Nursing Leadership and Management (Luansing)

This can also be found under my summary of Luansing’s PALMER review book.

Nursing Leadership

Leadership is the process of persuasion and example-setting of an individual to influence a group to take action in accordance with their common goals, and achieve desired objectives. This process may be formal or informal based on appointment or status of the leader or de-facto leader. This process may be achieved through:

1. Rationalization
2. Coercion
3. Exchange
4. Blocking
5. Assertion
6. Ingratiation

Elements of Nursing Leadership

1. Leader: the influencer.
2. Followers: the members who are duty-bound to follow and respect the leader.
3. Group: the combination of the leader and their followers.
4. Process: the means, style, formulas, and policies used by the group to reach their common goals.
5. Goal: the purpose, objective, or reason of a group.

Theories in Leadership

• Great Man Theory: the prospect that leaders are born; that experience is less significant in what makes an individual a good leader. The characteristics of a leader are inherent and is not something that can be developed easily.
• Trait Theory: certain traits, such as personality, intelligence, and abilities, make a leader. Individuals should strive to attain and develop these traits to become an excellent leader.
• Charismatic Theory: the driving force of leadership is charisma.
• Situational Theory: the greatest leader depends on the contexts and attributes of the situation; leadership is a “case-by-case” basis.
• Vroom-Yetton Expectancy Theory: a model of decision-making where the leader determines the amount of participation by followers depending on the situation.
• Contingency Theory: the most appropriate leadership style is contingent on situational factors.
• Transformational Leadership Theory: the utilization of group empowerment to allow for success.
• Transactional Leadership Theory: the utilization of policies, rules, or other written documents for objectives. Performance is important and rewarded or sanctioned.
• Fielder’s Theory: the style utilized by a leader must match the situation it is being used in. (to-do: differentiate from contingency theory)
• Path-Goal Theory: the leader is the one to set a path and traverse it along with his followers in achieving a goal, e.g., setting clear directions for a certain objective.

Leadership Styles

1. Authoritarian; Autocratic; Dictatorial; “Hard” Leadership: a leadership style that focuses all power towards those in authority or higher positions. Decision-making is done without the influence of the followers or members of the group.
   • Leaders that utilize this style are often task-oriented and insensitive, and subject to dissatisfaction. They often display characteristics like a commanding, boisterous voice; a unilateral approach; a demanding attitude; a hostile personality; exploitative means; and demands no inputs or intervention from others.
   • This style may only become effective in emergent situations.
2. Permissive; Ultra-liberal; Laissez-Faire; “Free-rein” Leadership: a leadership style opposite to a hard leadership, where freedom is freely given to the group, and results are often poor. Decision-making is light on all members of the team and no single individual holds initiative for action.
   • Leaders that utilize this style receive criticism for not taking on major responsibilities, and members often exercise vast and even leadership functions to compensate.
   • This style is dangerous in health care settings because of the risk of malpractice. It may only be utilized if all members of the team are well-trained or skilled.
3. Democratic; Participative Leadership: the “mutual” style, where the leader exercises his powers and control to all members but allows for the participation of subordinates in the decision-making process. In this style, both the goals of the group and the welfare of its members are valued.
   • This style of leadership is highly valuable as it allows for highly flexible and cohesive group functioning.

The Powers of a Leader

1. Legitimate Power: all powers vested upon the leader along with his position or rank; power formalized and sanctioned by the institution itself.
2. Expert Power: the power of control based on the exceptional expertise a leader that is not ordinarily found in other members of the staff.
3. Referent Power: power obtained from the admiration and respect of members based on special characteristics (e.g. charisma) of the leader.
4. Connection Power: the ability to influence others based on linkages to other influential or powerful individuals.
5. Reward Power: the positive power of a leader to incentivise actions or achievements, such as with bonuses, awards, promotions, or transfers.
6. Coercive Power: the negative power of a leader to use duress to gain control, such as with reprimands, termination, and penalties.

Skills and Qualities of a Leader

Authority

Authority is the legitimate right of a leader to exact obligations from his subordinates. The abilities of a leader to delegate tasks to his subordinates for its compliance and discipline for its non-compliance.

• Accountability is the legal liability arising from any omission or improper performance of any task or responsibility.
• Responsibility is the personal or professional obligation and dependability to perform a specific task.

There are two ways of delegating authority:

1. Centralized Authority: only individuals occupying administrative or top-level positions obtain the right to authority.
   • Ex.: staffing patterns and schedules is solely given to the Office of the Nursing Director, and they issue notices to inform all subordinates and demands immediate compliance.
2. Decentralized Authority: authority itself is delegated to the operational level or even to ordinary personnel. This encourages full participation, better communication, representation, and relationship in a group.
   • Ex.: before the approval of a staff pattern or schedule, the Nursing Director requests unit managers for the type of schedules and patterns applicable for their respective units, where the unit manager then consults their subordinates. The Director then simply approves the submitted plans for each unit manager.

