This section will discuss ways to enhance decision-making skills and strategies. Because decision making is a complex, abstract process, individuals may have many different ways of thinking about it. A discussion of various decision-making models can be helpful in explaining and understanding this phenomenon (Fig. 10-1).


Brief snapshots of the following models are intended to guide readers to an understanding of the decision-making process:

■ Information processing model: Continuum consisting of short- and long-term memory using a four-stage process, including weighing the pros and cons of each decision alternative

■ Wheeler’s model: Knowing the context in which choices can be made from options that affect the individual and up through the society at large as represented in concentric circles

■ Nursing process: Evaluation process allows for continual assessment of the response to any decision, with new plans being implemented for alternative responses

Information Processing Model

In this model, decision making is seen on a continuum and not as an either/or process (Thompson, 1999). This model consists of two components: short- and long-term memory. Short-term memory contains the stimuli information necessary to “unlock” factual and experimental knowledge that is stored in the long-term memory. The clinician uses a four-stage process to make decisions in this theory:

1. Gather clinical patient data.

2. Generate hypotheses or predictions about the issue.

3. Interpret the data and confirm or refute the hypotheses.

4. Weigh the pros and cons of each decision alternative.

One of the strengths of this model is that it allows the use of all types of assessment data, including individual “memory” data, which is the information each person carries consisting of previous knowledge and experiences. An experienced clinician can use experience and knowledge to predict that a decision will or will not work. For example, an experienced nurse manager is faced with completing the summer vacation schedule for the unit. The manager is aware of the restrictions placed by administration about the number of individuals who may be on vacation for each shift and other issues regarding seniority. After weighing the pros and cons of the choices (allowing employee choice takes more time; allowing employee choice makes the nurses happier; allowing choice could propel arguments), the manager could decide to:

1. Complete and post the vacation schedule.

2. Ask for requests in advance and post the vacation schedule.

3. Post a tentative schedule and ask for comments and suggestions.

4. Post a blank schedule and ask everyone to complete this schedule within the required administrative restrictions by a certain date. Based on experience and knowledge of human nature regarding choice, he rejects options 1, 2, and 3 and decides to post a blank schedule. It is a good model to use to process information because it offers the opportunity to consider many alternatives and demonstrates the importance of a thorough assessment in order to develop alternative choices.

Wheeler’s Model

Wheeler (2000) suggests that having choices and knowing the context in which choices are made are the most important elements of proactive decision making. Being proactive allows the anticipation of an event and allows one to generate actions before the event. For instance, planning for staff replacement during a maternity leave provides options: temporary replacement with additional part-time use, agency nurses, overtime use, extended shifts, and so on (Fig. 10-2). Having a choice involves having at least two options. One of the options may be not to act at all,

but that does constitute a choice. In that situation,the decision maker allows other people or events todetermine the outcome. Wheeler uses concentric circles to conceptualize the relationships between the five primary areas (contexts) for consideration when determining choice and context. Knowing the context helps to put the choices in perspective. The personal arena is the first level. Here, decisions occur that pertain solely to the individual. The second level is the family arena. The third is the social arena, where decisions can affect business associates and close friends. The fourth level is the community arena, which includes cultural, ethnic, religious, and national groups. The fifth level is the global or international arena, involving philosophical, political, and financial issues.

Wheeler’s model might have limited usefulness in a nursing environment as it is described; however, changing the labels of the circles (see Fig.10-2) might allow one to use it to determine context and how far-reaching an anticipated decision might be. For example, levels could be changed to reflect unit personnel, patients/families, budget, the nursing organization, the entire agency, and so on. Circles could be added to indicate a more complex decision. The strength of this model is the fact that it is graphic. In the example presented in Figure 10-2, choice #1 will affect the unit staff and may also influence the budget to some extent. Choice #2 will definitely affect the budget and may affect patient care if staff becomes overextended or fatigued. Choice #3 affects the existing staff to orient the agency and traveling staff; patient care might be affected, and the budget will be affected because of the increased cost in hiring nurses. The nursing department will become involved because these nurses will be processed through other departments, such as Employee Health and Nursing Education. Finally, choice #4, which is actually a choice not to make a choice, will affect the entire agency. After all, failing to provide adequate staffing can result in poor clinical outcomes, dissatisfied patients and nurses, increased complaints, the possibility of risk of liability to the agency, and damage to the agency’s reputation. All the individuals involved in the decision can judge what the impact of the decision might be on their part of the entire organization. This model allows one to look at the perspectives of others and what their concerns and issues might be. Finally, it encourages one to consider as many alternatives as possible to satisfy the needs of everyone involvedNursing Process Although there are many decision-making models, the nursing process may be the most familiar and comfortable model for nurses to utilize to make decisions. The nursing process is ongoing and begins with phase I, assessment, according to Figure 10-3. This phase includes defining the assumptions and context, collecting data, identifying and naming the problem(s), and deciding on actions or interventions. Phase II is implementation or intervention as planned in phase I. Phase III is evaluating the outcomes. Based on the evaluation, the process begins over again with more data collection, if indicated.

For example, during a home visit to a patient, the nurse is concerned about the safety of an elderly man who is post–cerebral vascular accident (stroke) with some mobility problems. She observes many throw rugs on the floor, extension cords that are visible in the walking areas, and several cats who roam around the patient when he gets up to walk into the kitchen or bathroom. The nurse identifies all these as safety hazards and labels the problem “Alteration in safety related to environmental hazards.” She makes a plan to review the environment with the patient and make necessary changes by eliminating the throw rugs or anchoring them to the floor, removing the extension cords or taping them down, and discussing how the cats can be controlled when the patient is walking through the house. The nurse then discusses the problems and possible solutions with the patient, comes to consensus about the changes, and makes arrangements for the alterations. This is the implementation phase. Shortterm evaluation of the changes will occur on her next home visit; long-term evaluation will be measured by the lack of falls by the patient. This nurse used the nursing process to make decisions about the care of this patient. The same process can be used to make all decisions, even those that do not involve patient care.

Using the nursing process as a guide, start the decision-making process by collecting data and assessing the situation. It is important to make decisions with as much information as possible. Leaders make their most successful decisions when they assess the strengths and weaknesses of the people and the environment. Good decision making relies on building relationships, knowing the politics of the players, understanding the time and other envi


Nursing model

ronmental constraints, integrating cultural values, and staying true to personal and organization ethics. Furthermore, the cultural diversity found in any organization needs to be considered in any decision that affects more than one person. Differences in frames of reference, perspectives, norms, values, and communication style are often aggravated by prejudices, stereotypes, and misunderstandings (Broome, et al., 2002). In the home care nursing example, major misunderstandings could occur if the nurse did not include the patient in any environmental alteration. The cats may be very important to the patient, who may be willing to risk falling rather than confining them to a separate room.

Aside from its familiarity, the strength of this model is its feedback mechanism. If evaluation reveals an unanticipated or unacceptable outcome, the assessment begins again. In today’s health-care environment, the concept of evidence-based practice supports the need to gather as much evidence as possible to make a decision that can lead to best practices. Sources of data for decision making come from more formal sources such as quality assurance, benchmarking, and risk management data (see Chapter 15). Observation and inquiry can also yield information about a situation. Finally, scientific research data make excellent assessment data and should be the basis for much of decision making in nursing whenever possible


Not all decisions are critical or global in their impact. Decisions are made at all levels of the hierarchy in organizations. Some experts believe that a decision should be made as close to the action as possible. At the same time, however, as demonstrated in the Wheeler model, good decision making also means considering the impact the decision will have beyond the immediate environment. Routine decisions can be used to respond to frequently occurring, common, and reasonably welldefined issues. Policies and procedures and established rules can be used to guide the decisionmaking process. The level of personnel that makes routine decisions can range from the staff nurse to top administrators. For example, when a patient falls, there is a clearly defined process to follow regarding immediate intervention, reporting, and follow-up. Decisions about who will do what and when can be made easily, based on the incident.

Leaders should attempt to determine quickly if there are established guidelines for a particular situation and apply them as soon as possible. Leaders should be careful, however, to avoid generalizing every situation and should make decisions that are appropriate in the context of each event. Innovative decisions are made when the situation or problem is unusual and the rules and guidelines do not clearly define or dictate a course of action. Nurses, from the bedside to top administration, need to make these kinds of decisions frequently. For innovative decisions, it is helpful if the nurse understands the art of decision making. In any event, there is work to be done before implementing the decision-making process at any level. Innovative decisions generally take longer to make and require more attention to data collection and assessment. Without rules and policies to guide the decision-making process, the leader must be sure to view all possible alternatives.


Before making a decision, ask several questions based on the assessment data. First, is there really a need to make a decision? Is there a problem that needs to be solved? The perception of a problem is relative. A headache is painful to the individual but is good for the pharmacist. A wise leader needs to


After determining that a decision must be made, the effective leader turns to the decision-making tools. The traditional problem-solving process is well known and was the basis for the development of the nursing process. This traditional model is a sevenstep process:

1. Identify the problem

2. Gather data

Comparison of the Traditional, Managerial, and Nursing Process Models for Decision Making and Problem Solving

3. Explore alternatives

4. Evaluate alternatives

5. Select the appropriate solution

6. Implement the solution

7. Evaluate the results

The managerial model is similar to the traditional model and comprises the following steps:

1. Set the objectives

2. Search for alternatives

3. Evaluate alternatives

4. Choose an alternative

5. Implement

6. Follow up

7. Control the outcomes

Decision making occurs at step four when a choice is made.Table 10-1 compares the traditional managerial, and nursing process for decision making and problem solving. There are strengths and weaknesses in each model. For example, in the managerial model the objective is determined at the beginning. Sometimes it is difficult to know what the objectives need to be to reach an outcome, and this model does not focus on data collection in order to identify the alternatives. The traditional model requires problem identification as a first step, whereas the nursing process collects data to determine if there is a problem. Both methods can be useful in making a decision, yet the nursing process allows for the possibility that there is no problem or no need to make a decision or take any action. Problem identification is the foundation of good decision making. If the correct problem is not identified initially, a very good decision can be made for the wrong problem.

Specific Decision-Making Tools

The use of tools is a systematic way to collect the data necessary for making a good decision. Specifically, pros and cons, SWOT analysis, and 2 Х 2 matrix are recommended for beginning nurse managers.

Pros and Cons

A simple strategy is to make a list with one side labeled “Pro (or Advantages)” and the other side “Con (or Disadvantages).” Writing down options helps to clarify the decision that needs to be made. More accurate decisions can be made by assigning weights to each factor, with 5 representing very significant and 1 representing minor significance. Table 10-2 illustrates the use of this strategy to make a decision about which shifts might be appropriate for a particular nursing unit. The use of a

Moving From 8- to 12-Hour Shifts

weighting system allows the decision maker to determine what the most important factors are.

SWOT Analysis

Once the problem has been identified, the SWOT analysis can be extremely useful for decision making. SWOT stands for Strengths, Weaknesses, Opportunities, and Threats. For example, a SWOT analysis can be used to assess:

■ A nursing unit and its position in the agency

■ A nursing care delivery system

■ A scheduling process

■ A recruitment idea

■ A strategic option, such as developing a specialty unit

■ A new management hierarchy

■ Outsourcing a service

■ A new documentation method

■ A different communication system

■ A job description for unlicensed personnel

For example, if a nursing department needs to determine the most effective and efficient method for providing ongoing professional education and development for staff, it can use a SWOT analysis to identify the risks and benefits in outsourcing this service. Strengths include not paying benefits and having specialists to provide specific services as opposed to generalists, yet there is a risk that the individuals may not have a commitment to the organization and may not be familiar with or comfortable with the culture of the organization. They may be perceived as “outsiders,” which can pose a threat to employee satisfaction. Making the final decision may involve determining how important each strength, weakness, opportunity, and threat is to the department. The final decision can be made only in the context of that nursing department, within the financial constraints of the organization, and in consideration of the culture of the organization.

2 Х 2 Matrix

Similar to the SWOT approach is the use of a 2 Х 2 matrix. The 2 [1] 2 matrix is a relatively simple way to visualize issues or concerns. It conveys the choices available in relationship to a goal. According to Lowy and Hood (2004), the x and y axes are used to clarify issues; a complicated situation can be reframed to allow everyone to understand all aspects of the issue. Instead of looking for a single right answer, conflicting goals are identified and labeled. Rather than discouraging differing perspec

tives, this approach encourages these differences in order to work toward a decision. A common issue confronting individuals personally and professionally is that of too much to do and not enough time in which to do it. Table 10-3 is an example of the use of a 2 Х 2 matrix to assist with decisions about time management. The axes in this matrix are the importance of the tasks described versus the urgency of completing these tasks. Striking a balance between getting things done on time and doing important work becomes the goal. Individuals can include items in the matrix based on personal choice. For instance, a nurse leader may include resolving a crisis and meeting deadlines as having high importance and high urgency but planning for the future, preventing crises, and preserving relationships as having high importance but low urgency. Another individual may put planning and prevention in high importance and high urgency boxes. This matrix becomes a quick and visual method of deciding what to do next.

Using a simple matrix model consistently can help a novice leader develop these skills quickly and continue to make good decisions in all areas. Even

Sample Matrix: Time Management

with the best of models, however, there are some common mistakes made by even the most experienced leaders. The following is a discussion on how to recognize and avoid making some of these mistakes.


According to Anderson (2004a), emotions can bias rational judgment because people have a subconscious tendency to decide what they want to do before they know why they want to do it. Another tendency is for people to be more engaged with things they like than with things they dislike. Anderson describes a number of traps into which people may fall when making decisions. One is the confirming evidence trap. She suggests that individuals check for this trap by examining all the evidence with equal rigor. Seek people who can offer independent information and opinions to play devil’s advocate.

The framing trap occurs when a decision is made based on how the choices are viewed or framed. For example, in Hospital A, the postanesthesia recovery unit (PACU) nurses who have been employed for more than 10 years are no longer required to be on call. But they are required to work a certain number of holidays each year. Because the unit is closed on holidays except for on-call emergencies, they are required to work on another unit in order to fulfill this obligation. The PACU nurses are not happy

Practice to Strive

about this arrangement. In Hospital B, the same rules apply. However, operative cases requiring PACU nurses on a holiday are called “unscheduled” rather than “emergencies.” PACU staff rotates coverage for unscheduled holiday cases with an option to stay home and wait for a case or come into the hospital and perform other duties in the PACU. Those who choose to stay home are paid a percentage of their regular hourly rate plus a holiday bonus; those who come into the hospital are paid at their regular hourly rate plus a holiday bonus. Simply using different terms to describe the pay rate and the obligation has resolved the on-call problem, and the nurses are happy with the arrangement. Try to reframe the problem or opportunity in several ways to maximize understanding and potential solutions.

The status quo trap occurs when people look for decisions that involve the least amount of change (Anderson, 2004b). Keep in mind, however, that change is necessary for growth. Look at possible future situations when considering a change. Even the status quo will change over time. The status quo should never be the only alternative to consider. It is difficult to change course or deviate from a decision whenever an investment of time, money, personal reputation, or other resources is at stake. Making similar decisions that justify past actions is comfortable but can become a trap (Anderson, 2004b). It can be risky to step off the path and decide that decisions need to be made to go in a different direction. Cultivate a climate where individuals can admit mistakes without enduring penalties. Do not apply sanctions or punishments when an individual admits making a mistake. Analyze the issues, and move on to different decisions. The prudence trap intervenes when estimates are made (and then making decisions based on these estimates) using the worst case scenario (Anderson, 2004a). This is sometimes called the knee-jerk response. When a situation has occurred with a negative outcome, it is tempting to make a global change or decisions based on this one bad event. For example, in an agency a patient fell in the shower and was injured. The agency immediately instituted a policy that patients could no longer shower. Careful consideration should be given to making any decisions based on one bad event. Again, analyze the issue, and consider many scenarios. Similarly, individuals may fall into the “recallability” trap, when overwhelming events and experiences influence decision making, even though the events are inapplicable to the current decision.

Other mistakes can include relying too much on “expert” information, overestimating the value of information received from others, highly selective hearing or seeing and, most important, not listening to one’s own feelings or “gut reactions.” Whenever possible, delay the decision, and the right choicemay become obvious. See Box 10-2 for some effective decision-making tips.

Problem Solving

The term “problem solving” is often used synonymously with decision making, but the processes are not the same. Decision making may or may not involve a problem but always involves selecting one action from several alternatives. Problem solving involves diagnosing or identifying a problem and solving it and includes making decisions along the way (Sullivan & Decker, 2001). In other words, problem solving is broader in scope than decision making in that it may include making many decisions in order to resolve the problem (Fig. 10-4). But problem solving is also more narrow in scope than decision making in that decisions are made about many different issues, not just about problems.

Decision model.

The problem-solving process can take some time to define the problem and its scope and the goal for problem solving. Problem solving should be a group process, involving all individuals or groups affected by the problem. Problems can also be viewed as opportunities to make change and improve outcomes. Start the investigation with who, what, when, where, why, and how. Either or both of the following techniques present effective ways to explore all aspects of the problem and obtain feedback about the decisions that are made along the way.


Using the basic brainstorming technique to solve problems can be a very powerful strategy. This is a group process using a strong facilitator who can control the discussion while allowing each individual the freedom to meet and express ideas without threat of ridicule or sanction. The purpose of the meeting must be clear to everyone involved, and the facilitator has the task of keeping everyone focused on that purpose. Deciding how much time will be allowed to brainstorm is critical, and the facilitator or leader should be prepared with ideas to get the process started and keep it moving. Frequent clarification and summary will help keep the discussion on track, and the outcomes should be apparent and flow logically from the discussion. The process begins with defining and agreeing on the objective and continuing as follows:

■ Brainstorm ideas and suggestions with an agreed upon time limit.

■ Categorize/condense/combine/refine.

■ Assess/analyze effects or results.

■ Prioritize options/rank-list as appropriate.

■ Agree on action and period.

■ Control and monitor follow-up.


A parallel thinking technique introduced by deBono (1985) can enhance problem solving. DeBono identified six thinking hats, with each colored hat representing a different viewpoint. This deliberate method encourages a group to think along similar lines at the same time so that personal egos do not interfere in the creation of facts, information, or solutions. Each individual in the group is expected to take a particular position or “wear a different color hat.” Individuals may be asked to change hats and review the issues from a different perspective.

■ Blue Hat thinking provides a formal structure to the thinking at all times. One person, usually the group facilitator, wears this hat. The blue hat is responsible for focusing the thinking at all times and keeping the various thinking hats trained on the correct tasks. One suggested sequence, controlled at all times by the blue hat, is to start with the white hat, followed by the red, yellow, green, and black hats.

