NURSING LEADERSHIP AND MANAGEMENT
During nursing school students are often more concerned with learning and developing clinical knowledge and skills and less concerned with management and leadership skills. However, immediately after graduation the new nurse is placed in many situations that require leadership and management skills—managing a group of assigned patients, serving on a task force or committee, acting as team leader or charge nurse, or supervising unlicensed assistive personnel and licensed vocational/practical nurses. In addition to providing excellent clinical care, the challenges for RNs in the twenty-first century are to manage nursing units that are constantly admitting and discharging higher-acuity patients, motivating and coordinating a variety of diverse health professionals and nonprofessionals, and managing limited resources and shrinking budgets (Belcher, 2000).
Regardless of what position the nurse has or in which area the nurse is employed, the health care organization will expect the professional nurse to have leadership and management skills. Professional nurses in each employment setting are expected to:
• Make good clinical decisions based on quality, cost, legal, and ethical aspects of care.
• Make good business decisions based on the organization's goals.
• Coordinate patient care activities for the transdisciplinary team.
• Promote staff satisfaction, patient satisfaction, and overall unit productivity.
• Provide leadership to maintain compliance with governmental regulations and accreditation standards.
As the reader can easily
visualize, leadership and management activities are a primary responsibility
for the RN. In fact, it has been suggested that the activities of a
professional nurse within the health care organization have more to do with
managing the delivery of care rather than actually providing that care (
Throughout this chapter the term organization is used to refer to the hospital, home health agency, postacute facility, long-term care facility, ambulatory clinic, managed care company, or any other area in which a nurse might be employed to practice professional nursing. Legal and ethical issues are a critical component of nursing management, although it is not within the scope of this chapter to discuss these issues. The reader is encouraged to review Chapter 8 regarding legal issues and Chapter 9 regarding ethical issues.
LEADERSHIP AND MANAGEMENT DEFINED AND DISTINGUISHED
Leadership occurs any time a person attempts to influence the beliefs, opinions, or behaviors of a person or group (Hersey and Blanchard, 1988). Leadership is a combination of intrinsic personality traits, learned leadership skills, and characteristics of the situation. The function of a leader is to guide people and groups to accomplish common goals. For example, an effective nurse leader is able to inspire others on the health care team to make patient education an important aspect of all care activities.
It is important to note that leaders may not have formal authority granted by the organization but are still able to influence others. "A job title alone does not make a person a leader. Only a person's behavior determines if he or she occupies a leadership position" (Marquis and Huston, 2000, p. 4). Leadership ability may be related to qualities such as unique personality characteristics, exceptional clinical expertise, or relationships with others in the organization.
Management refers to the activities involved in coordinating people, time, and supplies to achieve desired outcomes; it involves problem-solving and decision-making processes. Managers maintain control of the day-to-day operations of a defined area of responsibility to achieve established goals and objectives. Managers plan and organize what is to be done, who is to do it, and how it is to be done. A nurse manager will have:
• An appointed management position within the organization with responsibilities to perform administrative tasks such as planning staffing requirements, performing employee performance appraisals, controlling use of supplies and time, and meeting budget and productivity goals.
• A formal line of authority and accountability to ensure that safe and effective patient care is delivered in a manner that meets the organization's goals and standards.
Leadership vs. Management
Although leadership and management are intertwined concepts and it is difficult to discuss one without the other, these concepts are different. Leadership is the ability to guide or influence others, whereas management is the coordination of resources (time, people, supplies) to achieve outcomes. People are led, whereas activities and things are managed. Leaders are able to motivate and inspire others, whereas managers have assigned responsibility for accomplishing the goals of an organization. A good manager also should be a good leader, but this may not always be the case. A person with good management skills may not have leadership ability. Similarly, a person with leadership abilities may not have good management skills. Leadership and management skills are complementary; both can be learned and developed through experience, and improving skills in one area will enhance abilities in the other.
