Communication & Collaboration in Nursing
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
Defined
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
Defined
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.
7.
Environment.
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.
Transformational Leadership
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.
Management Theory
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.
Organizational Theory
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).
MANAGEMENT FUNCTIONS
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.
Planning
Planning Questions
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.
The mission statement, the foundation of planning
for any organization, describes the purpose of the organization and the reason
it exists. Most health care organizations exist to provide high-quality patient
care, but emphasis may be on different concepts such as research, teaching,
preventive care, spiritual care, or community service. The philosophy is the
set of values and beliefs that guides the actions of the organization and thus
serves as the basis of all planning. The philosophy statement should speak for
the primary mission of the organization and reflect the values of the
organization, any special approaches to care, and/or any particular beliefs
regarding patients and/or employees (Marquis and Huston, 1998). New nurses
should be aware of the mission and philosophy of the employing organization and
understand the relationship between their own personal value system and that of
the organization.
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.