■ White Hat thinking deals with figures and facts in an objective or neutral way. Individual opinion is excluded. It provides an opportunity to move back down the abstraction ladder to the data, or lowest-rung, level. An example of white hat thinking is “There are RNs and UAPs in all nursing departments.” It would be unacceptable to say “I think all nursing departments should consist of RNs and UAPs.”

■ Red Hat thinking involves emotion and is not rational. It is based on feelings and intuitions that can be positive or negative. The key to red hat thinking is that explanations are unnecessary. The red hat puts positive and negative feelings out in the open so they do not lurk in the background and cloud the thinkingprocess. The red hat acknowledges the fact that feelings can shape perceptions.

■ Yellow Hat thinking is visionary. It is about constructive thinking and making things happen. Here, alternatives are discussed and may be speculative in nature. “Long shots” are included because they expand the thinking and provide the opportunity to clarify other ideas. Ideas do not have to be new or unique; yellow hat thinking is concerned about finding effective ways to accomplish the task.

■ Green Hat thinking involves the creation of new ideas or thinking about things in different ways. This hat legitimizes the wild and crazy ideas. It involves movement in a forward direction. Here, the fact that that there is more than one right answer to a problem is acknowledged.

■ Black Hat thinking is logical and negative, never emotional. This hat does not consider arguments for or against, only negative statements that are based on reason and logic. Facts produced in the white hat thinking can be challenged when wearing the black hat. Statements take the form of “I am concerned about” and “Can you help me with this concern?”

All Good Things…

■ Critical thinking is the process that guides scientific reasoning, the nursing process, problem solving, and decision making.

■ Critical thinking involves the use of the cognitive process, which includes divergent thinking, reasoning, reflection, creativity, clarification, and basic support.

■ Decision making and problem solving are not synonymous.

■ Decision making involves identifying and selecting a course of action from several alternatives.

■ Problem solving requires identifying a problem and finding a solution.

■ There are many decision-making models, which are derived from theories to guide the process.

■ There are two types of decisions: routine and innovative.

■ The problem-solving process involves identifying the problem, gathering and analyzing information, developing and implementing the solutions, and evaluating the outcomes.

Nurses Leading Change

Change is nothing new. In fact, it is often said that change is the only constant. Change, particularly in the health-care environment, is complex and is occurring at an unprecedented rate. Change is driven by many factors: the increasing cost of health-care delivery, the nursing shortage, the rapid advancements in technology and information management, and new expectations by the public to have a more active role in health-care decisions. Meeting the health-care needs of the world requires that the nurse be proactive and creative in guiding change. The ability to create and manage meaningful change is an essential skill for nurses in the 21st century. Change fosters growth and innovation; progress cannot occur without change. If nurses are to be leaders of change, it is imperative that they understand the changes occurring in the health-care arena, use political clout to have a hand in the changes, and master the change process. This chapter will introduce readers to the principles of planned change, barriers commonly encountered when introducing change, strategies for overcoming barriers, and the role of the nurse as the change agent.

Elements of Change

Change is an integral part of any organization, and the process can be uncomfortable and disturbing to those who are affected. An awareness of the elements common to the change process is important.


Change means to be different, to cause to be different, or to alter. Change may be personal or organizational and can occur suddenly or incrementally. Change may be planned or unplanned. Unplanned change, or reactive change, usually occurs suddenly and in response to some event or set of circumstances. For example, an unanticipated rise in patient census may precipitate the need for a change in patient assignments. Decisions are made—and change follows—as a reaction to an event. Planned change, however, entails planning and application of strategic actions designed to promote movement toward a desired goal. Planned change is deliberate and proactive. For example, changing staffing patterns from extensive use of unlicensed assistive personnel to an all-professional staff requires time and planning. Specific strategies need to be developed and implemented before such a sweeping change is adopted. Generally, planned change is more likely to occur incrementally, over time. Planned change responds to anticipated events in the environment or community.

Change may be initiated in response to internal or external forces. Internal forces stem from within the organization. Internal forces include organizational values and beliefs, culture, and past experiences with change. External forces come from outside the organization. These can be social influences, economic factors, or legislation. For example, a 1996 legislative mandate put the federal Health Insurance Portability and Accountability Act (HIPAA) in place (Public Law 104-191). This piece of legislation forced all health-care agencies, schools of nursing, and their governing bodies to plan and implement major system-wide changes in the way personal information is collected, handled, and stored.

Another factor essential to change is the presence of a change agent. A change agent is one who generates ideas, introduces the innovation, and works to bring about the desired change. In fact, the one who assumes the leadership role of change agent in today’s health-care environment is the nurse. Members of an organization assume different roles in a change, depending on the nature of the change and their role in the organization. A leader often assumes the role of change agent and initiates change; an effective follower actively participates in the change effort and is essential to the successful implementation of change. Registered nurses are frequently in a position of leadership within health care organizations and, as such, are well positioned to be the leaders of change.


When initiating change, the following assumptions are important to consider. Assumption 1 Change of any kind represents loss. Even if the change is positive, there is a loss of stability. This loss of the familiar may produce anxiety and even grief in many individuals. The leader of change must be sensitive to the loss experienced by others.

Assumption 2

The more consistent the change goal is with the individual’s personal values and beliefs, the more likely the change is to be accepted. Likewise, the more different the goal is from the individual’s personal values, the more likely it is to be rejected. The change agent needs to know and respect the values and beliefs of those most affected by the change.

Assumption 3

Those who actively participate in the change feel accountable for the outcome. The more people who are involved in the process, the more the group will feel responsible for the outcome.

Assumption 4

With each successive change in a series of changes, individuals’ psychological adjustment to the change occurs more slowly. It is for this reason that the leader of change must avoid initiating too many changes at once. Timing is important.

Assumption 5

Power is important to the change process. Organizations with many layers of hierarchy between the initiator of change and the ultimate decision makers may have difficulty with implementing change. The shorter the distance the change proposal must travel from the initiator to the decision maker, the greater the likelihood that the change will be accepted. Conversely, the greater the distance, the more likely resistance will occur.


Assessing readiness for change is generally the first step in any change project. Until participants are ready for change, little can be done to bring about change. According to Terry (1993), readiness for change is assessed by answering the following questions:

1. What is the ultimate purpose of the action/ change?

2. Why might I lead or be involved in this change?

3. What is at stake if I lead or participate in this change action?

4. What structures are in place either to foster success or hinder the change?

5. Are the necessary resources available to achieve this change action?

6. What is the stakeholders’ level of commitment to the change?

Practice to Strive

Strategies for Leading Planned Change

Those wishing to bring about change must develop strategies to foster change. Bennis, Benne, and Chin (1969), in their classic text, The Planning of Change, identified three strategies to promote change: rational-empirical, normative-re-educative, and power-coercive. Decisions about which strategies to employ depend, to a great extent, on three factors: the type of change planned, the power of the change agent, and the amount of resistance expected. These strategies may be used independently or together. More often than not, some combination of strategies is indicated: the larger the change and the more resistance expected, the more strategies the change agent must employ.


This strategy assumes that people are rational beings and will adopt a change if it is justified and in their self-interest. When using this strategy, the change agent’s role includes communicating the merit of the change to the group. If the change is understood by the group to be justified and in the best interest of the organization, it is likely to be accepted. This strategy emphasizes reason and knowledge. It presents those affected by the change with the knowledge and rationale they need to accept and implement the change. This strategy is most useful when little resistance to a change is expected. The power of the change agent is typically not a factor in changes amenable to this strategy. This strategy assumes that once given the knowledge and the rationales, people will internalize the need for the change and value the result.


A second strategy takes into account social and cultural implications of change and is based on the assumption that group norms are used to socialize individuals. This strategy requires “winning over” those affected by the change. Success is often relationship-based; relationship, not information, is the key to this strategy. The success of this approach often requires a change in attitude, values, and/or relationships. Sufficient time is essential to the successful use of the normative-re-educative strategy. This strategy is most frequently used when the change is based in the culture and relationships within the organization. The power of the change agent, both positional and informal, becomes integral to the change process. For example, one of the most powerful changes in recent history occurred when the norm changed regarding when to wear surgical gloves for preventing the spread of infection. More than knowledge (rational-empirical) and administrative directives were needed to bring about this change: it took a change in cultural values that redefined the practice norms.


This strategy is based on power, authority, and control. Political or economic power is often used to bring about desired change. The change agent “orders” change, and those with less power comply. This strategy requires that the change agent have the positional power to mandate the change. Change effected by this strategy is often based either on the followers’ desire to please the leader or fear of the consequences for not complying with the change. This strategy is very effective for legislated changes, but other changes accomplished using this strategy are usually short-lived if people have not embraced the need for the change through some other mechanism (Table 11-1).

Barriers to Change and Strategies to Overcome Them

All changes have the potential for both gain and loss. It is important to identify all the potential barriers to change, to  examine them contextually with those affected by the proposed change, and to  develop strategies collectively to reduce or remove the barriers. Barriers most common to change within the health-care environment are discussed below, along with some strategies to overcome them. Additional barriers appear in Table 11-2.

Change requires movement, which, as physics indicates, is a kinetic activity that requires energy to overcome resistance. Also, as in physics, an object at rest (and that includes an organization) prefers to remain at rest. Movement over barriers requires an


Change Strategies

Common Barriers to Change and Strategies to Overcome Them

Common Barriers to Change and Strategies to Overcome Them (continued)

even greater expenditure of energy. The very energy requirement to change ay be too much of a drain on an already overtaxed organization, and the energy required to be a leader of change in a resistant group can be overwhelming. For this reason, timing is a critical element of the change process. Correctly determining when people are most receptive to the initiation of change can be the determining factor in the success or failure of the change process. When people are dissatisfied with the status quo and yet not too overwhelmed with merely trying to keep up, the time for change is ripe. People become comfortable with what “is.” The functional parameters are clear as are expectations and rewards. Change, by its very nature, moves people away from their comfort zones. By providing realistic planning of and adequate information about how the impending change will affect each of those areas, some—probably not all—of this resistance can be minimized.

Although legendary heroes and heroines led massive societal changes, within an organization change rarely occurs without the assistance of others. Frequently, individuals have great ideas that would truly improve the function of the organization, but because the idea cannot be implemented by one person, it becomes lost to the organization. The support of both formal and informal leaders can be a critical element to successful change. Both types of leaders have their own audiences and their own abilities to sway groups and influence the “buy-in.” That buyin and ownership of the change will become a shared vision for the organization that will draw in other supporters. Because the formal and informal leaders have, in essence, “blessed” the change, a number of trust issues for subordinates will also have been overcome.

Change Theories

A number of theories exist to explain the change process. These theories provide a framework within which to guide change efforts. They are useful for planning both personal change and organizational change. Tiffany et al. (1994) surveyed 176 nurseauthored journal articles dealing with planned change. This study identified the type and frequency of planned change theories found in the nursing literature. Lewin’s Change Theory was most commonly used as a framework for change. Several other change theories were also frequently referenced. A brief description of Lewin’s theory, along with Lippitt’s Phases of Change, Havelock’s Six Step Change Model, and Rogers’ Diffusion of Innovations Theory, follows. These models of change are a mere sampling of change models. They provide a strong basis for understanding change theory. Before exploring the change theories, consider this brief discussion of change agents, an element in any change theory.


A change agent is the individual or group that seeks to lead change. The change agent may be from inside or outside the organization. Change agents may have formal lines of authority or may be informal leaders. In either case, the change agent is responsible for moving those affected by the change through the process and implementing the change. Effective change agents are masters of change. They do three things correctly: they sense the right moment to initiate the plan, they find supporters for their ideas, and they have vision (Bruning, 1993).

The successful change agent earns the respect and trust of the target system (individuals, groups, or organizations) by communicating openly and honestly, offering assistance, and demonstrating ability. A change agent’s success depends on communication and consultation style, interpersonal skills, and expert power. Ongoing communication is integral to the role of the change agent (Box 11-1).

Becoming a Change Agent: A Practical Guide

Change is an inevitable part of life; learning to lead change effectively is a skill that can be cultivated

and mastered with practice. If you have been given the responsibility of leading an organizational change, there are several practical steps you can take to increase your chance for success.

1. Begin by articulating the change vision clearly and concisely.

2. Select the change project team carefully.

3. Identify the formal and informal leaders who can help you implement the change successfully.

4. Stay alert to political forces, both for and against the change.

5. Develop communication skills. Keep communication lines open.

6. Practice problem-solving skills.

7. Develop conflict resolution skills.

8. Learn to trust yourself and your project team. Functioning effectively as a change agent requires the nurse to have an understanding of the theoretical frameworks of change. A discussion of several classic, as well as emerging, theories of change follows.


Lewin’s Force Field Analysis is probably one of the best known and frequently used change theories (Tiffany et al., 1994). This theory conceptualizes change as movement across time. Lewin views behavior as a dynamic balance of forces working in opposite direction within a field (individual or organization). According to Lewin, change occurs in response to disequilibrium within a system (Lewin, 1951). Therefore, in order to effect change, there must be an imbalance between the forces that push for change (driving forces) and those forces that oppose change (restraining forces) staving to maintain the status quo. Basically, strategies for change are aimed at increasing driving forces and decreasing restraining forces. Lewin identified three phases of change: unfreezing, moving, and refreezing.


Unfreezing the existing equilibrium involves motivating others for change. The change agent must loosen, or “unfreeze,” the forces that are maintaining the status quo. This involves increasing the perceived need for change and creating discontent with the system as it exists. If individuals do not see a need for change, they are not likely to be motivated or ready for change and may even hinder change. Assessment of readiness for change is critical in this phase.


During the moving phase, the change agent identifies, plans, and implements strategies to bring about the change. The change agent must do all that is possible to reduce restraining forces and strengthen driving forces. It is critical that the change agent continue to work to build trust and enlist as many others as possible. The more ownership there is in the change, the more likely the change will be adopted. Timing is also important during this phase. People need time to assimilate change; therefore, the change agent must allow enough time for people to redefine how they view this change cognitively.


During the  refreezing phase, the change agent reinforces new patterns of behavior brought about by the change. Institutionalizing the change by creating new policies and procedures helps to refreeze the system at a new level of equilibrium. Refreezing has occurred when the new way of doing things becomes the new status quo.


Lippitt’s Phases of Change Theory (1958) is built on the Lewin model. He extended the model to include seven steps in the change process. Lippitt’s model focuses more on the role of the change agent than on the evolution of the change process. Communication skills, team building, and problem solving are central to this theory. The participation of key personnel, those most affected by the change, and those most critical in promoting the change is essential to the success of the change effort (Noone, 1987). The seven steps of Lippitt’s phases of change are:

Step 1: Diagnosis of the Problem

The person or organization must believe there is a problem that requires change. The change agent helps others see the need for change and involves key people in data collecting and problem solving. The ideal situation exists when both the organization and the change agent recognize and accept the need for change.

Step 2: Assessment of the Motivation and Capacity for Change

Determine if people are ready for change. Assess the financial and human resources. Are they sufficient for change? Analyze the structure and function of the organization. Will it support the change, or does there need to be organizational redesign? This process is essentially defining the restraining and driving forces for change within the organization.

Step 3: Assessment of the Change Agent’s Motivation and Resources

This step is crucial to achieving change. The change agent (either an individual or a team) must count the personal cost of change. The change agent must be willing to make the commitment necessary to bring about the planned change. He or she must have the energy, time, and necessary power base to be successful. The change agent may take on the role of leader, expert consultant, facilitator, or cheerleader, but whatever role is assumed, the change agent must be willing to see the change through.

Step 4: Selection of Progressive Change Objectives

The change is clearly defined in this step. Establish the change objectives. Develop a plan of action; include specific strategies for meeting the objectives. Decide how to evaluate the change plan and final result.

Step 5: Implement the Plan

It is critical to remain flexible during implementation. If resistance is higher than anticipated, slow down. Give others a chance to catch up. On the other hand, if all is going well and the momentum is good, keep the plan moving ahead.

Step 6: Maintenance of the Change

During this phase the change is integrated into the organization. It is becoming the new norm. In this phase, the role of the change agent is to provide support, positive feedback and, if necessary, make modifications to the change.

Step 7: Termination of the Helping Relationship

The change agent gradually withdraws from the role and resumes the role of member of the organization (Lippitt, Watson, & Wesley, 1958).


Havelock’s Six Step Change Model (1973) is another variation of Lewin’s change theory. The emphasis of this model is on the planning stage of change. Havelock’s model asserts that with sufficient, careful, and thorough planning, change agents can overcome resistance to change. Using this model, essential to the success of change is inclusion. It is imperative that the change agent encourage participation at all levels. This follows the assumption that the more people are part of the plan, the more they feel responsible for the outcome, and the more likely they will work to make the plan succeed.

The planning stage of Havelock’s model includes: (1) building a relationship; (2) diagnosing the problem; and (3) acquiring resources. This planning stage is followed by the moving stage, which includes choosing the solution and gaining acceptance. The last stage is stabilization and renewal (Havelock, 1973).


Everett Rogers (1983) developed a diffusion theory, as opposed to a planned change theory. It is included with change theories because it describes how an individual or organization passes from “first knowledge of an innovation” to confirmation of the decision to adopt or reject an innovation or change. Rogers defined diffusion as “the process by which innovation is communicated through certain channels over time among the members of a social system” (as cited in Hagerman and Tiffany, 1994, p. 58). Rogers’ framework emphasizes the reversible nature of change. Initial rejection of change does not mean the change will never occur. Likewise, the adoption of change does not ensure its continuation. Rogers’ five-step innovation/decision-making process is:

Step 1: Knowledge

The decision-making unit (individual, team, or organization) is introduced to the innovation (change) and begins to understand it.

Step 2: Persuasion

The change agent works to develop a favorable attitude toward the innovation (change).

Step 3: Decision

A decision is made to adopt or reject the innovation.

Step 4: Implementation/Trial

The innovation is put in place. Reinvention or alterations may occur.

Step 5: Confirmation

The individual or decision-making unit seeks reinforcement that the decision made was correct. It is at this point that a decision previously made may be reversed.


The classic models of change are linear. While they have been used successfully in many situations, they may not be as useful as they once were in the complex, ever-changing health-care arena. Because health care is changing so rapidly, health-care organizations must be able to organize and implement change quickly. The linear models of the past may not be sufficient to meet this challenge. Two models

of change that are quickly becoming recognized in leadership circles are the Learning Organizations and Chaos theories.