Power and Authority
Leadership and management require power and authority to motivate people to act in a certain way. Authority is the legitimate right to direct others and is given to a person by the organization through an authorized position such as nurse manager. For example, a nurse manager has the authority to direct staff nurses to work a specific schedule. Whereas authority is the formal right to direct others granted by the organization, power is the ability to motivate people to get things done with or without the formal right granted by the organization. Power originates from several sources as defined by Marriner-Tomey (2000):
1. Reward power comes from the ability to reward others for complying and may include such rewards as money, desired assignments, or the acknowledgment of accomplishments.
2. Coercive power, the opposite of reward power, is based on fear of punishment for failure to comply. Sources of coercive power include withheld pay increases, undesired assignments, verbal and written warnings, and termination.
3. Legitimate power is based on an official position in the organization. Through legitimate power, the manager has the right to influence staff members, and staff members have an obligation to accept that influence.
4. Referent power comes from the followers' identification with the leader. The admired leader is able to influence others because of the followers' desire to be like the leader.
5. Expert power is based on knowledge, skills, and information. For example, nurses who have expertise in areas such as physical assessment or technical skills or who keep up with current information on important topics will gain respect and compliance from others.
6. Informal power is based on personal characteristics. Informal power may result from personal relationships, connections with people in positions of power, being in the right place at the right time, or unique personal characteristics such as attractiveness, education, experience, drive, or decisiveness.
By understanding the authority of an assigned position and the sources of formal and informal power, the nurse manager will be better able to influence others to accomplish goals.
Formal and Informal Leadership
Both formal and informal leadership can exist in every organization. Formal leadership is practiced by the nurse who is appointed to an approved position (e.g., nurse manager, supervisor, charge nurse, coordinator) and given the authority to act by the organization. Informal leadership is exercised by the person who has no official or appointed authority to act but is able to persuade and influence others in the work group (Sullivan and Decker, 1997). The informal leader, who may or may not be a professional nurse, may have considerable power in the work group and can influence the group's attitude and significantly affect the efficiency and effectiveness of work flow, goal setting, and problem solving.
The nurse manager must learn to recognize and effectively work with informal leaders. Informal leadership may be positive if the informal leader's purpose is congruent with that of the nursing unit and organizational goals. For example, the informal leader of a patient care group may be highly supportive of a new nursing care delivery model being implemented on the unit, and, as a result, the other team members will be more willing to accept the change. However, an informal leader who is not supportive of the nursing unit's goals can create an uncomfortable work environment for the nurse manager and the entire team. Following are some strategies the nurse manager can use to work with informal leaders:
1. Identify the informal leaders in the work team and develop an understanding of their source of power.
2. Involve the informal leader, as well as other staff members, in decision-making and change-implementation processes.
3. Clearly communicate the goals and work expectations to all staff members.
4. Do not ignore an informal leader's attempt to undermine teamwork and change processes; counseling the person and setting clear expectations may be required.
LEADERSHIP AND MANAGEMENT THEORY
Understanding the development and progression of leadership theory is a necessary building block for developing leadership and management skills. Researchers began to study leadership in the early 1900s in an attempt to describe and understand the nature of leadership. Early leadership theory centered on describing the qualities or traits of leaders and has been commonly referred to as trait theory (Stogdill, 1974).
Leadership Trait Theory
Leadership trait theory sought to describe intrinsic traits of leaders and was based on the assumption that leaders were born with certain leadership characteristics. Traits found to be associated with leadership include intelligence, alertness, dependability, energy, drive, enthusiasm, ambition, decisiveness, self-confidence, a spirit of cooperation, and technical mastery (Stogdill, 1974). Although trait theories have been important in identifying qualities that distinguish today's leaders, these theories have neglected the interaction between other elements of the leadership situation. Trait theories also have failed to recognize the possibility that leadership traits can be learned and developed through experience. However, keeping in mind these traits associated with effective leadership, the new nurse can identify areas in which he or she should improve and develop.