Behavior

Behavior affects leadership. It is required that a leader must possess a behavior that is group-centered:

1. Vision
2. Integrity
3. Patience
4. Passion
5. Direction and Purpose
6. Ability to Motivate
7. Ability to Listen
8. Trustworthy
9. Critical Thinker
10. Intelligence
11. Self-Confidence
12. Flexibility

Communication

The transfer of information with understanding from one person to another. This is used for Therapeutic Relationships, and occurs with four phases:

1. Pre-interaction: prior to any initial contact with a client, where all relevant and necessary information related to the client are collected and reviewed prior to any initial meeting. The data obtained could be either primary or secondary depending on its source.
2. Orientation: the initial meeting between the client and caregiver, where rapport and trust are established.
3. Interaction/Working: the caregiver and client communicate and work together in order to determine, plan for, and intervene with the client’s problems for the fulfillment of the client’s needs.
4. Termination: the client’s needs are met and the relationship is terminated.

Communication undergoes a cyclic process. The sender produces a message, encodes it via a means to deliver the message (verbal, nonverbal, written), and transmits it to the receiver. The receiver then decodes the message, then produces a message in return (feedback) to the initial sender.

1. Sender/Encoder: the initiator of the communication process in order to transmit information.
2. Message: the actual meaning sent.
3. Encoding: the form the meaning takes in order to be delivered. This may be verbal, non-verbal, written, etc.
4. Transmission: the actual transference of data.
5. Receiver: the recipient of the message, and the one to decode (interpretation, perception, understanding of the message).
   • Decoding a message may meet barriers (alterations in the intended message) by various environmental, social, or cultural obstacles (Noise) like language barriers, physical noise, perceptive biases, etc. Discussed later in this section.
6. Feedback: the response or alteration in behavior of the receiver as a reaction to the received message.

There are various types of communication behaviors utilized for the delivery of various kinds of data:

1. Aggressive-Type Communication: loud, inappropriate, and confronting behavior utilized by hostile, egotistic, and sarcastic individuals.
2. Passive-Type Communication: shy, quiet, uninvolved, apologetic, repressive, and easily manipulated individuals use this form of communication.
3. Assertive-Type Communication: a balance of aggression and passivity, altering the dominance of one or the other depending on the needs of the context wherein communication is necessary. They may display the following characteristics (mn. FEW RIGHTS):
   • Facial Expressions are appropriate to the scenario and people.
   • Eye Contact is proper.
   • Well-Modulated Voice, tone, and intonation.
   • Respectful in communication.
   • Ideal in all situations.
   • Gestures are used appropriately.
   • Honest
   • Truthful
   • Spontaneously responsive

Effective communication utilizes various techniques:

1. Offering Oneself
2. Focusing on the Client
3. Clarifying
4. Summarizing
5. Open-ended Questions
6. Conveying Acceptance
7. Supporting
8. Providing Information
9. Reflecting

Communication may be “blocked” by various barriers:

1. Psychological Barrier: psychological states like panic, phobias, extreme anxiety, grief, loss, intense fear, aggression, or other emotional disturbances can alter the perception or even reception of messages.
2. Environmental Barriers: noise, distance, and space, etc.
3. Disinterested Listeners: a lack of interest in the sender’s messages interrupts the meaningful transference of information, even if the message is physically heard by the receivers.
4. Semantic Barriers: multiple interpretations may be obtained from a single message due to ambiguity, lack of tone indicators, or the decoder.
5. Physical Barriers: defects in speaking, seeing, listening, or cognition of the message.
6. Others include non-legible handwriting, differences in dialect, use of jargon, etc.

Channels of Communication:

1. Downward Communication: top-level positions that transmit messages down to subordinates, e.g. imposition of a new staffing pattern for all nursing personnels.
2. Upward Communication: operational-level messages transmitted to the top-level positions, e.g. an appeal for an increment in wages and compensation from staff nurses.
3. Lateral Communication: communication between equally-positioned individuals in the hierarchy.
4. Diagonal Communication: the flow between different hierarchal levels but without a direct supervisor-subordinate relationship.