Learning Organizations Theory

The Learning Organizations Theory is based on systems theory. It is a framework for seeing the interrelatedness of relationships; the whole is not just the sum of its parts, because each separate part affects the whole. Indeed, each part is essential in defining the whole. Peter Senge (1990) described learning organizations as organizations where people at all levels are collectively and continuously working together to improve what they do. Learning organizations celebrate differences and recognize that every member of the organization has something to contribute to organizational growth.

Over time, a learning organization embraces change as a means of creating the organizational environment it desires. A learning organization develops the capacity to recreate itself in response to change. Senge describes five disciplines that must be mastered if an organization is to achieve the status of a learning organization. Learning organizations model the change process (Table 11-3).

Discipline 1: Personal Mastery

First, the members of a learning organization must develop personal mastery. Personal mastery involves clarifying and deepening a personal vision. There must be personal vision before there can be shared vision. People with a high level of personal mastery are continually expanding their ability to create the results they want in life. Two important characteristics of personal mastery are a clear vision of what one wants and the ability to see current

Senge’s Five Disciplines of Learning Organizations

reality accurately. Creative tension exists whenь there is a gap between the vision and the current reality. In order to shorten the gap, change must occur.

Discipline 2: Mental Models

A mental model is an internal picture of how one views the world. Mental models are deeply held thoughts or beliefs about how the world works. They are the filters for everything one sees or hears. Often, mental models are so deeply engrained that individuals are not consciously aware of them.Mental models shape action. Learning to recognize and question mental models is crucial to becoming part of a learning organization. Change will require the development of new mental models.

Discipline 3: Building Shared Vision

Shared vision is translating a personal vision into a collective vision, created together. Shared vision derives its power from a common caring about something the organization truly wants. Individuals do not have to give up their personal beliefs or passions, but instead continue to learn and grow together. Shared vision is essential if members of an organization are going to work well together. Shared vision takes time and ongoing conversation to create. When building shared vision, the goal is to create the most inclusive environment possible. It is a process that requires commitment, not just compliance. Shared vision does not require knowing how to get where you want to go; it does require knowing where you want to go.

Discipline 4: Team Learning

Team learning is the process of aligning and developing the capacity of organizational members to achieve the vision. This requires much communication. It involves examining all ideas. It requires listening to others’ ideas and suspending judgment for a time. When people suspend judgment and think together, new ideas arise. The objective is to go beyond personal understanding and gain new insight into the issue. When this process is used, people become observers of their own thinking, and that leads to greater insight. Learning teams, as the name implies, are highly participatory in decision making. One person is not the teacher or leader; rather, all members have something to teach and a responsibility to lead. Team learning accepts both individualism and collectivism.

Discipline 5: Systems Thinking

Systems thinking is the cornerstone for learning organizations. This fifth discipline weaves the other four disciplines together into a cohesive body of theory and practice. It is a shift from seeing “parts” to seeing “wholes.” When problems are identified in the organization, they are examined through the lens of a system. The question asked is, “What is wrong with the system?” Systems thinking is about finding solutions to problems, not placing blame. Learning organizations are distinctive because of their ability to learn and not simply be content with what they are doing (Senge, 1990). The capacity to reflect and to see patterns of interdependency is critical. Senge states “Systems thinking is the discipline for seeing wholes. It is a framework for seeing interrelationships rather than things, for seeing patterns of change rather than static snapshots” (p. 68). The art of systems thinking lies in being able to recognize increasingly complex and subtle structures amid the wealth of details, pressures, and cross-currents that exist in real management settings. The essence of mastering systems thinking as a management discipline lies in seeing the patterns where others see only singular events. Senge lists some of the laws of the fifth discipline:

1. Today’s problems come from yesterday’s “solutions.”

2. The harder you push, the harder the system pushes back.

3. Behavior grows better before it grows worse.

4. The easy way out usually leads back in.

5. The cure can be worse than the disease.

6. Faster is slower.

7. Cause and effect are not closely related in time and space.

8. Small changes can produce big results—but the areas of highest leverage are often the least obvious.

9. You can have your cake and eat it too, but not at once.

10. Dividing an elephant in half does not produce two small elephants.

11. There is no blame.

Chaos Theory (1995)

Chaos Theory has its genesis in quantum physics. The universe does not run rigidly in accordance with the laws of classic physics. Hawking (1987) noted that this uncertainty was likely the result of tiny fluctuations that interacted within systems and resulted in large-scale effects. The result stems from multiple interrelated changes within the universe. Chaos Theory hypothesizes that chaos actually has an order. Changes that seem to occur at random are, in reality, the result of a complex order.

Complex systems give rise to complex and interrelated behaviors. The paradox that disorder can be a source of order is particularly encouraging to nursing and to health care in general. Health care is in chaos. Instability is caused by many interrelated variables, including managed care, shifting demographics, age, gender, and ethnicity. According to Valadez and Sportsman (1999), three principles can be drawn from quantum/chaos theory to help leaders in nursing manage the environment: “a) the world is unpredictable, b) the world is not independent of the observer; rather, the intent of the observer influences what is seen; and c) the relationships among things are what counts, not the things themselves” (p. 210). While strategic planning remains important to the life of an organization, the plan cannot remain static; it must change, take into account new data, examine the relationships inherent in the system, and allow for the exploration of differences of multiple perspectives of stakeholders in the organization. Pascale (2002) states that innovation increases near the edge of chaos. In the face of threat or opportunity, organizations move into mutation and experimentation. The challenge is to disturb the system in a manner that will push the system in the direction of a desired outcome. Just as the path of the universe cannot be changed with complete accuracy, neither can the path of health care be directed. But it can be nudged in the right direction.

Example of Chaos Theory in Action

Consider this example of Chaos Theory in action at Medical Surgical Services of Utopia Medical Center:

Mission Statement

It is the mission of our collaborative, interdisciplinary health-care team to provide holistic care for the patients on our units and their families. We will support each other in the accomplishment of our responsibilities through open communication and by striving for flexibility through which to manage the multiple priorities of our service.

Members of the Medical Surgical Services Team Nurses

Physical therapists

Respiratory therapists

Radiology technicians


Unlicensed assistive personnel

Registered dietitians


The nurses have approached their manager about the problems associated with nursing care that are caused by professionals from other disciplines who appear on the unit and commandeer the patients. These situations have been long-standing, are interrupting patient care, are causing delays in administration of medication, and have resulted in the inability of the nurses to conduct patient education sessions on much needed topics, such as diabetes care.

Problem Solving

The Director of Medical Surgical Services has called a team meeting to discuss potential solutions to these problems. Each discipline voices understanding of the problem, but there seems to be no solution to which everyone can agree immediately. This is an example that the world is not independent of the observer and that the intent of the observer influences what is seen. Each discipline agrees there is a problem but views it primarily from its own frame of reference. The director asks one of the charge nurses for ideas about how to solve the dilemma. The charge nurse suggests that the group focus on the mission statement for the area. As the team discusses the implications of the mission statement, it is reminded that holistic patient care is the ultimate goal, and the members recognize that fragmented care is not holistic care. They also recognize that their environment is complex and rapidly changing. Their worldview recognizes unpredictability. They recall their commitment to supporting each other through open communication and a flexible approach. They decide that, together, they can make a general schedule for when certain activities will occur and that through communication about exceptions or crisis situations they can arrange to provide patient care in a more organized, synchronized fashion. The relationships among things is what counts, not the things themselves. In this situation, the mission statement served as the “strange attractor” that brought the team together to meet a common goal

All Good Things...

It is important to remember that change is a journey, not a destination; it is a process, not an outcome. It is less important to know how many steps are in the change process than it is to understand the process of change. With this in mind, recognize that change theories, regardless of the number of steps involved, have several common elements. All change theories begin with diagnosing a problem, identifying what requires change. They provide a thoughtful plan for an innovation—the change idea. Change theories develop strategies to bring about the change. These strategies include a plan for implementation, and contingency plans for overcoming obstacles to change. Finally, they should provide a means for evaluation of the change. Pascale (2002) wrote that “ships can’t steer if they are not moving, and living systems—such as organizations—can’t survive without change, challenge, variety, and surprise” (p. 17). Learn to lead change, rather than let change lead you.


Power, Politics, and Policy

Power, politics, and policy should be familiar concepts for all nurses and are especially important for nursing leaders. Power, politics, and policy influence nursing practice, education, and research, which in turn influence health care. Power and politics are intricately entwined concepts and are sometimes difficult to differentiate. Both are used to achieve ends or goals, and both do so through manipulation of others. Power and politics also interact. People who are powerful are able to exert more political pressure; political success brings power that allows people to accomplish goals through policy development and implementation. Power is the ability to do or act; it is a state in which one can manipulate others. Politics is negotiation for (scarce) resources; it is a process through which one tries successfully or unsuccessfully to reach a goal. Policy is the “consciously chosen course of action (or inaction) directed toward some end” (Kalish & Kalish, 1982, p. 61). Obtaining and allocating resources are two examples of possession and use of power. They also exemplify the use of politics in that influence is needed to get what you want and need. Policies are guidelines that tell us how we obtain and allocate those resources. Understanding power, politics, and policy is crucial to effective patient care because these concepts have a significant impact on access to care, allocation of funds, and standards of care.


There are multiple definitions of power. Some assert that power is an overall concept that includes authority and influence. Others see authority and influence as separate ideas or concepts; as such, they require individual consideration. Power is the ability to influence other people despite their resistance and may be actual or potential, intended or unintended. It may be used for good or evil, for serious purposes or for frivolous and selfish ones. Power is the ability to control, dominate, or manipulate the actions of others or, as Rollo May stated, “power is the ability to cause or prevent change” (1972, p. 99). It is a term used freely by politicians, policy analysts, and many others. Power is important to nursing because having it is necessary to achieve goals as individuals, professionals, and leaders. There are no definitive models of power, which often makes aspects of power complex and contradictory. Power can shift; it is dynamic. There are a variety of sources (types or bases) of power that have been identified, as derived from the work of French and Raven (1959), Hersey, Blanchard, and Natemeyer (1979), Ferguson (1993), and Joel and Kelly (2002). Understanding sources of power facilitates analysis of individual and organizational behavior and enables prediction in specific situations. Power sources or types are presented below.


Power can be either positional and personal. Positional power is awarded or granted to a person, but it is derived from a person’s position, office, or rank in a formal organization system. Personal power, on the other hand, is derived from followers. Leaders who act in ways that are important to followers are given power. An example is the nurse managers who have power because they are seen as highly competent, are good role models, or have some personal attribute that makes them effective in their roles. Expertise (which is discussed below) is a way to gain personal power. Common types of power include (a) authority, (b) expertise, (c) reward, (d) coercive, and (e) referent.

Authority and Administrative

Administrative (sometimes called legitimate) or positional power requires that one serve in a line position and have responsibility for management and actions of other employees. This kind of authority is given to a position rather than to a particular person, for it is part of a role regardless of who fills that role. For example, although the chief executive officer (CEO) in a health-care organization has the most power, the CEO is still answerable to the board of trustees or directors. The chief nurse executive (CNE) has the most power relative to the nurses who are situated further down the chart of the organization, such as supervisory staff, nurse managers, and staff nurses. It is power accorded to a person by virtue of the position held by that person. Nurse managers and team leaders have more power than do staff nurses. CNEs, deans, senators, mayors, governors, presidents, and other elected officials have administrative power.

Administrative authority is the power or right to give orders or commands, to enforce compliance, to take action, and to make final decisions. For example, the dean of a nursing school has authoritative power from her position. As dean, she has the power to make decisions that have both short- and long-term consequences and that directly affect education and student life. Similarly, the primary nurse has more authority in regard to her primary patients than do other nurses or nursing assistants. Authority can also be personal and as such is defined as power or influence that results from knowledge or expertise. Professional authority is granted by choice, not position, and applies to competent professionals, whereas administrative authority depends upon job descriptions and place in the organization. Authority has been a problem for nursing since at least the Victorian Era, when nurses were first seen in the aggregate. For most of nursing’s modern history, nurses were kept under the authority of physicians. Reverby (1987a, b) states that nurses had to limit revelation of the scope of their knowledge and the effectiveness of their care. They had the responsibility for patient care without needed authority. Reverby asserts that nurses are ordered to care by a society that does not value care. Nurses gained authority through knowledge, feminist influences on society, and slow increases in the scope of practice. Nurse leaders worked hard to gain the power of authority. Judicious, skilled use of power and politics in an environment set for change helped them to change policy with legislation and regulations to achieve their goals. Nursing leaders fought hard for standardization of nursing education, development of knowledge, and professionalization. Feminism from the late 19th century to the present helped achieve increasing professionalization and improved status. As education and professionalization grew, so did nursing’s scope of practice. In 1972, New York State passed the first nurse practice act. For the first time, the essential role of nursing in dealing with human response to illness or treatment was stated, debated, and legislated (Diers & Molde, 1983). The nurse practice act conferred authority on nurses and nursing. Authority was, and is, necessary to nursing as it gives status and power within institutions and communities to mobilize resources to achieve health care goals.


Expert power is influence that results from knowledge or expertise that is needed by others. It is similar to personal authority, but it is gained and affirmed through respect for expertise. Expertise can be an indispensable source of power within health-care organizations. Such power is granted by choice to a person, not to a position, and applies to competent professionals. Nurses work in dynamic environments where change is rapid and where power and influence often take new forms. Expertise brings knowledge and skills to the assessment of problems and issues, which brings about solutions and change. Those who are lifelong learners have an important effect on deliberations and decision making because they understand those changes and can participate fully and find and implement important and creative solutions to situations or problems. Those who do not keep their knowledge current fail to earn or retain expert power. Continued acquisition of new knowledge and skills is essential to maintain this form of power. Expert nurses, nurse practitioners, clinical specialists, and other nurses have power based on their knowledge and expertise. Benner (1984) asserts that nurses can use this power source as they become expert practitioners. This is a source of power that nurses can and must use, because they have expertise that policy makers generally lack. Such professionals have power to exert successful change. Expert power follows the person as long as the person maintains his skills. Reward Reward power is the ability to offer rewards, which is a potent type of power. It is the promise or perception of money, goods, services, recognition, and  other recompense in exchange for some action that benefits the powerful person. Behavior is affected in that a person will often honor wishes or demands for the potential (or actual) rewards from the powerful person. Managers, supervisors, and administrators have access and ability to use this power through their authority to  reward people with bonuses, salary increases, promotions, and recognition. Appropriate use of reward power is the promotion of a nurse who has earned and is qualified for a new position. Inappropriate use of rewards is the assignment of a rotating nurse (bypassing others) to the day shift in return for favors or friendship

Power to punish is included in the concept of reward. Those who have the capacity to reward also have the ability to punish. In organizations the person with reward power can usually also discipline and fire employees.

Lobbyists often use reward power. They educate legislators and other government officials. Lobbyists bring a high degree of access to and accountability from elected officials. They form coalitions to influence needed legislation and policy change and development. The American Nurses Association (ANA) lobbies for legislation that is important to patient care and nursing. Lobbyists or advocates can have relationships with legislators where one rewards the other. For example, lobbyists promise monetary support for reelection campaigns in exchange for favorable votes on beneficial legislation. Legislators who are found to participate in this kind of power brokering are prosecuted.


Coercion is the real or perceived threat of pain or harm of one person by another. Coercive power may be physical, psychological, social, or economic and involves the use of force in the form of penalties and rewards to effect change. It shows a lack of respect for the autonomy of others and is seen in sexual harassment and threats to livelihood. Those who use coercion are interested in their own goals and are rarely interested in the wants and needs of subordinates. An example is the threat by a supervisor to fire whistle-blowers (people who speak out about a wrong). The threat of a state health commissioner to implement onerous regulations for nurse practitioners or visiting nurses if some action is not done is coercion. A volunteer religious group that demands religious conversion by threatening to withhold or withdraw education, expertise, materials, or care coerces the people it is there to help.


A leader who is followed based on admiration and belief has referent power. The chair of a committee, for example, has referent power for those who work closely with her. Referent power is gained through association with a powerful person or organization. Selection of a powerful person as a mentor and working on powerful committees are ways to develop and hold referent power.


Nurses are predominantly women and provide the most direct patient care in male-dominated organizations. Nurses have rarely had significant power in health-care organizations. Over the past 15 years, nurse administrators have made progress in gaining recognition at the top levels; some have even made inroads to governance. These leaders are all too often terminated, however, which is an all too graphic indication that role acceptance has not been accomplished (Camuñas, 1994a, b, 1998; Carroll, DiVincenti, & Show, 1995; Donnelly, 2006; Kopala, 2001; Sabiston & Laschinger, 1995; Vestal, 1990; Vestal, 1995). Power commensurate with knowledge and expertise is needed to enable nurses to provide competent, humanistic, and affordable care to people; to participate in health-care policy development; to gain leverage proportionate with their numbers; and to ensure that nursing is an attractive career choice for all who want to provide care, influence, and improve nursing, health care, and health policy.


There are multiple ways to accumulate, or gain, power. Some may be more appropriate at higher positions in an organization. Skills to achieve and maintain power take time and patience to learn, develop, and refine. Methods to acquire power include the following:

■ Broad human networks: the more networks and the more extensive they are, the more power potential.

■ Broad information networks: the more diverse types of information controlled, the more power.

■ Multiple formal and informal leadership roles: high engagement and visibility bring increased power.

■ Ability to assess situations accurately (especially unstructured ones) and to solve problems.

■ Authority over others and resources via legitimate work organizational roles.

■ Vision for the future and creativity.

■ Ability to grant services to others, which builds debts.

■ Expertise that is sought by others.

Ways to Increase Expert Power

There are many ways to enhance your power, for example. Professionals, to maintain their competence and develop their careers, use these tactics:

■ Participate in interdisciplinary conferences to broaden knowledge, develop skills, and build networks

■ Keep knowledge and skills current to maintain and extend power. Continuing education offerings, books, and journals are effective means.

■ Earn higher degrees; education brings expertise and enhances credibility.

■ Participate actively in professional associations such as the ANA, state nurses associations, and specialty groups to broaden networks, hone expertise, and develop legitimate and referent power.

■ Participate in nursing research to develop knowledge and increase expertise.

■ Problem-solve with colleagues in nursing and other disciplines to develop expertise and networks and to polish skills.

■ Participate in nursing and interdisciplinary committees to develop and enhance expert, referent, and legitimate power.

■ Publish to develop expert power.

■ Learn from mentors; be a mentor (Flynn, 1997; Vance & Olson, 1998) to develop expertise and connections or referent power.