Interactional Leadership Theories
Researchers progressed from developing trait theory to studying the interaction between the leader and other variables of the leadership situation. Contemporary theories of leadership such as situational and behavioral theories have attempted to integrate the dynamics of the interaction between the leader, the worker, and elements of the leadership situation, arguing that effective leadership depends on several variables, including (Marquis and Huston, 2000):
1. Organizational culture.
2. Values of the leader.
3. Values of the followers.
4. Influence of the leader/manager.
5. Complexities of the situation.
6. Work to be accomplished.
Situational leadership theory has explored the impact of the situation on the leadership role and suggests that leadership may vary in relation to the situation. The expectations, needs, attitudes, personalities, and developmental level of the leaders and followers will influence the style and effectiveness of leadership. Other aspects of a situation that influence the leadership role include the degree of interpersonal contact, time constraints, organizational structure, physical environment, and influence of the leader outside of the group. Situational theory suggests that a person may be a leader in one situation and a follower in another (Stogdill, 1974). By understanding the various elements that may influence the leadership situation, the nurse can become a more effective leader.
In a contemporary concept of leadership, Burns (1978) identified and defined transformational leadership. Burns contends that there are two types of leaders: (1) the transactional leader, who is concerned with the day-to-day operations of the facility; and (2) the transformational leader, who is committed to organizational goals, has a vision, and is able to empower others with that vision. Studies have reported that, as nurse executives demonstrate more transformational leadership characteristics, they achieve higher levels of staff satisfaction and work group effectiveness. In one large national study of 396 randomly selected hospital nurse executives, Dunham-Taylor (2000) explored nurse executives' leadership characteristics and the relationship to staff satisfaction, work group effectiveness, and the nurse executive's effectiveness as rated by his or her superior. The study results demonstrated that staff satisfaction and work group effectiveness decreased as nurse executives were rated higher on transactional characteristics. The implication for nurse managers is that transformational leadership is very effective in increasing staff satisfaction and work effectiveness. The student is encouraged to read more about transformational leadership and to seek out transformational leaders as mentors.
Behavioral theories emerged to explain aspects of management and leadership based on behaviors of managers/leaders and followers. Three prevalent management behavior styles were identified by Lewin (1951) and White and Lippit (1960): authoritarian, democratic, and laissez-faire. These three management styles vary in the amount of control exhibited by the manager and the amount of involvement that the staff has in decision making. At one extreme the autocratic manager makes all decisions with no staff input and uses the authority of the position to accomplish goals. At the opposite extreme is the laissez-faire manager, who provides little direction or guidance and will forego decision making. Democratic management is also often referred to as participative management because of its basic premise of encouraging staff members to participate in decision making.
Depending on the situation, the nurse manager may need to use different types of management styles. This concept of situational leadership requires consideration of staff members' needs and experiences, the manager's abilities, and the goals and tasks to be accomplished. For example, in a life-threatening situation such as treating a patient in cardiac arrest, autocratic management might be appropriate. However, when structuring the weekend call schedule for a home health agency, a participative style of management would be more effective.
The health care system of the twenty-first century requires the use of a democratic or participative management style that will involve the staff in goal setting, problem solving, and decision making. Health care settings are driven to become increasingly cost-effective while continuing to improve quality, customer satisfaction, and positive patient outcomes. Staff directly involved in the challenges presented by patient care often can suggest the most workable, practical solutions. Problem solving and goal attainment are more likely to be successful when staff are involved in decisions affecting their daily work.
Research has shown that staff nurses'job satisfaction increases as the involvement in decision making and problem solving increases (Moss and Rowles, 1997). The new nurse manager should understand that his or her management style is what the staff perceives it to be, not what the manager has decided to practice. "What the staff perceives as the management style is the management style" (Moss and Rowles, 1997, p. 33). Managers have a responsibility to develop astute self-awareness about their intended leadership and management style and the style that the staff is perceiving. Although there is no one best leadership theory, nurses need to be aware of their own leadership behavior.