Decision Making

Decision-making is the process of providing resolutions of conflicts or problems by careful analyses of all possible information, data, or alternative solutions. This occurs in stages, almost similar to the nursing process, but where diagnosis occurs first (identify the problem and individuals affected), followed by assessment (gather all pertinent data), then PIE:

1. Identify the Problem with the group.
2. Determine the People Affected
3. Gather All Pertinent Data
4. Brainstorm All Possible Solutions
5. Choose the Best Solution
6. Implement the Chosen Solution
7. Develop a Criteria for Evaluation of the solution’s effect on the problem.
8. Evaluate the Solution Using the Criteria

Ethical

A leader is ethical. They must have good manners and the right conduct. They display appropriate behaviors, morality, and conscience in guiding and motivating other members of the team to function conscientiously.

Conflict Resolution

Conflict is the clash of ideas resulting in a potential crisis. These must be resolved by leaders as conflict hinders the achievement of common objectives. Conflict occurs in three contexts: Intrapersonal, occuring within an individual; Interpersonal, occuring between individuals; and Organizational or Interdepartmental, where conflict arises between two units, departments, or groups.

Conflict resolution utilizes different methods:

1. Avoidance: the problem is avoided by the leader.
2. Bargaining/Compromising: something is given up to gain something else; both parties gain something and lose something. They attempt to meet half-way their respective demands, and do their best to equally benefit all parties i.e. “We both win some and lose some”.
3. Competing/Unilateral Action: the side with an advantage takes the opportunity to exploit the other party, i.e. “I win, you lose”.
4. Smoothing/Accommodating: a party appeases the other party by using conscientious efforts or kindness. This may not resolve the conflict, producing a temporary result.
5. Negotiation: the most advisable solution; both parties recognize the problem and mutually look for a solution acceptable to both.

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Nursing Management

Management is a process for the accomplishment of organizational objects using both interpersonal and technical aspects, and using resources efficiently and effectively. A manager coordinates actions and resources available to achieve organizational goals and outcomes.

Theories in Management

• Frederick Taylor’s Scientific Management Theory: management work can be scientifically done to be able to increase work production or output. It may be summarized as follows:
  • Selection of workers
  • Training of selected workers
  • Provision of adequate tools for workers
  • Proper treatment or evaluation
• Human Relations Theory: effective management arises from good working relationships between the manager and laborers, and among the laborers themselves.
• Douglas McGregor’s Motivational Theory: a manager may have two classes of workers:
  • Theory X: a “negative” type of worker that dislikes work and avoids responsibilities. They require duress to perform obligations. A high level of motivation is required for them to work.
  • Theory Y: a “positive” type of worker that are reliable and gives importance to their job for the best results. These workers are responsible, diligent, and trustworthy. They productively utilize time, energy, and efforts.
• Henry Fayol’s Principles of Management: fourteen principles of management are outlined.
  • Division of Work:
  • Proper Authority, Responsibility, and Accountability:
  • Unity of Command:
  • Unity of Direction:
  • Remuneration of Personnel:
  • Balance between Centralization and Decentralization:
  • Subordination of Personal Interest with General Interest:
  • Scalar Chain/Chain of Command:
  • Security of Tenure:
  • Esprit de Corps; Team Spirit:
  • Span of Control:
  • Channels of Communication:
  • Respondeat Superior; Command Responsibility:
• William Ouchi’s Theory Z: management is a shared relationships between the manager and their members. A participative form of management is utilized.
• Total Quality Management: TQM; effective management involves a collective approach of the whole organization with the aim of providing quality and continuous client satisfaction based on resulting data.

Management Process

Planning

Planning involves no actual or physical tasks, and is merely a management tool used to conceptualized what is to be done in a future time. It is a future projection of the group’s goal and allows for the team to decide (form a blueprint) in advance. There are different types of plans:

• Standing/Operational Plan: a plan used for regular or daily activities.
• Strategic/Contingency Plan: a plan used during emergencies or crises.
• Long-Term Plan: a plan utilized and revised or amended as necessary over weeks, months, or even years to accomplish and evaluate.

Planning involves multiple elements that outline the organization’s concept:

• Mission: the present reason for establishing the organization, and the actual function and purpose of its existence.
• Vision: what the organization wishes to achieve in the future; the prospective reason for its establishment.
• Philosophy: the set of values and beliefs in an organization to promote unity in the fulfillment of their respective goal.
• Goal: the general statement of the purpose of the organization.
• Objective: the specific and measurable statement of the purpose of the organization.
• Policies: a general statement on the course of action to be undertaken in fulfilling the organizational goals.
• Procedure: the specific statement of a step-by-step process in undertaking the goal of the organization.
• Rules: punitive steps in the event of any misdemeanor or omissions in the organization.

Budgeting is a tool used by a nurse manager during planning when allocating future resources in their respective health care units.