Empowerment is a sense of having both the ability and the opportunity to act effectively. Empowerment is a process or strategy the goal of which is to change the nature and distribution of power in a specific context. It is a group activity that increases political and social consciousness, is based on the need for autonomy, and is accomplished with continuing cycles of assessment and action. Nursing organizations seek to empower nurses; nurses endeavor to empower patients to seek and adopt healthy lifestyles. Likewise, nursing managers and administrators take actions to empower nurses to achieve effective, rewarding, competent practice. Empowered nurses have three required characteristics that enable them to participate in policy development. The first is a raised consciousness of the social, political, and economic realities of their situation or environment and society. They are aware of culture and diversity and of gender, race, and class biases, prejudices, discrimination, and stereotyping that produce the need for policy development or change. Such nurses can evaluate and understand the dynamics of a situation or issue in which they find themselves and can more readily find or help to find remedies. The second quality empowered nurses have is a positive sense of self and self-efficacy regarding their ability to effect, or facilitate, change. They value themselves and have voice to articulate and effect change. Within an institution, for example, they can identify situations that constrict professional practice, lower quality of care, waste resources, and cause myriad other problems. They can also contribute to the resolution of problems that affect health at the community, state, and national levels. Development of skills that allow active participation in change processes is the third important characteristic. Empowered nurses know how to use traditional methods of power and politics in policy making. Concrete knowledge and information are necessary, as is understanding interpersonal communication skills, politics, and power and how to use them (Kuokkanen & Katajisto, 2003; Manojlovich & Laschinger, 2002).

Power and politics are often discussed together in the nursing literature. The linkage may be due to the difficulty that arises in attempts to distinguish them. Those with power find it easy to participate in politics, and those who participate in politics gain power. Both power and politics serve to achieve goals, and both do so through the ability to use skills to convince others to serve the power holder’s purposes. Power and politics are the means to achieve health-care goals in a compassionate and humane way. Application of power and politics through collaboration, creativity, and empowerment are effective ways to influence policy.


Politics is the negotiation for, or influencing of, allocation of scarce resources. Influence is the act or power to produce an effect without apparent use of force or direct command. Politics is a neutral term and a process. Flexibility is perhaps the most important trait of a good politician.


The process of influencing others, or politics, in order to achieve ends can be seen in relation to four arenas, spheres, or domains. These spheres are (a) the workplace, (b) professional organizations, (c) community, and (d) local, state, and federal governments. Although the ranges of these domains differ, and the target publics to be influenced differ, the political tactics and strategies are similar. These spheres overlap; what happens in one affects the other. Ignoring one can jeopardize outcomes in the others. The fact that nurses have not consistently paid attention to this has contributed to the fact that the level of influence nurses possess is not com

mensurate with the numbers of nurses, their abilities, and their responsibilities and contributions.


Nurses work in organizations with varied characteristics—private or public; profit, nonprofit, or charitable; large, small, or medium; and in large or small cities, towns, small towns, or rural areas. In the workplace, there are many issues with which nurses are involved. Power and politics may be necessary to resolve issues. Some issues that may be found in some, or all, workplaces include the following:

■ Mandatory overtime work requirements.

■ A nursing clinical ladder program that rewards excellence with promotions and pay incentives.

■ Work scheduling length of shift, evening and night rotation, vacation priority.

■ A smoking ban in the entire facility; designation of smoking areas.

■ Visiting hours in special care units.

■ Identification and security procedures.

■ Authority to delay discharge from or admission to special care units based on professional nurse assessment.

■ Authority to refer patients to a home healthcare agency.

■ Decisions regarding substitution of unlicensed personnel for RNs to provide care.

Politics are part of every organization; nurse executives have to use politics to administer their areas of control. They have to negotiate with CEOs and other administrators (their peers) for budgets to meet organizational goals.

Professional Organizations

Professional organizations have been essential to the “professionalization” of nursing. The modern nursing movement began in 1873 in response to the changing role of women. Pioneers of this movement worked for a new profession for women and for better health for the public (Reverby, 1987a). These women used political power to open nurse training schools, organize professional associations, and participate in social issues such as women’s suffrage, public health, and integration (Rogge, 1987). These leaders sharpened their political expertise in nursing organizations they created beginning in 1893. Professional organizations have made significant contributions in developing nursing practice. They have set standards of practice, advocated for change in the scope of practice and passage of nurse practice acts, and advocated for nurses in collective action in the workplace. Such organizations have an ever-increasing role in health policy development. Fewer than 10% of nurses belong to the ANA, even though it represents the interests of all nurses in the United States (Foley, 2001). Membership in specialty nursing organizations rarely exceeds 30% of those eligible to join (Foley, 2001). These organizations are essential for advocating for nurses and for humanistic health promotion. A strong professional organization needs to be a visible force: a national organization should have national visibility; a local organization should be known locally. For example, the ANA works on national issues in Washington, DC; the state nurse associations work on state-wide issues; and the local districts work on issues in the local community. These three levels of the ANA work in concert. Organizations can identify issues that concern nursing and health care, bring them to the public, and take a leadership role in advocating for development of policies that improve health and ensure high-quality nursing care. To achieve this, organizations need support of nurses through their membership and through their political acumen.

The New York State Nurses Association (NYSNA), for instance, developed and championed the legal definition of professional nursing in New York State. The New York State Nurse Practice Act was passed in 1972 and was the first law to define nursing as an independent profession. This definition of nursing still stands and has served as the model for nurse practice acts in the other states. The ANA is working to influence legislation to deal with overcrowded emergency departments (Trossman, 2006).


Community is most often defined as a geographic area with boundaries, but during the 1960s the idea of community empowerment grew to define a group with a common good that required coordinated action. Power, politics, and policy became attached; community, in this context, is defined as a population, a neighborhood, a state, a nation, and the world. It can be a nursing organization or an online group. An individual is usually a member of more than one community. The other three political action spheres exist in the sphere of community. For example, an individual can be a member of the education, religious, and nursing communities. The countries of Western Europe have joined together to become the European Economic Community; they are also joined with the United States in the North Atlantic Treaty Organization.

Nurses are members of a community with the responsibility to promote the wellbeing of the community and its members. In exchange, the community provides important resources for nurses’ work in health promotion and health-care delivery. Many of the people who live in a community, such as health-care administrators, corporate managers, industrial leaders, elected and career government officials, and patients, have power. These people can, and do, participate in community activities; they have status, expertise, and connections. By building relationships with community members, nurses can gain supporters to achieve goals. The connections they make can transform into networks, and the people in the networks can be asked to support agendas.

In exchange, nurses should support community agendas to work to improve community life. There are innumerable ways to participate actively in the community. Groups such as parent-teacher associations, community boards, councils, conservancies, civic groups, and soup kitchens are but some groups that need and welcome participation and help. Nurses can help mobilize communities on issues such as recycling, environmental clean-up, safety, energy conservation, health screening, and the like. Although activism may grow out of private inter-

ests, it can affect professional life with increased skills, knowledge, experience, and power development. In addition, nurses who are active and form connections in their communities become role models and represent the whole profession.


Government affects most aspects of our lives. We must document births, marriages, and deaths; the buying and selling of real estate; and mandatory childhood immunizations. Government establishes the age at which people may drink alcohol, drive a car, cast a vote, and join the military. Laws determine the health services and social security available to people in old age. Our collective society is organized in ways that make us interdependent; the health and welfare of each of us are dependent on the health and welfare of all. Government is needed to ensure that what we need to get done is accomplished.

Government plays an essential role in nursing and in health care. State government defines what nursing is, and it defines what nurses do. It influences how our health-care system is organized. Government influences reimbursement systems, such as Medicare and Medicaid. Government influences and supports the current managed care arrangement, which provides for reimbursement for health and nursing care. To a large extent, government determines who has access to care and to what type of care. Federal, state, and local governments make decisions about major health issues in our society. Recent decisions include:

■ The kinds of foods and snacks available to children at schools

■ Prohibition of smoking in some public places

■ The initiation and continuation of Head Start

■ Provision of meals for the poorest children

■ The health services available at schools and whether schools may provide sexual and reproductive information; whether schools may provide condoms to sexually active students to prevent the spread of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS)

■ Whether public funds can be used to distribute clean needles to intravenous drug users to reduce the spread of HIV and AIDS

■ Whether women can receive full information about reproductive rights and who can provide that information

■ Whether violence is treated only as a crime or also as a public health issue and whether to regulate the use of hand guns

■ Allocation of funds for housing development and maintenance


Effective use of power and politics to facilitate strategy development for the policy process requires systematic analysis of the issues. The following is a framework for systematic analysis. Adroit use will increase nurses’ political leverage. Although this is directed at broad political action in government and the community, it is also applicable to workplace and organizational policy processes (see Box 13-1).

Components of Political Analysis Identify and Analyze the Problem

Identification and analysis of the problem or issue is the first step. The problem must be understood in order to frame it in ways that will move elected officials to action. It must be carefully crafted in terms that make sense; calls for public action must be clearly justified. Use of public relations theory will help with the expression of, or framing, the issue. To frame the problem adequately, state the scope, duration, and history of the problem. An important point is to be explicit about whom this problem affects. Then collect all data that are available to describe the issue and its implications. Identify any gaps in the data. Identify whether more research might be useful and, if so, what types would help. Outline and Analyze Proposed Solutions Present possible solutions to public officials along with the identified problem. It is best to develop more than one solution because costs, effectiveness, and durability differ from approach to approach. For example, an enduring problem is the nursing shortage; multiple proposals have been developed to correct it and its effects. If increased access to nursing education is a proposed solution, then the proposal must include how this is to be accomplished.

The federal budget is limited; there are many demands for funding for worthy goals, and they must be considered. Competition for federal funds is stiff; nursing education and health care are only two goods among many. Each funding solution— grants, tax incentives, and other sources—has different implications, and each must be understood before making a proposal for federal aid.

A proposal for addressing safe patient handling and prevention of musculoskeletal disorders (MSDs) among nurses was promoted by NYSNA and proposed for legislation. Research showed that promoting proper body mechanics alone is an ineffective way to reduce MSDs in health-care workers. The governor signed a measure for funding a demonstration project. A change in policy will protect patients and health-care workers. Added benefits include increased employee retention and reduced worker replacement and compensation costs (ANA, 2005, p. 4). The ANA and NYSNA performed an effective problem analysis based on solid data. They now have state funding to gather more data and ultimately work for a change in policy.

Understand the Background, Including Its History and Attempts to Solve the Problem It is important to understand what attempts have been made to address an issue. The history, including why and how previous attempts failed, will provide an estimation of the potential success of the current proposal. For example, the reform of our health-care system, especially implementation of a national health service, would require a review of the background of the Medicare/Medicaid system and also a review of President Clinton’s Health Security Act. Assessment of the public’s perceptions of public funding and American emphasis on individualism is needed so that political action can be planned thoroughly. Knowledge of positions of key public officials will also assist in planning. Even in a workplace context, understanding the background of an issue is important. If you believe that the staffing on a unit needs to be changed to improve patient care, efficiency, and nurse satisfaction, you must assess how the staffing was structured, why it was done in that particular way, and why and how that format is outdated before you present your proposal to the nurse manager or appropriate committee.

Locate the Political Situation and Its Structure After the problem and solutions have been delineated, assess and choose the appropriate political venues. The choice is between the private sector and government. If the decision made is to approach government, decide on the level and branch. There are times when both the public and private sectors are involved, but in that case, only one has the decision-making responsibility. When all sectors have equal power, no one sector has the responsibility to make a decision nor the vested interest to prevent a decision. Be sure to identify the political settingaccurately, because making an error can cause you a loss of credibility and a loss of power. For example, if nurses are concerned about an aspect of patient care, the employer must be approached through the organization structure. It is unfair and impolitic to go to public officials before internal mechanisms have been exhausted. It is also imprudent to exclude the nurse manager and go directly to the chief nurse executive or a supervisor. Again, so doing will cause loss of face, credibility, and power.

Evaluate the Stakeholders

The next step is to identify the stakeholders. Stakeholders are those who are affected by or have influence over an issue or who could be recruited to care about it. Stakeholders include policy makers who have proposals related to the issue, special interest groups, and those with a position on the issue. For example, after her husband was fatally shot and her son seriously wounded, Congresswoman Carolyn McCarthy, an LPN, became a respected and powerful proponent for gun control.

She was able to recruit other stakeholders, such as victims of gun violence, during her campaign. One of the most important stakeholders she identified was the American Academy of Pediatrics, which has significant power and resources. The congresswoman recently established the Carolyn McCarthy Center on Gun Violence and Harm Reduction to mobilize public support at the grassroots level for new gun safety legislation.

Conduct a Values Assessment

All political issues have value or moral aspects. Human rights, international health law, the right to health, genetic engineering, embryonic stem cell research, genetic technologies, terrorism, abortion, and the death penalty are among the most visible moral issues today (Annas, 2005). Issues necessitate that stakeholders assess their own values and those of their opponents.

Ascertain Financial and Personnel Needs to Attain Goals

Any effective political strategy must include assessment of resources needed to reach goals. In addition to money, other needed resources include time, connections or network, volunteers, contributors, and intangibles, such as people who are strategists and those with creative ideas. Short- and long-term tactics and goals must be considered in resource analysis.

The budget structure within an organization or government agency must be considered. It is important to understand the budget process, including how money is allocated to a cost center or line budget, who makes decisions regarding expenditures, how use of funds is evaluated, and how an individual or group can influence budget development and implementation.

Analyze Power Bases

In any setting, assessment of power bases of both proponents and opponents is essential. Review the section on power for further discussion. After the political analysis is accomplished, it is time to plan political strategies and identify tactics and guidelines.


After the political analysis is completed, a plan of action with strategies is developed. Strategies are the plans to achieve political and policy goals. One strategy does not work in all situations. To achieve goals, it is useful to follow these tactics:

■ Persistence. Change takes time; conflict is almost always part of policy change. Usually there is much discussion, negotiation, and col

laboration with attendant delays, retrenchment, and realignments. Policy change or new policy development and implementation is a long-term commitment and requires commitment and endurance.

■ Look at big picture. Always prepare for the political process of policy development by clarifying aspects of the issue. This includes knowing your position and possible solutions supported by data, assessing your power base and that of others involved, planning strategies, and knowing the opposition and their plans and rationales. Understand the context of the issue.

■ Frame issue adequately. Understand the stakeholders and target audience to present the issue in ways that are congruent with their values.

■ Develop and use networks. Use power that accrues through personal connections, which requires keeping track of what you have done for others and asking them to reciprocate.

■ Assess timing. Consider carefully when is the most opportune time to act. Knowing when the time is right requires accurate assessment of the values, concerns, goals, and resources of those you have to convince that your way is best.

■ Collaborate. Work with others to achieve policy goals. Collaboration usually achieves goals more effectively than does individual action.

■ Prepare to take risks. Do a risk-and-benefit analysis of an action. This analysis entails consideration of the benefits gained or goals achieved in relation to the expenditure of all resources, including personnel, money, time spent that could have been used on another endeavor, and coherence with values.

■ Understand the opposition. Put aside emotional positions, focus on the issues, and try to understand the fears and concerns of the opposition. Educate the opposition to appreciate the nursing position.

Political Tactics

The effective functioning of an organization depends on the relationships between individuals and groups. Effective use of politics in the workplace can facilitate achievement of goals. A characteristic of political action is that it creates obligation; that is, to get something, something may be expected in return. Such an approach may achieve only part of a goal, but that partial achievement is a step toward the goal.

■ Employ opportunism; act when the time is right.

■ Use trade-offs; support a cause or person in exchange for the goal at hand.

■ Sell votes on one issue for votes on another.

■ Negotiate; each side gives up lesser values to achieve greater values.

■ Form coalitions; two or more smaller groups band together to defeat a larger power.

■ Compromise; each side settles for a partial win or part of what it hopes to achieve.

■ Lobby; attempt to build collectible debts with persons who may influence (or vote) in your favor.

Skills and Tactics in the Workplace

The effective functioning of an organization depends on relationships between individuals and groups. Often, problematic conflicts arise that are threatening to groups. Resolution of these conflicts requires significant managerial skill. Effective use of politics can facilitate conflict resolution and achieve goals. Not all the following skills and tactics may be acceptable, useful, or necessary in a particular situation, but they are useful and have a high probability of success:

■ Build your own team. Executives, administrators, and managers are often defeated in their roles because persons from the previous team are unhappy, jealous, and disgruntled and do not support, or actively sabotage, the work of the new boss.

■ Choose your second-in-command carefully. “An aggressive, ambitious, upwardly mobile number two man (or woman) is dangerous and often difficult to control” (McMurray, 1973, p. 70).

■ Establish alliances with superiors and peers. Determine expectations and motivations of others before you form true friendships. Alliances with superiors and peers are needed to achieve goals.

■ Use all possible channels of communication. Develop and maintain open, effective channels of communication to avoid isolation pre-emption, and loss in power struggles. Be fair, but learn to recognize aggressive, manipulative people.

■ Do not be naïve about how decisions are made.Learn and understand the preferences and the way powerful people act in the organization in order to predict how they will make a decision; then plan accordingly.

■ Know what takes priority. Know what the goals are and how the organization generally works to achieve those goals. In other words, know the modus operandi.

■ Be courteous. Treat others with respect. Respect can prevent feelings that can lead to sabotage and retaliation.

■ Maintain a flexible position and maneuverability. Identify what is ethically important and nonnegotiable. Then you can maneuver confidently to change and power.

■ Disclose information judiciously. In order to work effectively, it may be necessary not to disclose how power strategies are used.

■ Use passive resistance when appropriate to gain time. Delay can be useful when time is needed for gathering information.

■ Project an image of confidence, status, power, and material success. The image of weakness conveys a lack of power and decreases ability to act and achieve goals.

■ Learn to negotiate and collaborate. Do not be ingratiating or conciliatory.


Coalitions have great power to achieve a specific, common goal. They bring diverse people together, with different worldviews, and encourage collaboration, creativity, and empowerment. There is strength in numbers, so coalitions increase the probability for success in political and policy processes. Coalitions take many forms and usually arise out of a challenge or opportunity. They are often disbanded when the goal is achieved, but sometimes they can be long-term and function for years. When they stay together, it is generally because after they achieve their goal, another goal becomes apparent and they choose to continue to work together. Effective coalitions have three important characteristics that are necessary to use power and politics skillfully and to influence policy processes. These characteristics are (a) leadership, (b) membership, and (c) creativity. Without these attributes, a coalition cannot identify, assess, plan, and implement or seize opportunities to further its goals. A coalition needs two types of leaders. One has to have spirit and passion for the cause. This leader has to motivate the membership to get the job done. The second leader must be an organizational leader who is adept at administration that supports the coalition. This leader may be paid if the coalition has funds; other leaders and members are volunteers.