Just as leadership and management theories have evolved to provide a framework for understanding these two concepts, organizational theory has evolved to provide a framework for understanding complex organizations. A brief review of bureaucracy theory, systems theory, and chaos theory can provide the reader with insight into the value of using organizational theory to understand the management process within today's dynamic, complex health care organizations.
Weber's Theory of Bureaucracy. Max Weber, known as the father of organizational theory, began his work in the 1920s when he observed the growth of large organizations and predicted that this growth required a formal set of procedures. Weber, in his classic work on defining the characteristics of bureaucracy, argued that its great benefit was in its ability to apply general rules to specific cases, making the actions of management fair and predictable. The basis of Weber's concepts of bureaucracy revolves around explaining authority within organizations. He postulated that authority, thus the right to issue commands within an organization, is based on the impersonal rules and rights granted by virtue of the management position rather than related to the person who occupies that position. Weber's conceptualization of bureaucracy emphasized rules instead of individuals and competency instead of favoritism as important for effective organizations. Other characteristics of organizations identified by Weber include:
1. Managers are chosen because they have demonstrated knowledge, skill, and ability to fill the position.
2. The division of labor, authority, and responsibility is clearly defined.
3. Impersonal rules govern the actions of superiors over subordinates.
4. All personnel are chosen for their competence and are subject to strict rules that are applied impersonally and uniformly.
Although the structure of bureaucracy described by Weber is still present in most organizations today, his work failed to recognize the complexity of human behavior within organizations and the constantly changing environment of today's organizations. As previously discussed, current leadership and management theory (participatory management, transformational leadership) recognizes the importance of supportive, respectful relationships between managers and employees, with employees being involved in decision making and problem solving.
Systems Theory. Systems theory views the organization as a set of interdependent parts that together form a whole (Thompson, 1967). The interdependent nature of the parts of the organization suggests that anything that affects the functioning of one aspect of the organization will affect the other parts of the organization. Open systems theory suggests that not only is the organization affected by internal changes among any of its parts, but also that external environmental forces will have a direct influence on the organization and vice versa—the internal forces will impact the external environment. In contrast to open systems theory, closed systems theory views the system as being totally independent of outside influences, which is an unrealistic view for health care organizations. To be successful, today's health care organizations must be able to continually adapt to both internal and external changes.
Consider the following example to help explain systems theory. The hospital in which Juan Hernandez, RN, works has reduced the number of RNs employed by the hospital and now requires that the remaining RNs work overtime "at the request of administration." The quality of patient care, patient safety, and the individual nurses' professional practice and personal health have been negatively affected by this change. Juan and his fellow RNs seek advice from their State Nurses Association (SNA) about their professional responsibility to work "mandatory overtime." The SNA is responding to the situation, which is occurring more frequently across the state and nation, by proposing legislation to mandate nurse/patient ratios and limit mandatory overtime. The SNA and state government may now require hospital administrators to respond to the need for increased staffing levels.
This example demonstrates open systems theory. As internal forces in one department (hospital administration) mandated changes that affected another area (RNs and patient care), internal forces (RNs) pushed for changes from the external environment (SNA and state government). The external environment may now force changes to the organization (hospital administration).
Systems theory has provided nurse managers with a framework to view nursing services as a subsystem of the larger health care organization and to realize the interrelatedness and interdependence of all the parts of the health care organization. Open systems theory suggests that shared responsibility among all groups is necessary to help patients gain and maintain health and wellness (McGuire, 1999). The nurse manager will be wise to consider open systems theory and the impact a change in one area will have in another area, both internal and external to the organization.
Chaos Theory. Chaos theory is a more recently developed organizational theory that attempts to account for the complexity and randomness in organizations. Despite the implications of the word "chaos," the theory actually suggests a degree of order by helping view com plicated behaviors and situations as predictable. Nurse managers may wish for balanced and steady work environments, but in reality the they are dealing with, what seems at best, a chaotic system. Chaos theory says that variation is a normal part of managing health care systems. Examples of variation in health care are cultural diversity, constantly fluctuating patient census, and staffing shortages. Until nurse managers understand that these variations are a normal, predictable state in the organization, they may continue to experience discomfort and dissatisfaction with their role (McGuire, 1999).