• Personnel Budget: allocated expenses for compensation and remuneration of staff or workers, and is the most important budget.
• Operational Budget: allotted expenses for day-to-day activities undertaken by an institution to operate, e.g. electricity, medical-surgical supplies, and other equipment for short-term use.
• Capital Budget: capital expenditures; major equipment and facilities that can be utilized for long periods of time. It is the most expensive form of budget.
• Other forms include a zero-based budget (all expenses equal all income), fixed-ceiling budget (a budget is set and does not move despite any changes in activity), and flexible budget (budget depends on organizational activity).

Organizing

Organizing is a management tool that determines the right people and their tasks to perform to achieve common objectives. It normally utilizes an Organizational Chart that structurally outlines the various parts and areas of an organization, and how they are interrelated with one another. It determines organizational control, the policy and decision-making process, and evaluates the strong and weak areas in an organization.

Staffing is a tool to determine the appropriate and adequate ratio of health care personnel to perform their respective organizational tasks for the benefit of the clients. These are schedules which the staff follows, and take various forms/types:

1. Traditional: an 8-hours/day schedule (40 hour week)
2. Non-Traditional: >8 hours/day schedule
3. Baylor Plan: the division of a schedule to both traditional and non-traditional schedules (8 hour shifts during weekdays, 12 hour shifts during weekends)
4. Part-Time: flexible (elective) and shorter schedules
5. On-Call: the worker may be called to work when necessary, but is otherwise off-work.

Staffing can take on different patterns, depending on how schedules are decided/change:

1. Centralized Staffing Pattern: schedules are decided and approved by top-level administrators.
2. Decentralized Staffing Pattern: schedules are discussed and submitted by unit managers to administrators, who then approve the schedules.
3. Permanent Schedule: an unchanging schedule.
4. Self-scheduling: the operational-level workers decide on their shifts.
5. Cyclical: definition needed

Nursing Care Delivery Methodologies enumerate the methods that a nursing staff team can respond to patient needs:

1. Case Method: total patient care is given by an individual nurse to a specific case or diagnosis of a client. The nurse informs the nurse-manager regarding the patient’s concerns (private duty nurse).
2. Functional Method: also commonly known as “task-based nursing”, wherein nurses are assigned specific tasks for patients. It is the poorest method of nursing care delivery, but is highly utilized when nurses are scarce or patients are abundant.
3. Team Nursing: teams are formed from the group, and appoint a team leader or “charge nurse”. They assume responsibilities from the nurse manager for their members, and coordinates and supervises all the care provided by members of the team.
4. Primary Nursing: direct patient care formulated by a primary nurse (and their team, if also utilizing team nursing) from the moment of admission until discharge. This is practically 24-hour continuous care, and demands an increase in accountability, responsibility, planning, communication, and coordination.

Directing/Delegation

Delegation is a management function wherein a task, procedure, or obligation is done by another person who accepts it. Effective delegation is done by:

1. Determine the task to be delegated.
2. Choose a delegee to perform the task.
3. Match staff competency with the task. There must be capacity and acceptance to perform the delegated task.
4. Provide open and continuous communication with the delegee.
5. Obtain constant feedback and evaluation from your subordinate during and after performing the task. As such, only tasks that the delegator can best perform, assess and evaluate may be delegated.

There are many principles and characteristics to follow for delegation to be effective:

• Provide a complete and continuous instruction for the delegated task.

• Assume a face-to-face position and utilize proper eye contact when delegating.

• Provide a calm environment when providing instructions.

• Do not delegate during an emergency situation, as this should normally take time. Rushing delegation may result in errors and miscommunication.

• Responsibilities may be delegated, but not accountability. Any errors by the delegee will be shared by the delegator.

• Delegation should not breach confidentiality.

• There must be a periodic and constant evaluation of tasks completed.

• Give appropriate assistance and supervision.

Coordinating/Collaboration

Quality care is provided by multiple members of the health care team. Continuous communication, relationship, and interaction with other professionals is required for holistic care. There are three kinds of coordination/collaboration:

• Intradepartmental/Interpersonal Coordination occurs within the same unit.
• Interdepartmental Coordination occurs between departments under the same institution.
• Interinstitutional/Agency Coordination occurs between institutions.

Evaluation/Controlling

The final step of the management process wherein the nurse manager determines whether the desired goal was met or achieved in accordance with organizational standards. It also involves management of possible outcome risk. Evaluation can be on-going, intermittent, terminal, or routine. Evaluation can be done through:

1. Self-appraisal
2. Checklist System
3. Peer Review
4. Nursing Audit
5. Performance Appraisal
6. Customs/Client Evaluation
7. Benchmarking
8. GANTT Charting
9. Program Evaluation and Review Technique (PERT)
10. Nursing Rounds
11. Sentinel Event Review