The more members, the more effective the coalition becomes. Without members, the coalition would not exist. Members do the work of the coalition and increase its visibility. Members benefit the coalition, but the coalition also benefits them because they learn and hone skills (Berkowitz & Wolff, 2000).

The ability to recognize and seize an unexpected opportunity and make the most of it is essential. This requires creativity, innovation, and the willingness to take risks. It also requires that leaders and members continually assess their environment, use and enlarge their networks, and keep track of politics associated with their goals in their community. It is hard work to keep a coalition on target to achieve goals. Effective leadership, management, and active, interested, and participating membership are essential to success. Coalitions bring diverse people together for a common cause. They meet regularly and implement or act on their plans. Members must be active and receptive to fresh ideas and innovations. Nurses and nursing must participate in coalitions to improve health care through policy change. An example of an effective coalition is that formed by nurse practitioners and nurse midwives in Maine. Although they had won a change in the nurse practice act, they did not have third-party reimbursement. A coalition was formed and after much work, they finally won payment (Leavitt, 2002).


We have defined power as the ability to act and politics as the allocation of resources that are used for an identified end, goal, or policy. Often during this process, conflicts develop and must be resolved. The resolution process includes negotiation, which can result in one side winning or both sides getting something (often referred to respectively as winlose and win-win resolutions, discussed in Chapter 20). A summary of win-lose methods was identified and characterized by Roe (1995): (1) denial or withdrawal, (2) suppression or smoothing over, (3) power or dominance, and (4) compromise. Win-Win Solutions Win-win solutions, on the other hand, manage conflict in a way that neither party loses and the outcome is creative and productive. Collaboration and principled negotiation are two approaches to winwin resolution to conflict. See Chapter 20 for further discussion.


The goal of collaboration is for parties to work cooperatively with one another in a way that everyone wins and no one has to give up anything. Marquis and Hurston (1994) explain that in collaboration “both parties set aside their original goals and work together to establish a supraordinate goal or common goal. Because both parties have identified the joint goal, each believes they have achieved their goal and an acceptable solution. The focus throughout collaboration remains on problem solving, and not on defeating the other party”(p. 290). Collaboration requires time and full commitment to the resolution process. Mutual respect, communication skills, and an environment where all are heard and considered are necessary for successful collaboration. Collaboration is the ideal solution where all parties are satisfied and all win. Senators from opposite sides of the aisle collaborate when they jointly propose a bill in the U.S. Senate.

Principled Negotiation

Principled negotiation is a form of conflict resolution developed at the Harvard Negotiation Project and has four basic steps as identified by Fisher, Ury, and Patton (1992). These steps are as follows.

■ Separate the people from the problem. This step strives to depersonalize the argument. All parties in the negotiation are persons with feelings, needs, values, experiences, and perceptions and come from different backgrounds. Each person has a personal worldview that must be respected. Because negotiation is easily influenced by the relationships and the problem, it is essential to keep to the issues and not let personalities and feelings intervene in the conflict in such a way as to cut off communication and productive search for a solution. Again, U.S. Senators may fight on the floor but it is done in a way that keeps the person out of the argument. Mutual respect is a must.

■ Focus on interests, not positions. Interests define the problem and are the motivators. Positions are generally conflict needs, wants, discomforts, and fears. For example, nursing staff suffers because patients are difficult, abusive, and manipulative, and they are increasingly unhappy. Staff members believe that they do not matter as people, that they cannot continue to act in professional ways. The interests are adequate staff, material resources, and support to care for these patients. The positions of the staff are anger at administration for allowing the situation to persist, anger at patients who do not appreciate their hard work, fears that they are inadequate, and so forth. The administration fears for their jobs if they do not allocate resources to in a responsible way. Positions are the objectives that arise out of interests. Identification of interests leaves room for alternative positions that serve mutual interests. It is important to identify the facts and feelings behind each party’s wants and fears. Doing so will identify shared and compatible interests. To focus on positions limits ability to consider other options as parties will be too engaged in defending their positions to negotiate in a meaningful way.

■ Invent options for mutual gain. Develop a large number of possible solutions to avoid stymied, narrow negotiations. The more options identified, the greater the possibility of creative, productive solutions.

■ Brainstorming is a frequently used successful method to create options free of judgment. Participants in the negotiation identify as many ideas as possible without critique. The expectation is that ideas should be congruent with shared interests. These interests are goals and need to be made explicit.

Insist on using objective criteria. Use of objective criteria such as research findings will ensure a better agreement. The criteria must be based on a fair standard and should be identified before agreement. Discuss criteria rather than positions to be gained or lost. Focus on objectives will preserve ego and keep relationships intact.

Nurses will continue to need expertise in conflict resolution as change continues to challenge health care. After all, so much is at stake. Negotiation often occurs with participants of unequal power, which puts the less powerful at a disadvantage that is not often acknowledged. Justice, equity, and fairness are uncertain or unlikely in such situations. Successful negotiation requires broad and deep knowledge, the ability to synthesize diverse components of a situation in order to bring trust and respect needed for conflict resolution. Adversity can be a good teacher and impetus for change. Conflict provides an opportunity for personal growth and development, creativity, and innovation that nurses would do well to use to improve health care. The steps outlined in Box 13-2 are useful in conflict resolution.

Power and politics are used to achieve goals. In nursing and health care, the goals are policies that help nurses to deliver appropriate care to persons in local, state, national, and international communities.


Policies are written directives or actions to follow to meet identified ends or goals. Policies reflect values; stakeholders work for policies that are morally congruent with their values. A policy is a guideline that has been formalized by administrative authority and guides or directs action to an identified purpose or specific goals. Policies are developed within organizations, associations, and governments at local, state, federal, and international levels. Values and goals are reflected in the choices an organization, community, and society make. In nursing and in health care, major choices relate to policies governing access to care, allocation of resources, and standards of care. Policies help organizations run smoothly and protect both health-care providers and patients.

A policy system is the total group of events and rules to that policy. The three major parts of a policy system are (1) a purpose or goal, (2), a policy rule, or how to achieve the goal, and (3) a written directive (procedure) on actions to follow in implementing the rule. For instance, an institution may have a policy that all nurses must participate in continuing education each year. This policy rule requires a written directive on the actions to be taken because the policy is still open to many interpretations. What is the content to be required? Can it be done in-house or outside? When must it be done? How many hours are needed? In the United States, health-care policy is particularly rife with disagreement because of four goals that are in conflict. These conflicting goals are (1) provision of the best possible care for all, (2) provision of equal care for all, (3) freedom of choice on the part of health-care providers and consumers, and (4) containment of costs. These conflicting goals and values demonstrate the reasons we have not been able to develop satisfactory health-care system reform. Accessible, cost-effective, equitable, and high-quality care has been elusive. The power, politics, and interests of the special lobbies of big business, such as the insurance, pharmaceutical, and supply industries, champion the free market for health-care system reform. These industries have great wealth and therefore great power to gain and keep control of reform. Weakest in this equation are the poor, the underinsured and the uninsured, and increasingly the working and middle classes who have little or no voice and power. Research has consistently demonstrated prevalent race and gender discrimination in health-care allocation (Bach et al., 2004; Bloche, 2004; Jha et al., 2005; Shischehbor et al., 2006; Smedley, Stith, & Nelson, 2003; Steinbrook, 2004.) The free market reforms that were implemented have failed to achieve important goals of the system. The amount of money spent on health care now exceeds 15% of the gross domestic product (Centers for Medicare & Medicaid Services, 2003). The Kaiser Family Foundation found that health care grew to over 16% in 2006. Administration costs of third-party payers have risen sharply. Both providers and consumers have little, if any, choice regarding care. Disparities in standards of care are growing. Fewer people have access to care; the number of people in 2004 without access was 45.8 million (American Journal of Nursing, 2006), which is up from 37 million in 1990 (Kaiser Commission, 2004). These statistics reveal that the free-market reforms have failed to improve access to care, control costs, and maintain standards of care. With increased free-market policies, the number of people without access to care has increased, costs have increased, and quality of care has decreased. The health-care system is extremely complex and is not wholly amenable to free-market forces. The marketplace has failed to reform the health-care system because of six characteristics or factors (Alward & Camuñas, 1991). These factors are (1) imperfect information, (2) third-party payers, (3) gatekeepers, (4) forced purchase, (5) lack of competition, and (6) distorted profit motives. These factors are discussed below. In the free market, consumers have the ability to gather all of the information they need to make informed choices. This is not the case in health care. It is difficult to obtain and understand all of the relevant information. In many cases, data simply do not exist.

Third-party payers remove the issue of cost for users (patients) and the direct providers of the service (physicians, nurses, hospitals). It is possible for consumers of goods, such as televisions, compact discs, clothing, or services such as lawn and hair care, to shop for what they can afford and for that which meets their wants and needs. When shopping for health care, it is the third-party payer who pays, which decreases the importance of price as a criterion regarding choice. Third-party payers also allow providers, such as physicians and hospitals, to charge what the market will bear. The patient is not the consumer who pays, so there is little incentive on the part of providers and consumers alike to contain costs. And yet, if individuals were left to pay all the costs, only the very rich could afford health care, as is the case in many developing nations. The system would be tattered indeed; modern health care and innovations would not be available and health-care science would falter. Gatekeepers have a profound effect on the efficacy of the free market in health care. When consumers decide to eat in a restaurant, buy a new car, or see a movie, they decide when, where, and how to make the purchase. In regard to health care, it is the physician, nurse, or hospital insurance company who decides. Very often, the purchase of health care is forced. The woman who has a heart attack, the man who has prostate cancer, the child who breaks a leg cannot plan, delay, or reasonably refuse or postpone the purchase of care. Persons need health care when they are hurt or sick. It is hard and often deadly to put off health care in the face of illness and injury. The lack of competition in health care further distorts the marketplace. Insurance is most often bought by employers who want to minimize costs, bypassing patient choice. Patients do not know with certainty if they will need health care, when, and what type. When patients are given a wide choice, it is confusing and difficult to make sense of all the options. The plethora of drug prescription plans available to Medicare recipients clearly demonstrates this. A case in point is the diabetes epidemic. In New York City, diabetes centers that delivered comprehensive care to diabetics had to close because they could not financially keep afloat. Good care means bad business (Urbina, 2006). Care that keeps people well is not affordable; insurance does not adequately reimburse preventive care, such as hypertension, diabetic, and cardiac chronic care. They do reimburse for care that deals with the complications of diabetes (and other chronic illnesses) such as renal dialysis and amputation.


The specific steps taken from identification of a policy problem to a functioning program to solve the problem are referred to as the policy process. Several models have been developed to implement the policy process. These models include Kingdon’s policy stream model (1995), Cohen, March, and Olsen’s “garbage can” model (1972), and the stagesequential models of Ripley (1996) and Anderson (1996). Stage-sequential models are systems-based approaches and may be more accessible and useful to the novice. A discussion of the stage-sequential approach to the policy process follows. A series of stages constitutes stage-sequential models. These stages are analogous to the nursing process (see Table 13-1).

A policy problem is identified and added to the policy agenda. Then the policy is developed, accepted, implemented, and evaluated. As with the nursing process, the policy process is dynamic and cyclical. Both are cyclical in that evaluation often leads back to assessment, and so the process continues. Areas that are not well delineated by the stagesequential model are (a) who gets what and why, and (b) the effect of stakeholder wants and the implications of their ideas, values, and agendas during policy development. The growing problem of childhood obesity and its solution can be examined from a stage-sequential model. Childhood obesity and its attendant risks are identified and are added to the policy agenda. Assessment revealed that easy access to junk food, high-calorie soft and sports drinks, and poor school cafeteria menu choices are major contributors to obesity. Additionally, lack of knowledge of good healthy food choices and lack of exercise worsen the problem. Policies that change foods available at schools, educate students and families about good nutrition, change gym and sports requirements, and educate regarding exercise are developed and implemented. Outcomes of new policies are evaluated for effectiveness, which brings the process back to assessment.

Aspects of Policy Development

Health-care agencies, organizations, institutions, and associations make private policy. Such policies include directives that govern employment conditions and service guidelines or provisions. For example, there are policies that stipulate licensure, education, and experience requirements for specific nursing positions. Other policies provide guidelines for patient care: the use of side rails and methods for dispensing medications are examples of service provisions. Local, state, and federal governments make public policy. Included are legislation, regulation, and court rulings that are made at respective levels and jurisdictions. In New York City, for example, a local policy regarding health care is the no-smoking law in public and workplaces. States control licensure for professional practice, and the federal govern

Comparison of Nursing Process and Policy-Setting Process

ment controls Medicare. Private and public policy have a linked relationship because public policy directly affects private policy, and the need for new or changed public policy arises from private institutions. Included in health policy are the private and public policies that control service delivery and reimbursement,

Government also develops and implements policies at the local, state, and federal levels. Health-care organizations must develop and implement internal policies as well. All policies have unanticipated outcomes that have both detrimental and positive effects. Within an organization, positive outcomes of a policy include rules that protect departmental autonomy, provide support when making unpleasant decisions, and help decide between choices when one does not have a clear advantage. Unanticipated effects of policies are seen when the original purpose is covert, unknown, or forgotten. Organizations sometimes have policies that are blindly followed long after their usefulness has been outgrown. An example is taking temperatures at 5 a.m. even when not warranted by patient condition because it is policy and procedure. Change in circumstances without concomitant change in policy can have detrimental consequences. Detrimental effects also occur when policies are implemented in ways not intended.

Despite the difficulties, risks, and hazards of policy change, change is often necessary. Change is a better alternative than continuing with outdated policies or working without a policy when one is clearly needed. Given the difficulties of change, it is essential to adhere to two rules before implementing the change: (1) test any new policy on a small group or unit; this is similar to conducting a pilot or feasibility study before initiating a research project or study; and (2) identify the purpose of the policy in the procedure or action directive. These steps will identify problems with the new procedure early so that changes may be made and will help with the implementation of the new policy as intended. This information will also be used in measuring the effectiveness of the policy.

All Good Things...

From the beginning, nurses have used power, politics, and policy to further and achieve their goals. It is important for nurses to develop group process, problem-solving, conflict management, crisis intervention, and communication skills to effectively help move toward goals to improve health and health care. These human relation activities are essential to exert such influence to make a positive impact on policy. Collectivity and collegiality help to empower nurse leaders who must position themselves to act to make policy rather than to react to policy proposals of others.

Calls for health-care delivery reform are coming from all segments of society. Big and small businesses want reform because the current system is costly and in many ways ineffective, resulting in reduced competitiveness. The high cost of health care is passed on to the consumer and makes products more expensive. Providers of health care have greatly reduced resources with which to provide care. Fewer resources jeopardize access and quality of care, resulting in less healthy populations, which decreases productivity and increases costs throughout the economy.

Patients, families, and communities are increasingly dissatisfied with the quality and kinds of health care and services available and received. Frustration, fear, and helplessness are growing in the face of a system unresponsive to needs. The health-care system is in dire need of major policy change. Health-care professionals must be proactive and participate in health-care reform. Nurses can and should be major participants in reform. They know well the problematic areas, the gaps, the weaknesses, the dysfunctionalities, and the strengths of the current system. Nurses have insight and knowledge of what works and what does not in setting standards of care, access to care, and allocation of resources. With adroit use of power and political theory, nurses can participate in shaping health policy to improve efficacy and distribution in an equitable way. Health-care reform is a major challenge. With

increased scope of knowledge and skills, coupled with conscious and conscientious development and use of political action, nurses can participate in and support policy development. Nurses are needed to change and improve health care at the institutional, community, state, and national levels. Nursing provides abundant resources to do so; nurses must develop and use political know-how to influence important needed changes and reforms.


Things were not easy at home, this was her fourth 12-hour shift in a row, and now she was being told that the patient in 412 was just impossible. "Don't be surprised if you spend all day in there," Marilyn had said. "And, no matter what you do, it won't be right. Good luck; you'll need it." Wearily, Lois started her morning assessments. Mr. Salcido in room 412 was grouchy and complained a lot. Lois could hardly complete a task before he expressed dissatisfaction or demanded something else. As Lois returned to the nurses' station to chart vital signs, she mentally reviewed her patient assignment and decided that she would save Mr. Salcido's morning care until last so that she could spend more time with him. The risk, of course, was that he would become impatient while waiting. In addition to providing more time with Mr. Salcido, Lois resolved to use all of her communication skills. She would greet him cheerfully, respond with kindness and patience regardless of his demeanor, make pleasant conversation, and-above all-would listen for clues to explain his behavior. Maybe she could do something to make him happier. Forty-five minutes later, Lois emerged from Mr. Salcido's room humbled and once again acutely aware of how easily a patient's deepest needs can go unrecognized. After rapport was finally established and Mr. Salcido decided he could trust Lois, he had confided to her that his wife had died in the same room 2 years earlier. He believed it was not masculine to cry or to express weakness with strangers. His anger was an expression of his unresolved grief over the death of his wife.

Questions to consider while reading this chapter

1. What communication techniques did Lois use to establish rapport with Mr. Salcido?

2. What nonverbal cues should Lois watch for as she begins initial care and communication with Mr. Salcido?

3. What strategies can Lois use to build trusting relationships with each of the patients she cares for?

4. How should Lois communicate her discovery about the source of Mr. Salcido's anger to the other staff members? '


Blocking Obstructing communication through noncommittal answers, generalization, or other techniques that hamper continued interaction.

Communication components The sender, the receiver, the message.

Communication subcomponents Interpretation, filtration, feedback.

Feedback Response from the receiver, which can be verbal or nonverbal.

Filtration Unconscious exclusion of extraneous stimuli.

Interpretation Receiver's understanding of the meaning of the communication. Negative communication techniques Behavior that blocks or impairs effective communication.

Nonverbal communication Unspoken cues (intentional or unintentional) from the communicant, such as body positioning, facial expression, or lack of attention.

Positive communication techniques Behavior that enhances effective communication.


Outcomes After studying this chapter, the reader will be able to:

1. Apply effective oral communication techniques in diverse situations.

2. Evaluate conflicting verbal and nonverbal communication cues.

3. Implement effective written communication skills.

4. Apply effective strategies for managing conflict.


Communication is one of the most basic human endeavors. At the moment of birth with the wail of new life, the infant begins a journey toward development of an effective way to interface with the world. Webster's New World Dictionary defines communication as, "

1. the act of transmitting,

2. a giving or exchanging of information, signals, or messages by talk, gestures, writing, etc. . . . " There are many styles of transmitting information. Observation of a preverbal child for any time will yield creative, humorous, and usually fairly clear methods of disclosing desires and needs. The exchange of ideas and feelings is hardly limited to verbal communication. Although the spoken word is most commonly used for societal communication, a highly developed sign language exists for people who are unable to speak or hear. There are many types of nonverbal communication that often are as effective as, and in some instances more effective than, audible expression. Effective communication is a major part of the nursing profession. Nurses interact with patients, families and significant others, nursing peers, student nurses, physicians, other members of the transdisciplinary team, and the public. Nurses communicate through a variety of media, including the spoken and written word, demonstration, role modeling, and, on occasion, public appearances. This chapter reviews the components of the communication process, communication styles, and principles of effective communication in professional nursing. In addition, communication issues related to cultural diversity, collaboration, dealing with conflict, effective delegation, and documentation are addressed.