Classic theories of management suggest that the primary functions of managers are planning, organizing, and controlling (Stogdill, 1974). Leaders in nursing management have added two additional functions to this list and now recognize five major management functions as necessary for the management of nursing organizations: (1) planning, (2) organizing, (3) staffing, (4) directing, and (5) controlling (Marquis and Huston, 2000) (Fig. 16-1).
• Planning includes defining goals and objectives, developing policies and procedures; determining resource allocation; and developing evaluation methods.
• Organizing includes identifying the management structure to accomplish work, determining communication processes, and coordinating people, time and work.
• Staffing includes those activities required to have qualified people accomplish work such as recruiting, hiring, training, scheduling and ongoing staff development.
• Directing encourages employees to accomplish goals and objectives and involves communicating, delegating, motivating, and managing conflict.
• Controlling analyzes results to evaluate accomplishments and includes evaluating employee performance, analyzing financial activities, and monitoring quality of care.
These management functions are interrelated; different phases of the process occur simultaneously, and the processes should be circular, with the manager always working toward improving the quality of health care, patient safety, and staff and customer satisfaction. Because understanding these five management functions is essential for success as a nurse manager, they will now be discussed in further detail.
What is the right thing to do for the organization, its customers, and its employees?
What programs or services do customers need or want?
What financial and manpower resources are available?
What goals and objectives can be established to meet customer needs?
How can goals and objectives be communicated throughout the organization?
Planning is the first management function and has been defined as "deciding in advance what to do; who is to do it; and how, when, and where it is to be done" (Marquis and Huston, 1998, p. 49). All management functions are based on planning. Without effective planning, the management process will fail. Effective planning requires the nurse manager to understand the:
• Mission statement and philosophy of the organization.
• Organizational strategic plan.
• Goals and objectives for the entire organization.
• Operational plan for the individual unit or facility.
Strategic Planning. Strategic planning is long-range planning (extending 3 to 5 years into the future) and results from an in-depth analysis of (1) the business, community, and regulatory and political environment outside the organization (external assessment); (2) customer needs; (3) technologic changes; and (4) strengths, problems, and weaknesses internal to the organization. The purposes of strategic planning are to:
• Provide direction for the organization.
• Identify strategies to respond to changes in customer needs, technology, health care legislation, the business environment, or the community.
• Dedicate resources to important services.
• Eliminate duplication, waste, and underused services.
The strategic plan is a written document that details organizational goals, allocates resources, assigns responsibilities, and determines time frames. Responsibility for development of the strategic plan rests with upper-level management, although there is increasing emphasis on including employees at all levels in strategic planning processes. Consider the following example.
Melanie Clements, an RN employed by the Quality Care Home Health Agency, noticed that the office had been receiving several calls per week for home nursing care for pediatric oncology patients. The agency did not provide services for pediatric patients. Melanie reported the situation to the administrator. Melanie soon was involved in gathering information about the number of home health agencies that offered pediatric oncology care, the standards of nursing care recommended for pediatric oncology patients, how many pediatric patients in the area might need such services, and what reimbursement was available for these services. Within the next few months, the administrator for Quality Care Home Health decided that, as part of the agency's strategic plan, a program for pediatric oncology services would be developed.
Goals and Objectives. Goals and objectives state the actions necessary to achieve the strategic plan and are central to the entire management process. Goals should be measurable, observable, and realistic. Objectives are more specific and detail how a goal will be accomplished with an established target date.
Goals and objectives serve as the manager's road map; without them it is difficult to know where one is going. Organization-wide goals will be established in the strategic planning process, and then unit goals that support the organization-wide goals should be developed. Every nurse manager should be able to clearly articulate the organization-wide goals, as well as the goals of the nursing unit for which he or she is responsible. In addition, goals and objectives must be communicated to everyone who is responsible for their attainment. Consider the following case example.