HISTORY Our nursing ancestors recognized the need for clear communication as a basic component of the profession. Their comments provide an interesting perspective on the development of nurse-patient and nurse-physician communication. Florence Nightingale (1859) admonished persons attending the sick to be cautious in speaking about the patient as if he or she were not present or in tones too low for the patient to hear. "I have often been surprised at the thoughtlessness... of friends or of doctors who will hold a long conversation just in the room or passage adjoining the room of the patient... who knows they are talking about him.... If it is a whispered conversation in the same room, then it is absolutely cruel." Later, in the chapter "Chattering Hopes and Advices," Nightingale inquires, "Do,you who are about the sick or who visit the sick, try and give them pleasure, remember to tell them what will do so. ... A sick person does so enjoy hearing good news.... A sick person also intensely enjoys hearing of any material good, any positive or practical success of the right." More than half a century later, Sue Parsons (1916) wrote regarding communication with the patient, "Just by your expression you may assure him that he is among friends. If you cannot speak his language, you will attempt to get an interpreter to explain what the examinations mean, what the doctors are trying to do to help him, and to ask him if there is anything he wishes." Regarding communication with physicians, Parsons advises the young nurse, "When she becomes sufficiently experienced to detect a mistake, she will, of course, call his attention to it by asking if her understanding of the order is correct." Under the subtitle of "Discretion," Parsons (1916) warns, "Nurses and doctors are sometimes thoughtless in conversation; they discuss a patient's condition before him, thinking he does not understand or care, and sometimes believing him too ill to notice what is said. This is a great mistake." Regarding idle conversation that breaches patient confidentiality, Parsons observes, "If a nurse, when meeting friends, finds herself invariably talking shop, gossiping about doctors, nurses, and patients, she must realize that she is on the road to unhappiness and cynicism." In today's environment she would be on the road to litigation as well. In the same era Katharine DeWitt (1917) penned, "She [the nurse] must not only respect expressed preferences, but her imagination must be on the alert, ready to perceive, without the need of words, what is agreeable or disagreeable to her charge." And, most profoundly, "Every nurse should be a health missionary, telling how to keep well, how to avoid disease, how to aid in the great campaign for public health, good living and morality."



Communication generally is thought to have three components—the sender, the receiver, and the message. As a dynamic process, communication is cyclic so that the receiver becomes the sender when responding. These roles then alternate as the communication process continues. Inherent in the process is a level of subcomponents, consisting of interpretation, filtration, and feedback. Fig. 17-1 is a visual representation of the basic communication process.


Interpretation of information can be influenced by such factors as context, environment, precipitating event, preconceived ideas, personal perceptions, style of transmission, and past experiences. Because of the interaction of these factors, the sender's message may mean to the receiver something that was entirely unplanned or unexpected by the sender (Fig. 17-2).

Context and Environment.

Context refers to the entire situation relevant to the communication, such as the environment, the background, and the particular circumstances that lead to the discussion. Environment can denote physical surroundings and happenings and the emotional conditions involved in the communication. 388 qjnit Three Leadership and Management in Nursing

Precipitating Event

Precipitating event refers specifically to the event or situation that prompted the communication. Precipitating event refers to a specific single event, whereas context describes the whole ambiance of the situation, with the inclusion of multiple circumstances that have led to the precipitating event.

Preconceived Ideas.

Preconceived ideas are conceptions, opinions, or thoughts that the receiver has developed before the encounter. Such ideas can dramatically affect the receiver's acceptance and understanding of the message.

Style of Transmission.

Style of transmission involves many aspects of the manner of conveyance of the message. Transmission styles include aspects such as open or closed statements or questions, body language, method of organizing the message, degree of attention to the topic or to the receiver, vocabulary chosen (professional jargon vs. language a layperson could easily understand), and intonation.

Past Experiences.

Each person comes to any type of communication, whether it is friendly conversation, informational lecture, staff meeting, performance evaluation, or any other possible scenario, with baggage in terms of past experiences. Because past experiences will be a variety of positive, neutral, and negative events, the influence that the experiences can and will have on communication may be positive, neutral, or negative. The importance of recognizing that any reaction from the receiver may be biased by previous experiences cannot be overstated. A perfect example is presented in the vignette when Mr. Salcido was hospitalized in the same room in which his wife died 2 years earlier. An astute sender will begin to investigate such a possibility if the receiver reacts in an unexpected or inappropriate manner to information that was not expected to produce such a response, which may range from nonresponse to overly vehement response.

Personal Perceptions.

Personal perceptions can have a profound effect on the quality of communication. Perception is awareness through the excitation of all the senses. Perception can be .described as all that the person knows about a situation or circumstance based on what each of the senses—taste, smell, sight, sound, touch, and intuition—discover and interpret. Consider the processes of interpretation that occur in the following example. Donna was an industrious young wife who managed a job, children, and housekeeping. She rarely became sick, but, when an illness did occur, she felt considerable dismay at the response she received from her husband, Dave. When she most needed him to provide assistance and care, he seemed to grow irritable and pull away, leaving her with less physical and emotional support than when she was well. On one such occasion tempers flared, and an argument ensued. Suddenly Dave burst out, "You're just like Mom. Sick all the time." Donna and Dave were shocked at the remark. Donna was not sick all the time. Dave's mother was sick all the time. Once the real issue, that of Dave's frustration with his mother's frequent illnesses, had been identified, Donna and Dave were able to work through the reality of the situation, and the problem was resolved.


The most concise delivery of information is subject to some amount of filtration. Compare the process to washing vegetables in a colander. A large amount of water is poured over the pro duce. Some of the water comes quickly through the colander holes, some water drips through more slowly; and some water hangs on the contents or settles in the solid portions of the colander and never filters through. If people were not able to filter out a part of the stimuli that bombard them daily, the clutter would be unmanageable! At the same time, however, it is possible to filter out some part of intended communication that is essential to facilitate understanding (Fig. 17-3).


Feedback, simply put, is the response from the receiver. However, as with all communication, feedback is a dynamic process. As the receiver interprets and responds to the original message, the sender begins the same process of feedback to the receiver. Because of this circular property, the process frequently is referred to as the "feedback loop" (van Servellen, 1997). As with the original message, feedback is not confined to verbal responses alone. Both communicants constantly assess nonverbal communication as well. Feedback is formed based on all the components of interpretation and filtration.



Verbal Communication

Verbal communication refers to the spoken word. Many factors influence the meaning of oral speech. An abundance of words can have several meanings. For example, consider the phrase, "He flew the plane." Suppose more information is provided. "The cropduster flew the plane." "The Air Force pilot flew the plane." "The Coast Guard Search and Rescue pilot flew the plane." The visual image of the plane changes with each statement from a small fixed-wing plane capable of dusting crops, to a jet, to an aquatic plane with pontoons for landing on 390 'Unit Three Leadership and Management in Nursing water. To carry the interpretation a step farther, it is likely that the impression of the intensity or style of flying also will change. Another clue to the meaning of oral communication is the tone or inflection with which the words are spoken. Suzette Haden Elgin (1993, p. 186) refers to the "... tune the words are set to." More of Elgin's work is available at The key to the true meaning of a statement may be contained in the emphasis placed on a specific word. Consider how differently the following phrase could be perceived based on the inflection or the emphasis on the wording:

• You are going to bed.

You are going to bed.

You are going to bed. With an emphasis on bed, the first phrase most likely will be perceived as an inquiry. The second phrase might imply that you are going to bed, but no one else is. The last phrase, an imperative, gives the impression of increased emotion such as anger or frustration.

Nonverbal Communication Nonverbal communication involves many factors that either confirm or deny the spoken word. Facial expression, the presence or absence of eye contact, posture, and body movement all project a direct message. Indirect messages that are nonverbal might include dressing style, lifestyle, or material possessions. Never presume that external trappings and physical presentation do not influence the quality of communication. Preconceived ideas and expectations interpret input from all such sources, often on an almost subconscious level. No one can miss the message regarding "body language" sung by the sea witch in the film The Little Mermaid (Ashman and Menken, 1988), which says that Ariel can win the Prince without her voice because of the power of body language. Body language can speak volumes—sometimes in support of the verbal message, but other times in direct opposition to the spoken words. Imagine being greeted by a door-to-door salesman with a proverbial silver tongue. He makes all the right statements about the lovely home and darling children but holds out a limp hand to shake and draws back when one of the children reaches toward him. Which message seems more likely to be true—the verbal or the nonverbal? The inability to make eye contact can be construed to mean that the speaker is shy, scared, or not telling the truth. The judgment of which condition is the correct one then is based on all the factors that feed into the receiver's interpretation—perception, preconceptions, precipitating event, context, past experiences, environment, and transmission. Faced with the many opportunities for incorrect interpretation, is it any wonder that misunderstandings occur? An important concept to remember is that, when the verbal and nonverbal messages do hot agree, the receiver is more likely to believe the nonverbal message. Jan Hargrave (2001) tells us that our bodies give "hidden messages" all the time. We can't get away from what our bodies say; they don't lie! An understanding of the importance prescribed to body language and other nonverbal clues to the intent of the message explains the advantage of face-to-face communication whenever possible. Although a telephone conversation supplies verbal messages, intonation, and feedback, other signals are missing such as facial expression, body position, and environmental clues. The perils inherent in written communication are discussed later in this chapter.



Many times we find ourselves influenced by what appear to be justifiable arguments of others. Sometimes these arguments are not based on sound logic. Recognition of faulty logic will promote effective communication and save a lot of confusion or even conflict. The following are some logical fallacies that are frequently encountered. For more information on logical fallacies, you can visit the following sites: or www.

Ad Hominem Abusive

Ad hominem abusive is an argument that attacks the person instead of the issue. The speaker hopes to discredit the other person by calling attention to some irrelevant fact about that person. Perhaps a nurse has just had a disagreement with a physician about laboratory results that were not properly reported. The nurse makes the following comment to colleagues: "She thinks she's so smart just because she's a doctor." What does that have to do with the disagreement? Nothing. It is an unwarranted attack on the doctor. Does it accomplish the purpose? Very likely the group will be influenced by the disparaging comment. They may even become angry at the physician who had legitimate cause to be upset about not receiving laboratory results. Ultimately the issue of unreported laboratory values is lost in the attack against the doctor.

Appeal to Common Practice

Appeal to common practice occurs when the argument is made that something is okay because most people do it. This logic is likely to be faulty in two ways: (1) do "most" people really do it? (2) does common practice really make an action okay? It's easy to imagine a situation in which using an explanation that you did something because you'd seen someone else do it that way, rather than checking the organization policy and procedure manual, could lead to significant professional and legal problems.

Appeal to Emotion

Appeal to emotion is an attempt to manipulate other people's emotions to avoid the real issue. For example, consider Deb, RN, who has made a medication error. She has been called into the nurse manager's office to discuss the incident and receives a written warning. She comes out tearful. It is obvious to her colleagues that she has been reprimanded. She begins to discuss the problem and makes the following statements: "I am the first person in my family to even go to college. I'm a single parent and I've worked so hard to get where I am. Our manager doesn't care anything about that. She just wants to pass out written warnings to cover herself. She doesn't care about us as individuals." After a bit of this type of talk, the entire staff is probably becoming angry with the nurse manager—who may feel very badly about having had to give the written warning because she does care about her staff. However, Deb has successfully deflected the attention away from the real issue, the medication error that was legitimately addressed, and appealed to the emotions of her colleagues.

Appeal to Tradition

Appeal to tradition is the argument that doing things a certain way is best because they've always been done that way. This argument is often expressed as, "that's just how it's done here." 392 (klnit 'Three Leadership and Management in Nursing Another version would be, "Oh, we tried that once, and it didn't work, so we went back to the old way." Change always brings some uncertainty, but choosing to continue a practice just because "that's the way we've always done it" is not very sound reasoning. Health care is a very dynamic arena. The old ways of doing things seldom work out to be the best in this time of rapid change.

Confusing Cause and Effect

Confusing cause and effect occurs when we assume that one event must cause another just because we often see the two events occur together. Amber and Chyane are nurses in labor and delivery. One night shift, two mothers delivered babies with significant "birthmarks." It happened to be a night with a full moon. Amber states, "Clearly, babies born on a night during the full moon are more likely to have birthmarks." She makes the assumption that since the moon was full and two babies were born with birthmarks, some cause-and-effect relationship must exist.

Hasty Generalization

Hasty generalization involves coming to a conclusion based on a very small number of examples. A hasty generalization occurs whenever an assumption is made that a small group represents the whole population. Two nurses are discussing a co-worker who seems a bit disorganized and always leaves a mess. One of the nurses makes the following statement, "Well, what do you expect from a blonde? You know how ditzy Capri was, and she was a blonde, too." The hasty generalization here is that, because the nurse knew two blondes who were disorganized and messy, all blondes must be disorganized and messy.

Red Herring

Red herring is the introduction of an irrelevant topic to divert attention away from the real issue. Two nurses, Brian and Nikoah, are having an argument regarding Brian's failure to complete his assigned tasks. Brian states, "It's not my work that you're really mad about. It's that I'm a guy. You just don't like male nurses." Nikoah then begins to defend herself, denying any prejudice against male nurses. The focus of the argument has been turned from the real issue, Brian's failure to complete his assigned tasks, to a situation in which Nikoah is on the defensive about her opinion of male nurses.

Slippery Slope

Slippery slope is the belief that an event will inevitably follow another without any real support for that belief. In fact, this type of logic often leads from a fairly harmless situation to an assumption akin to the notion that the sky is falling. Kathy and Janet are talking in the nurses' lounge over lunch. Kathy is upset over the recent announcement that the unit is going to convert to computerized bedside charting. Kathy states, "It was bad enough having to chart all we do. Now we have to learn to use computers and make all kinds of entries. We'll probably have just as much paperwork. We'll end up spending even less time with the patients. The next thing you know, nurses will be sitting at a computer terminal, and someone else will be taking care of patients. Then they'll decide they don't really need nurses at all!" Kathy's logic takes her from a simple unit change to the end of nursing as we know it! Yet we often hear that kind of "escalating disaster" logic when change is introduced.

Straw Man

Straw man occurs when the actual issue is ignored and replaced with a distorted or exaggerated version. Cindy and Toi, both labor and delivery nurses, are discussing one of the local politician's stand on abortion. Toi states, "Dave Stroud said in an interview that he is very strongly opposed to late-term abortions." Cindy becomes angered immediately and says, "Oh, so he doesn't believe in abortion. He thinks a woman doesn't have a right to choose, to say what happens to her own body. I figured him for that kind of a person." In actuality, the interview said nothing about the politician's opinion on abortion earlier in a pregnancy. Cindy's faulty logic has effectively represented Mr. Stroud as insensitive to women, with nothing to support that position. She has not only exaggerated his stated opinion but distorted it to imply an attitude that was never addressed in the statement. Understanding these logical fallacies should help the nurse recognize the difference between legitimate and faulty reasoning. A clear understanding and use of sound logic will help health care providers present issues and resolve problems effectively.



Trust rust between the nurse and the patient is essential to effective communication and often must be cultivated. Factors that enhance the development of trust include openness on the part of the nurse, honesty, integrity, and dependability. These can be achieved by:

• Communicating clearly in language that laypersons can understand.

• Keeping promises.

• Protecting confidentiality.

• Avoiding negative communication techniques such as blocking and false reassurance.

• Being available to the patient.

The need for trust is not limited to the nurse-patient relationship, but rather it pervades all associations. Care is more effective when the nursing team and the transdisciplinary team share the essential element of trust.

"I Messages"

The use of "I messages" is a fundamental component in acceptable communication. Consider the following exchange. Laura: "You make me so mad, Donald." Donald: "I don't mean to make you mad." Laura: "Well, you do. You never think about how I feel. You know I hate it when you leave a patient's room as cluttered as 103." Donald: "You don't have the vaguest idea what went on here last night! That's what I hate about you—always so quick to judge. You are so critical. You must think that you're perfect!" When a comment starts with "you," most commonly the receiver's defenses will promptly go on alert. The use of "you" in such a context sounds—and most probably is meant to be— accusatory. Notice how the emotions quickly escalate to anger. Notice that, although initially the receiver tries to sound conciliatory, he soon begins to respond in like form. Instead of using accusatory and defensive language, the sender should place emphasis on his or her feelings, rather than on the receiver as the cause of the feelings.

"Donald, I feel so upset when I find a cluttered room like 103 at the beginning of my shift. I feel as if I'm behind when I start." The difference is obvious. When "I messages" are used, they become less likely to sound accusatory. By using such an opening, the sender allows the receiver to respond to the true message rather than start to mount a defense. It allows for more effective communication because the receiver is more likely to offer an explanation such as the following. 'Tm really sorry about room 103, Laura. I guess the wheel that doesn't squeak doesn't get oiled, as they say. Our shift started last night with a patient coding right after he arrived from the Emergency Department. There was no family here. It took forever to find them and then to support them through the shock. About the time things settled down, the patient in room 110 coded. It was quite a night." In this instance the "I message" enhances communication by giving Donald the opportunity to address the real concern. In addition, if Laura is truly astute, she has a wonderful opportunity to support her colleague by voicing appreciation for the working circumstances of his shift. Most people respond gratefully to recognition and commiseration. The exchange could build collegiality between the two co-workers and perhaps between the two shifts.

Eye Contact

As mentioned previously, avoiding eye contact can be interpreted a number of different ways. A person who does not make eye contact may be thought to be shy, scared, insecure, preoccupied, unprepared, dishonest—the list could go on and on. None of these qualities is likely to be appreciated in a primary caregiver. By making direct eye contact, the nurse gives undivided attention to the patient, and the patient is likely to feel valued and understood by the nurse. Eye contact in essence says, "I am wholly available to you. What you are saying is important to me." Eye contact is equally important in communication with co-workers and other members of the transdisciplinary team. This quality is lost in telephone conversations or written communications. Keep in mind that the use of direct eye contact is a Western value. In some cultures avoidance of eye contact is more appropriate social behavior. By careful observation, the nurse quickly will recognize whether direct eye contact is interpreted as inappropriate or disrespectful. Nurses must make every effort to be sensitive to the cultural values of the client and their co-workers to enhance effective communication.

Promise Keeping

Little else can destroy the fragile trust developing in any interpersonal relationship as quickly as making and then breaking promises. Inherent in the concept of promise keeping are the qualities of honesty and integrity. Once a commitment is made, every effort must be expended to fulfill the expectation. Sometimes the request is impossible to satisfy. If this happens, the nurse must explain the situation or circumstances. The fact that the patient understands that the nurse has made an effort to meet his or her needs or desires often is more important than whether the goal is accomplished. If the nurse responds, "I'll check on that," and then finds the request impossible to fulfill but never returns with an explanation, the lack of dependability per


Empathy is the ability to mentally place oneself in another person's situation to better understand the person and to share the emotions or feelings of the person. Empathy is not feeling sorry for another. Empathy is understanding the experiences of the other person. Devel opment of empathy builds the nurse's ability to help the patient through a true understanding of the patient's feelings and needs. Empathy is integral to the therapeutic relationship. The nurse is able to perceive and address the needs of the patient without emotional involvement to the point of becoming inappropriately immersed in the situation.

Open Communication Style

Certain styles of phrasing questions and statements lend themselves to obtaining more information. For example, suppose Chris asks Mr. Barrow, "Do you know where you are?" and Mr. Barrow responds, "Yes." Can Chris assume that Mr. Barrow knows he is in the hospital? Not necessarily. Chris may be surprised to hear a completely unexpected response if he rephrases the inquiry. "Mr. Barrow, tell me where you are." "Why I'm in the honeymoon berth of the Titanic, of course. Have you seen my lovely bride?" Using open-ended questions or statements that require more information than "yes" or "no" can augment gathering enough facts to build a more complete picture of the circumstances. Questions or statements that are phrased to require only one- or two-word responses may miss the mark entirely.


Both communicants have a responsibility to clarify anything not understood. The sender should ask for feedback to be certain the receiver is correctly interpreting what is being said. The receiver should stop the sender anytime the message becomes unclear and should provide feedback regularly so that misinterpretation can be identified quickly. Such phrases as, "What I hear you saying is ..." or "I understand you to mean ..." help to communicate to the sender what is being perceived. Other techniques of clarification include using easily understood language, giving examples, drawing a picture, making a list, and finding ways to stimulate all the senses to enhance the ability to understand.

Body Language

Body positioning and movement send loud messages to others. The nurse can imply openness that facilitates effective communication by awareness of body position and movement. In addition to eye contact, effective communication is enriched through an open stance, such as holding one's arms at the side or out toward the patient, rather than crossed, or leaning toward the patient as if to hear more clearly rather than away from the patient.


Most people have a fairly well-defined personal space. It is important for the nurse to be sensitive to each patient's personal preference and cultural differences in terms of touch. However, for many people a gentle touch can scale mountains in terms of demonstrating genuine interest and concern. A pat on the back, a hand held, a back rub are all behaviors that indicate availability and accessibility on the part of the nurse.



Several negative communication techniques have been alluded to in the previous discussion. Closed communication styles such as asking yes-no questions or making inquiries or statements that require single-word answers potentially limits the response of the person and may prevent the discovery of pertinent facts. Closed body language also can hinder effective communication. Crossed arms, hands on the hips, avoidance of eye contact, and turning or moving away from the person all impose a sense of distance in the relationship.


Another technique that is detrimental to good communication and the development of a trusting relationship is blocking. Blocking occurs when the nurse responds with noncommittal or generalized answers. For example: "Nurse, I've never had surgery before. I'm afraid I might not ever wake up." Mr. Clayton is twisting the bedsheet as he speaks. "Oh, Mr. Clayton, many people feel that way. It'll be okay." Amanda Butler, RN, smiles brightly, pats his hand, picks up the dirty linen bag, and bounces out of the room. Does Mr. Clayton feel reassured? Not likely. Will he be inclined to broach the subject with Amanda again? Probably not. Amanda has incorporated some important aspects of communication into her response—cheerfulness and touch—but she has not truly communicated. She has effectively blocked Mr. Clayton's attempt to get the reassurance he wanted from her. He may be too intimidated to ask anyone else, assuming that his fear is invalid. By generalizing in this way, Amanda has trivialized Mr. Clayton's concerns. He is not "many people." He needs to be validated as a person experiencing a legitimate feeling. Amanda can validate his fear and put it into perspective at the same time with a different approach. Nurse: What makes you think you might not wake up, Mr. Clayton? Patient: Well, my wife's cousin's husband had surgery about 25years ago, and he never woke up. Nurse: What kind of surgery did he have ? Patient: Uh, it was some kind of heart surgery, and he had another heart attack on the table and died right there. Nurse: It sounds like his condition was critical going into surgery. Patient: Yes, ma'am. He'd been sick for a long time. Nurse: It's not uncommon to feel afraid of being put to sleep, especially if you have never had surgery before. There are rare cases in which complications do occur during surgery. That's why we put the disclosures on the consent form, so that you will know just what the risks are. Thankfully most surgeries are without such drastic problems. Although your gallbladder certainly has made you uncomfortable, you are otherwise in good health. The tests that were done before surgery, like the chest radiograph and the laboratory work, show that you are healthy and should do well with the anesthesia. That drastically decreases the chance for complications in your case. I would be glad to answer any other questions you have or to ask the anesthetist to come and talk with you some more. Amanda has validated Mr. Clayton's feeling as legitimate, provided an explanation with reasonable reassurances, and offered to explore the issue with him further, or to have someone else talk with him. Some things are difficult to talk about with another person. The dying patient may want to talk about how he or she feels, ask questions, or perform a life review. A nurse who is uncomfortable with such topics may consciously or unconsciously block communication through generalizations or closed responses. Avoiding the blocking technique requires a good understanding of oneself. If unable to provide the open communication the patient obviously needs, the nurse should access other personnel who are more comfortable in the situation. This might be another nurse, a social worker, a physician, a member of the clergy, a family member, or a friend of the patient.

False Assurances

False assurances are similar to and have about the same effect as blocking. When someone is trying to get real answers or express serious concerns, an answer such as "Don't worry," or "It'll be okay" sends several unintended messages. Such an answer can be interpreted by the patient as placating or showing a lack of concern or a lack of knowledge. The patient might even conclude that the nurse is being neglectful through trivialization of an issue that is important to him or her. At the very least, the nurse has neither recognized the need the patient has expressed nor provided validation.

Conflicting Messages

Conflicting messages also have been alluded to in the previous discussion. If a person professes pleasure at seeing someone but draws back when that person extends a hand of greeting, the nonverbal message speaks more loudly than the words spoken. If a nurse enters a room and goes through the routine greeting by rote (even with a smiling face and a bouncing step), a patient can quickly perceive this and consider the nurse less approachable. The nurse's statement that the patient's condition is important to the nurse followed by failing to answer the call bell in a timely manner or by forgetting to bring items promised to the patient sends a double message. Such behavior can leave the patient confused, frustrated, or angry. Carrying through with a commitment, no matter how unimportant it may seem, is a premier method of saying to the patient, "You are important to me."


Neal Samuels, RN, decided to make an unplanned stop at the clinic one evening after hours, arriving without his magnetized name badge that would let him in select doors. As he pushed the intercom button outside the door to contact security, he formulated a concise message to explain his predicament. He could see the security guard through the tinted window. A clear voice sounded through the speaker, "Police Department. Can I help you?" Neal responded, "Yes, my name is Neal Samuels. I am on the School of Nursing faculty. While I was out shopping, I realized I needed to stop by my office, and I don't have my badge with me to open the door. Would you let me in?" "Do you work here?" the officer asked. "Yes, I work in the School of Nursing." "Then use your badge to get in." "I don't have it with me," Ned repeated. "What did you say your name was?" the officer responded. And so it went. Listening certainly is as important an element in clear and effective communication as any other component. Many distracters contribute to poor listening habits. Framing an answer while the other person is still talking interferes with receiving the entire message. Environmental disturbances can provide major disruption. A crying baby, a call light buzzing, or multiple concurrent conversations in a busy nurses' station are a few of the interruptions that jumble the simplest of instructions. Preexisting concerns or worries can block absorption of conversation because of the preoccupation. Attempts to continue work in progress leads to inattention. Ineffective engagement or peculiar mannerisms on the part of the speaker can be distracting. A person who does not make eye contact, shuffles through papers while talking, or overuses hand movements actually can deter communication.

A number of techniques can be used by the receiver to facilitate the ability to listen.

• Give undivided attention to the sender by moving to a quieter area and stopping the speaker to clarify any points not understood.

• Provide feedback in terms of perceived meaning of the message rephrased in the receiver's own words.

• Give attention to positioning to face the sender and make eye contact.

• Note nonverbal messages such as body language and respond to them.

Mindful listening will dramatically improve the likelihood of receiving the correct message. However, equally important is the fact that attentive listening implies a respect for the speaker and communicates a regard for what the speaker has to offer. The nonverbal message that keen listening delivers is, "I value you, and what you have to say is important to me."


Rhonda stared at the sign in amusement. Concurrent seminar sessions had been planned in a large room equipped with sliding soundproof panels that could be rolled along a track to effectively divide the large room into two smaller conference rooms. However, the sections had not been moved into place to create the dividing wall—the panels remained in two rows on short tracks against a structural wall. For the past 20 minutes, Rhonda had watched several of the attendees struggle to move the dividers along the track. The group quickly realized that the sections would need to be moved in an alternating fashion from first one side row and then the other row. When the last piece should have slid into place, it became obvious that the panels should have been pulled out in reverse order. All the panels had to be replaced in storage position. The process then was redone starting with the opposite panel row. When the last section finally was pulled into place, the audience burst into a round of applause. Simultaneously, the following sign, written in large black print on white paper and posted at eye level, came into view (Fig. 17-4). The message certainly is clear. Did the sign accomplish its intended mission? Not by a long stretch! Undoubtedly the placard was effective when the dividing wall was in use because it could be clearly seen. However, when the panels were stored, the sign was completely covered. Even the most carefully worded and designed message can go astray if not properly directed to the intended audience.



Do NOT move panels.

Contact authorities

for proper assistance!

Thank you.


The professional nurse must interface with many forms of written communication on a daily basis. Nursing documentation includes a variety of reports—the nurse's notes in patient charts, memos, kardexes, incident reports, discharge teaching forms, and written shift reports, to name a few. Many of the forms that nurses use for documentation are part of the legal record and require careful consideration. Unclear instructions or reports either written or read by the nurse can lead to misunderstandings, errors, and the potential for litigation. Most profoundly, misinformation potentially can lead to patient harm or injury. Therefore special attention must be paid to communicating effectively in writing.


Absolute accuracy is paramount in recording legal documentation. For the nurse, this most specifically applies to the nursing notes or any other entry in the patient's chart. Every effort should be made to report concisely, descriptively, and truthfully. To write "Patient walked today" is not adequate. A more concise and descriptive entry reads, "Patient walked to the nurses' station and back three times this shift, a total distance of 96 yards." (Many hospitals have distance measures marked in the hallway for this purpose.) Cody Johnson, RN, entered a patient's room and found her agitated and speaking loudly into the phone as she twisted her hair with her free hand. She was crying and periodically pounded the bedside table with her fist. Later the patient told Cody that she had been talking with her mother. Would it be appropriate for Cody to chart, "Patient became very angry with her mother while talking on the phone." No! The nurse must be diligent not to include personal judgments or quantify the patient's emotional state in such terms. More accurately, Cody could chart, "Patient found crying while talking on the phone in a loud tone to her mother. Patient was twisting her hair and hitting bedside table with her fist." The information is descriptive and states exactly what Cody observed factually without any judgmental conclusions. If, however, the patient had said, "My mother makes me so mad," Cody could have charted the statement as a direct quote (enclosed in quotation marks).

Attention to Detail

In addition to absolute accuracy, written documents should be descriptive. As mentioned in the previous section, information should be quantified whenever possible. How many feet did the patient walk? How many times was the patient out of bed? How many milliliters of fluid did the patient drink? Precisely what did the patient say? Words can be used to depict a verbal picture of a wound, rash, bruise, or any type of injury or situation. Illustrative terms can create a mental image for the person reading the notes, memo, or other communication. Descriptive categories can include measurement, color, position, location, drainage, or condition when speaking of a physical condition; or time, setting, people present, issues or goals discussed, or direct quotes when speaking of a meeting, conference, evaluation, or other interchange. Consider the differences between the following written communications. "1000 Dressing change completed. Site healthy." "1000 Dressing change completed. Edges of 4-inch surgical wound approximated, no drainage noted. Skin pink without any redness or edema."

The second entry allows the reader to "see" the wound mentally and follow the progress of healing even when unable to be present at the time of the dressing change. A good rule when describing any kind of break in skin integrity—whether from a stabbing, a surgical wound, an intravenous line, and so on—is to describe color, drainage, and presence or absence of edema. Consider the memo written in

Box 1
. What does this memo really tell the nurse manager? Not much—only that there is some kind of perceived problem between Lucas and the students. The nurse manager does not know based on the information provided if the problem is "real," if it is based on a bias of Jessica's or a student bias, if it has occurred more than once, if an interpersonal communication problem or misunderstanding exists, or if obvious mistreatment of a student or students has occurred. Now consider the memo written in
Box 2
. Carefully constructing a factual memo of this length is more time-consuming initially, but it will save a lot of frustration in the long run. The nurse manager now has a clear picture of what has occurred and knows that an ongoing problem exists. Most appropriately, Jessica will speak to Bonnie about the problem, even if only briefly, when she delivers the memo. However, a written account of the incident must be submitted and should be composed promptly while the facts are freshly remembered. In addition, written communication often is the first source of contact because the nurse manager is not likely to be immediately available on all shifts. The skill of writing concisely yet descriptively must be developed. Over some time, nurses build a repertoire of phrases and illustrative terminology that are useful and effective. Often, when a nurse is stumped as to how to express a situation, she or he will ask a colleague, "How would you write...?" Accessing the experience and expertise of nursing peers is productive in terms of problem solving while also demonstrating respect for the colleague.




Anecdotal report


To: Bonnie Thompson, RN, BSN, Nurse Manager

From: Jessica Lindsay, RN, BSN, Charge Nurse

Date: August 18

Subject: Lucas Alfred, RN



Descriptive, Thorough Memo

Anecdotal report



To: Bonnie Thompson, RN, BSN, Nurse Manager

From: Jessica Lindsay, RN, BSN, Charge Nurse

Date: August 18

Subject: Student Precepting



I have had lots of complaints about Lucas Alfred's treatment of students. I do not think he should be assigned as a preceptor anymore and do not plan to do so from now on.


The memo example in the previous section also illustrates the need for thoroughness. In addition to being descriptive in terms of the incident, Jessica reported her interview with other nursing students. By doing so, Jessica has been thorough in describing and reporting the extent of the problem she has discovered. Providing such complete information helps to avoid communication breakdown. Anticipating and answering relevant questions before they are asked exemplifies thoroughness and clarifies communication.

Today (Monday, August 18) at 07101 observed what appeared to be an animated conversation between Lucas Alfred, RN, and John Roberts, SN, a student nurse from North Hills University. As I moved toward them, I heard Lucas say loudly, "Well, you better stay with me because I am not going to come looking for you all day. I know how lazy students are." I asked Lucas, "Is there a problem?" He replied, "Oh, no problem. I just hate having students, that's all. They're more trouble than they're worth." I asked Lucas, "Would you prefer that I reassign the student?" He shrugged his shoulders and walked away. I suggested to the student that I assign him to another nurse for the day. He responded, "I'd really appreciate that. Mr. Alfred has let me know since I arrived that he didn't want to work with me."

Because this group of students has been on the unit 2 days a week for the past 3 weeks, I spoke to the other students who had worked with Lucas and asked them how things had gone. The other three students who have worked with him reported similar experiences.

I would like to arrange a time to meet with you and Lucas to address this problem.



Written communication must be concise. The message must state the necessary information as clearly and as briefly as possible. Consider the memo written in

Box 3



Anecdotal Note

Subject: Student precepting

Today at about 0730 (it may have been earlier because I don't remember whether the breakfast trays had been served or not), I observed what appeared to be an animated conversation between Lucas Alfred, RN, and John Roberts, SN, a student nurse from North Hills University. I thought they might be arguing, but I couldn't tell for sure, so I decided to go over and see what the conversation was about. It really seemed like Lucas was angry because he was talking loudly and not smiling, and neither was the student smiling, and I heard Lucas say, "Welt, you better stay with me because I am not going to come looking for you all day. I know how lazy students are." Well, I could just imagine how that made the student feel, so I asked, "Is there a problem?" even though it was pretty obvious that something was wrong. Lucas said, "Oh, no problem. I just hate having students, that's all. They're more trouble than they're worth." I asked Lucas, "Would you prefer that I reassign the student?" He shrugged his shoulders and walked away. Well, I don't know for sure about the student, but I really thought that was rude. I suggested to the student that I assign him to another nurse for the day. He responded, "I'd really appreciate that He has let me know since I arrived that he didn't want to work with me." Well, I know how that would make me feel-to be a student and be treated that way. The same group of students has been on the unit 2 days a week for the past 3 weeks (maybe a month, I'm not sure, and some of them may have been here on make-up days, too), so I talked to other students who had worked with Lucas and asked them how things had been going. They said he'd acted the same way to them. We need to talk to him.



Whew! Extraneous details tend to confuse more than clarify. An inherent dilemma often develops as the nurse attempts to determine how to be descriptive and concise at the same time. One must determine what facts are pertinent to enable the reader to understand the true message. When in doubt and when appropriate, the writer can ask another party to read the message and provide feedback to the writer as to what the reader believes the message means. However, the right to confidentiality and privacy of the people involved must be observed. This basic principle applies to patients, families, students, members of the health care team—to all persons. Consequently, the nurse must be as judicious in handling written material in a confidential matter as with any other form of communication.



More and more communication is computer-based using e-mail, chat rooms, attachments, and other electronic modes. The computer-based written record can be somewhat more transient than other written documents. For example, e-mails are often read and then deleted. However, remember that communication via the computer can be saved and is often retrievable even after deletion. As with any form of written communication, computer-based interaction loses nonverbal cues. Therefore it is important for the sender to elicit feedback and/or for the receiver to ask for clarification if the meaning of the communication is not clear.



Development of truly effective communication necessitates understanding various communication styles. In addition to the concepts discussed up to this point, characteristics exist that might impede efficacious exchange of information. Issues such as gender differences, cultural diversity, assertiveness vs. aggressiveness, and dissimilarities in the professional approach of the various health care disciplines all contribute to disparate understandings and interpretations.

Communication and Gender Differences

A significant clarification must be made regarding communication between men and women. Although research and many years of observations and writings have produced information about gender differences resulting from socialization, these are generalizations and should be viewed from that perspective. Attributes described do not necessarily apply to all persons or all of the time. Nevertheless, a plethora of observations indicate that men and women solve problems, make decisions, and communicate from different perspectives based on socialization that begins shortly after birth (Cummings, 1995; Elgin, 1993; Heim, 1995). Typically boys are taught to be tough and competitive; girls are taught to be nice and avoid conflict. Dr. Pat Heim (1995, p. 8) suggests, "Playing team sports boys learn to compete, be aggressive, play to win, strategize, take risks, mask emotions, and focus on the goal line." Regarding girls' play, Dr. Heim comments, "Relationships are central in girls' culture and therefore they learn to negotiate differences, seek win-win solutions, and focus on what is fair for all instead of winning." Clearly, learning to approach life on such different terms—with different rules—can lead to frustration, sometimes a sense of total defeat in the communication arena! For the most part women work toward compromise, even when it means relinquishing some of the original goal. Preserving relationships is usually of paramount importance to women. The role of peacemaker and nurturer has been a traditional expectation of women throughout the ages. Generally men work toward winning. Traditional role expectations of men have included provider and protector. Men learn early in life how to focus on goals and move aggressively toward accomplishment. Team sports teach men that relationships are not destroyed in the "battle" (Heim, 1995). Consequently, men have been socialized to behave assertively when such performance is needed in pursuit of the goal and then move on without loss of friendships. Women have been socialized that assertive behavior will endanger relationships and that conflict should be avoided to preserve friendships. On the other hand, men tend to communicate with a purpose to achieve an identified goal. If conflict occurs during the process, it is simply dealt with as part of the routine. Men are more likely to give concise responses and make prompt, straightforward decisions. Women most often seek to communicate with sensitivity (i.e., how the information is being received and what adjustments need to be made in the presentation, and perhaps the proposed solution, to avoid outright conflict). Decision making involves discussion as part of the problem-solving process. Men typically use communication as a tool to deliver information, whereas women value the process of communication itself as an important part of the relationship. Therefore, in an effort to improve communication, men might try spending more time in discussion, and women might try to phrase comments more succinctly. Consider the following conversation. Nurse: Dr. Vernon, I'm calling to talk to you about Mrs. Guevara. She says she's having more pain and feels a little dizzy. I've given her her pain medicine as soon as I can each time. She says she's a little nauseated. Her husband's in the room, and he says she feels worse too. She did not sleep much last night and has not been able to nap today... Doctor: I have patients to see! Just give me the facts. Nurse: Okay, she's had her medication every 4 to 5 hours this shift. I don't know if she needs a higher dose or just needs the medication more frequently, or maybe we should try a different medicine. Doctor: What are her vitals? Does she have any drug allergies?" Nurse: Just a second, and I'll get the chart. Doctor: Confound it, when you get your act together, call me back! Dr. Vernon slams down the phone. Consider the many communication styles and concepts illustrated by the previous conversation. Preparedness, conciseness, contributing environmental conditions (patients waiting), and even courtesy are issues that could be more competently addressed. The fact that the conversation is occurring by telephone instead of in person also is a factor, responsible for the lack of eye contact and the lost potential for additional information through other body language. Telephone conversations are a fact of life in health care. Careful planning and preparation of what will be said will facilitate effective information exchange. In the professional setting especially, men are more prone to favor brief, concise information exchange. In the professional setting women still tend to prefer verbal problem solving as the situation is discussed. Knowledge of the gender differences in communication style could have altered the nurse's telephone call in the following manner. "Dr. Vernon, this is Holly Michaels, RN, from Fairmont General calling about Mrs. Guevara in room 496. She has been receiving her pain medication exactly every 4 hours and continues to complain of incisional pain. She currently is complaining of slight dizziness and nausea, although she has had no emesis. Her blood pressure is 135/86; pulse, 112; and respirations, 24, which are higher than they have been running. Her temperature is 98.8° F. She has no drug allergies. How would you like to change her orders?" Holly has prepared the information the physician will need and communicates it in an orderly fashion. The issue of gender differences deserves special consideration in health care. Most nurses are women, whereas male physicians significantly outnumber female physicians (Heim, 1995). The current gender mix in medical schools is approaching 50-50 (Heim, 1995), although a number of years will pass before that balance permeates the population of practicing physicians. Unfortunately the general public continues to view nurses and physicians somewhat stereotypically—the female nurse as the helper of the male physician. Consequently, the health care arena is almost "set up" to experience increased problems associated with differing communication styles between genders. Dealing with resultant conflict is discussed later in the chapter.

Cultural Diversity

Although Chapter 11 is devoted to cultural and social issues, it is important to highlight cultural issues specific to communication. Sensitivity to cultural differences is an integral part of the nurse's responsibility. Many cultural beliefs are tightly interwoven with strong religious convictions. Societies throughout the world depend as strongly or even more strongly on a variety of alternative healing sources as they do on medical science. Some people rarely have an opportunity to interface with medical science as it is known in the "developed" countries. The obvious difficulty is a potential language barrier. Even if the person speaks English as a second language, the preponderance of slang terms and colloquialisms can confound a literal translation. In addition, the stress associated with illness and possibly hospitalization only adds to the potential for misunderstanding and frustration. Fortunately most communities have interpreters willing to translate in the health care setting. The variety of language interpreters (including sign language for the deaf) available even in smaller communities is surprising. Although many persons of various cultural backgrounds willingly access the health care system, they concurrently adhere to the beliefs and traditions of many generations of their ancestors. Health customs often involve a faith healer and the use of alternative treatments such as herbal remedies, rituals, and blessings. Attributing healing powers to material objects such as stones, statues, or blessed water (whether in containers or rivers) is not uncommon. Latasha Williams, RN, an intensive care unit nurse with many years of experience, recently relocated to the southwestern United States. On entering the room of a septic patient, she observed a family member slowly moving an egg above the prone body of the patient. Latasha was shocked at the peculiar behavior, hardly knowing how to respond. Because other family members encircled the bed in what appeared to be an almost prayerful stance, Latasha quickly backed out of the room and went to the nurses' desk. Sitting down with a stunned expression, she said to a colleague, "Manuel, you will never believe what I saw in your patient's room when I went in to check the monitor alarm." Latasha proceeded to describe the scene. Manuel Garcia, RN, chuckled and responded, "Latasha, the family is removing the patient's fever. The egg will absorb the fever and help make the patient well." "You have got to be kidding," snapped Latasha. "What kind of hocus-pocus is that?" "It is part of faith healing." Manuel looked irritated. "Surely you do not believe in such a thing. Why don't you stop them and teach them what will really help the patient? We're supposed to teach patients and their families real health care." Latasha was incredulous. "How can we judge what part faith plays in healing? I have taught the patient and family about sepsis and explained every procedure and treatment. They have expressed an understanding of what we are doing and how it is helping. Their use of the egg to remove fever is not disrupting patient care. They're not even touching the patient! Don't you think that in this case nontraditional healing practices and medical science can combine for the best treatment of the patient and the family?" Latasha's reaction to a behavior unknown to her is neither surprising nor unusual. Her commitment to patient teaching to promote understanding of the medical beliefs she embraces as a nurse is exactly as it should be. However, Manuel's approach to tolerance of cultural healing beliefs while delivering competent, scientific nursing care is vastly more sensitive. The balance between alternative healing and medical science sometimes is precarious. Maintaining equilibrium with quality patient care at the center requires knowledge and perceptivity.

Many forms of communication do not carry the same meanings in various cultures. In some instances direct eye contact is to be avoided if possible. Touch, also considered a positive communication technique in Western culture, may be perceived as a serious invasion of privacy. Some gestures considered innocuous in one culture may represent vulgarity in another. Some cultures strictly adhere to paternalism; unless the male head of the family agrees to a procedure or treatment, the family member will refuse under any circumstance. Although a sense of modesty is shared by many people, some cultures experience a greater feeling of violation at having to expose certain body parts than do others. The consumption of certain foods, the use of blood or blood products—the possibilities of culturally diverse practices are endless. The prudent nurse will become familiar with the specific cultural practices in the region of her or his employment. Assertiveness vs. Aggressiveness There is a clear distinction between the terms assertive and aggressive. Aggressiveness implies an inclination to start quarrels or fights, whereas assertiveness connotes a style of positive declaration, a persistent demonstration of confidence. The difference becomes obviousaggression conveys dominance, assertion conveys confidence and competence. The line between the two behaviors can easily become blurred if one or both parties direct or receive controversial comments personally. A review of the vignette involving Donald and Laura ("I Messages") provides an example of how easily a conversation can be perceived as a personal attack and escalate into aggressive behavior. All of the positive communication techniques and styles that have been discussed must be used to produce assertive rather than aggressive communication. To speak assertively, the person must be sure of the facts, have carefully considered the options, and exude confidence while making the observation, request, or point. Aggressive behavior often leads to conflict and seldom to resolution or effective communication.

The Transdisciplinary Team

The transdisciplinary team is composed of a variety of disciplines approaching health care from the unique perspective of the theories and therapies of the individual profession. Consider the variety represented by nurses, physicians, dietitians, respiratory therapists, pharmacists, physical therapists, psychologists, and social workers. Then add to the mosaic the sublevel of specialists: cardiologists, endocrinologists, oncologists, orthopedists, recreational therapists, occupational therapists, licensed vocational (or practical) nurses, registered nurses, nurse anesthetists, nurse practitioners, nurse scientists, and unlicensed assistive personnel. Registered nurses with varied educational backgrounds (diploma, associate degree, bachelor or master of science in nursing) and licensed vocational nurses sometimes can be found in the same unit with similar assignments. Now add managers, administrators, clerical staff, accountants, and housekeeping, to name a few. Also consider cultural differences among health care professionals and workers. Is it any wonder that communication disasters occur? All of the positive communication techniques have to be used to clearly understand another's perception. Listening is an essential tool for determination of the intended message as seen from the unique perspective of the other discipline. Frequent clarification and a sense of "safety" are paramount as people explore the meanings that each person attributes to the situation and the discipline-specific suggested solutions. Realization that the fundamental basis of all health care professionals and of ancillary staff is to provide quality patient care should keep all interactions focused on a common goal.

Confidentiality and Privacy

No discussion of communication would be complete without reference to the proverbial "grapevine," which, despite consistent efforts to the contrary, appears to be alive and well. Breach of confidentiality and the patient's right to privacy through careless gossip has ethical and legal ramifications. Thoughtless conversation in the elevator, the dining room, the parking lot, or any other public place has created heartache for the client and the health care provider. Other sites where communication about confidential or personal patient issues needs to be controlled include the nurses' station, any desks or tables along the halls commonly used for charting, and the utility rooms. Such locations are not often viewed as "public" places, but many people pass by these areas and overhear information they should not, especially during change-of-shift reports. Unfortunately there is a great curiosity among people regarding illness and health care issues, and some people may linger in these areas to glean information. In some circumstances diagnoses carry major social implications that can easily lead to prejudicial treatment in terms of employment, insurance coverage, and social standing. The nurse is bound by the ethics of the profession and the laws of the United States to protect the patient and the patient's family from improper disclosure of personal information. To carry the concept a step further, the nurse is limited in the type of information that is appropriate to access. In the age of informatics, more information is available, literally at the fingertips. For example, accessing the record of an acquaintance simply to know "what's going on" with the patient is an absolute infraction of ethical and legal standards. The professional nurse is obligated to know only information that will facilitate quality physical, spiritual, and emotional care to his or her assigned patients. Satisfying curiosity beyond the legitimate requirements of providing care, engaging in gossip, or otherwise compromising the patient's confidentiality is a grievous breach of nursing standards.


Although an entire chapter is dedicated to delegation, the importance of effective communication in the delegation process cannot be overemphasized. Hansten and Washburn (1992) suggest that communication is frequently the primary stumbling block to the successful completion of a delegated task. Work satisfaction from the point of view of the delegatee is negatively affected by ambiguity and lack of courtesy (Hansten and Washburn, 1992). The delegation of duties requires a thorough explanation of exactly what is expected in terms of what is to be done, as well as any other information not likely to be known to the delegatee. Such information might include the location of supplies needed, time frame for completion of the work, how to document properly (if applicable), and who is available to answer questions or provide assistance if needed. Solicitation of verbal feedback for assurance of understanding can avoid complications that may result from delegation. The use of everyday courtesies such as "please," "thank you," and "you're welcome" helps establish rapport in a situation that sometimes lends itself to the development of interpersonal friction. Establishing an interaction as a win-win situation and demonstrating intent to be available enforces a sense of collegiality and team work.



1. When a conversation is obviously escalating, try to move to a more private location.

2. Speak in a normal tone of voice.

3. Use "I messages."

4. Maintain eye contact (keeping cultural differences in mind). This may be difficult, but it conveys to the other party that you are confident and competent.

5. Maintain an open body stance with your hands at your side or open toward the person (but not invading the other person's space). Do not cross your arms, tap your toe, wag your finger, or perform any body language that is commonly associated with anger.

6. Do not physically back away unless you perceive you actually are in physical danger. By standing your ground, your carriage will convey the message of assurance.

7. Offer explanations, but do not make excuses.

8. If you say you will take care of something, report something, or change something, do it. Then seek out the person to whom you made the commitment and report your action and the result. Little else will go as far as demonstrating that you are dependable and want to work toward a solution.



The many styles of communication, varying beliefs and traditions, and even a level of "turf protection" can lead to misunderstandings. The stress inherent in the care of the sick, injured, and dying only adds to the likelihood that disagreements will occur.

Box 17-4
presents some basic principles that can augment professional response to verbal conflict. For the most part, verbal conflict is the result of poor communication, distraction, or varying perspectives. However, some persons use verbal abuse as a tool. Whether the behavior is meant to draw attention, express anger, build a sense of power, or accomplish any other equally inappropriate objectives often is immaterial. Problems can be solved without demeaning another human or creating an unpleasant scene. The principles listed are remarkably effective in cases of verbal abuse. Considered together, the principles demonstrate a person of confidence, assurance, and competence who will not react to inappropriate behavior in like form but also will not withdraw from the issues. As always, the focus should be kept on the delivery of quality patient care.


The discipline of nursing is recognized as a profession because of the standards of advanced education, licensure, intellectual challenge, and commitment to the greater good of humankind. The professional nurse will touch many lives during a career of caregiving, teaching, and leading. Through capable role modeling for patients, families and significant others, nurse colleagues, other health care professionals, and students, the professional nurse can facilitate positive health practices in unlimited numbers of people—just as the ripple of a stone thrown into a stream creates an ever-widening circle. The nurse who astutely uses positive communication techniques, provides a safe environment for a patient to ask questions and learn, and focuses energy toward the resolution of conflict has the opportunity to bring the best of nursing to the most of humanity. Through clear, open, sensitive communication, nurses portray the consummate professional image.


The first attempts at communication begin shortly after birth and continue throughout life. Effective communication is an essential part of competent professional nursing care. Historically nurses recognized communication to be integral in the duties of the caregiver. Communication has three basic components: the sender, the receiver, and the message. Subcomponents consist of interpretation, filtration, and feedback. Interpretation of messages involves such factors as context, environment, precipitating event, preconceived ideas, personal perceptions, style of transmission, and past experiences. Communication can be verbal and nonverbal. If the verbal and nonverbal messages do not match, most people will believe the nonverbal message; they will be correct in that belief most of the time. Positive communication techniques include the development of trust; use of "I messages," eye contact, empathy, open communication style, clarification, open body language, and touch; and commitment to keeping promises. Listening is an essential element in efficacious communication. Negative communication techniques include closed communication style, closed body language, blocking, false assurances, and conflicting messages. There are many differences in communication styles. Such variances include gender differences, cultural diversity, assertiveness vs. aggressiveness, and dissimilarities in the professional approach of various health care disciplines. Other concepts pertinent to communication within the health care arena include written communication techniques, the patient's right to confidentiality and privacy, delegation, and the skill of dealing with verbal conflict. As a professional, the nurse must be committed to quality patient care. An essential component of quality care is the ability to communicate clearly and to listen well. The strong public image of the nurse is that of nurturer, caregiver, teacher, and leader. The development of effective communication skills can only enhance each nurse's professional image while building strong relationships with patients and colleagues.

Critical Thinkingc/Ictwities

1. You have been assigned to care for Rhonda, a young wife and mother who was admitted through the Emergency Department last night with significant abdominal pain. As you inquire about her symptoms, she repeatedly glances at her husband,Tommy, before she answers. Although she denies any pain at this time, you observe that she guards her stomach, has a "clinched" jawline, and does not make eye contact with you. Her skin is warm and slightly diaphoretic. As you assess and question Rhonda, Tommy often interrupts with comments such as, "She's just fine. It was only a big stomachache, and it's gone this morning, isn't it, dear?" You suspect that Rhonda is experiencing pain but is reluctant to increase her husband's obvious concern. How will you address the nonverbal cues? How will you evaluate the conflicting cues? What strategies will you use to enhance communication with this couple?

2. Dr. Blademan, whom you recently paged to report an abnormal laboratory result, approaches you shouting angrily, "Why did you page me with that report? You know I make rounds in the evenings, and I would have been here soon." You attempt to explain that the client was symptomatic, that the abnormal laboratory result was high enough to be labeled critical value, and that you believed prompt reporting was in the best interest of the client. You also are thinking about the fact that "in the evening" could be anytime from to for this particular physician. Nothing you say in defense of your decision appeases the physician, who has digressed to general statements about the lack of consideration that nurses give doctors. What do you perceive to be the true message here? How will you respond to the physician's comments? What techniques can you use to prevent the situation from escalating? If the situation continues to escalate, what would be your next course of action?

3. You are talking with Mr. Phillips about his new diagnosis of diabetes mellitus. You state, "Mr. Phillips, I noticed that the diabetic educator was in to talk with you this morning. What did you talk about?" His response is, "Oh, she told me about the special d i e t . . . you know . . . no sugar and that stuff. But I'm going to tell you now that I drink sodas, and nobody is going to take those away from me!" You comment, "Have you tried diet sodas?" to which he responds, "Are you kidding? That stuff tastes like crankcase oil! I'm not using any of that sweetener stuff!"The conversation continues along the same lines, indicating a lack of commitment to healthy self-regulation on his part. What will you do? It appears that Mr. Phillips is resistant to the restrictions of his new diagnosis. What additional resources can you use to help interpret his health beliefs? What techniques will you use to clarify the issues he must address?





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