Who are leaders in health care?
nagementBy Stacey Whitney
Essential Questions
· What qualities should a good leader have?
· Who are leaders in health care?
· What is the difference between a leader and a manager?
· What types of leadership styles are observed in the workplace?
Introduction
Nurse leaders are at the forefront of health care and set the standards for nursing practice in terms of delivering safe and efficient patient care. This chapter will review the need for both nursing leadership and nursing management and examine a broad range of theoretical viewpoints and concepts associated with each. Applying the skills necessary for leading and managing staff will be discussed. The process of becoming an effective leader-manager includes developing personal leadership and management preferences, styles, and characteristics. The integration of both leadership and management skills is vital to the long-term success of all health care organizations.
Leadership in Health Care
The Health Care System
·
Nurses have been challenged over time to adapt to the ever-changing health care system. Because of recent events, such as health care reform, decreased government funding, and a growing number of patients to serve, the need for quality patient care that is safe and effective has never been greater. Strong nurse leaders and managers are needed to meet challenges today, throughout the next decade, and beyond. As the nation continues to adjust to health care changes under the Affordable Care Act, nurse leaders must advocate for their patients and influence change in the health care system (Fackler, Chambers, & Bourbonniere, 2015).
The American Organization of Nurse Executives (AONE) has identified the knowledge, skills, and abilities that nurse leaders will need to guide their practice within the health care system today and in the future. Collectively, these competencies include professionalism, communication, relationship management, knowledge of the health care environment, and business skills and principles (American Organization of Nurse Executives [AONE], 2015). Furthermore, AONE outlines knowledge and skills required to meet each competency effectively (see Table 1.1).
Figure 1.1
Nursing Leadership Competencies
A Venn diagram depicts nursing leadership competencies. Leadership is in the center circle, with competencies of communication and relationship management, professionalism, knowledge of health care environment, and business skills and principles encircling and overlapping the center leadership circle.
Note. Adapted from AONE Nurse Executive Competencies, by the American Organization of Nurse Executives, 2015, p. 3.
Table 1.1
Leadership Competencies Identified by American Organization of Nurse Executives
Communication and Relationship Management
Professionalism
Knowledge of Health Care Environment
Business Skills and Principles
Effective Communication
Personal and Professional Accountability
Clinical Practice Knowledge
Financial Management
Relationship Management
Career Planning
Delivery Models – Work Design
Human Resource Management
Influencing Behaviors
Ethics
Health Care Economics and Policy
Strategic Management
Diversity
Advocacy
Governance
Information Management and Technology
Community Involvement
Evidence-Based Practice/Outcome Measurement and Research
Medical/Staff Relationships
Patient Safety
Academic Relationships
Performance Improvements/Metrics
Risk Management
Note. Adapted from AONE Nurse Executive Competencies, by the American Organization of Nurse Executives, 2015, pp. 4-11.
Leadership skills can be studied and learned in courses and seminars, but experience is vital for grasping the fundamentals of excellence in leadership. It is best to learn leadership skills early in one’s career, and then refine and practice those skills over time. Jayson DeMers (2015) identified basic lessons that should be learned early in the profession. When the lessons are applied over time in professional practice, an exceptional nurse leader can emerge:
1. Finding the right people is the ultimate priority.
2. Mutual trust is essential.
3. Adversity is a reality of leadership.
4. Ideas must be grounded in pragmatism.
5. No one has ever learned enough. (DeMers, 2015)
Contemporary Health Care Environments
Contemporary health care environments are influenced by economic, political, and societal changes occurring in today’s world. As these factors and others impact the health care system, nurse leaders should be ready to guide the process with a clear understanding of the health care environment. “As we look ahead into the next century, leaders will be those who empower others.” — Bill Gates This is an ideal opportunity for the nurse leader, who is considered an expert in the health care field, to influence patient satisfaction and improve quality of care. Knowledge of clinical practice should include an understanding of current nursing practice and roles of health care team members. Compliance with the state Nurse Practice Act, state board of nursing, state and federal regulatory agency standards, federal labor standards, and organizational policies is required. The nurse leader should also follow professional association standards of nursing practice. It is best practice to review and update organizational clinical policies and procedures according to evidence-based practice. Bioethical and legal considerations should be included in clinical and management decision making as well. This includes protection of human subject rights and safety in clinical research and study (AONE, 2015).
Health care environment delivery models should demonstrate current knowledge of the patient-care delivery system. The nurse leader should have knowledge of the advantages and disadvantages of various health care delivery systems and the effectiveness of age appropriate patient care models. A nurse leader with this knowledge base should be willing to participate in developing and designing new patient care facilities.
It is vital that the nurse leader understand organizational finance, specifically regulations and payment issues, including the organization’s payer mix. When opportunities to adjust operations arise, the nurse leader should be equipped to respond effectively considering knowledge of federal and state laws and regulations related to patient care. Examples include reimbursement, tort reform, malpractice, and negligence.
Nurse leaders have the power to influence the political process and can make a positive impact by developing relationships with legislators. The nurse leader should be an active participant in the legislative process concerning health care issues and work with others in the profession toward common goals. By utilizing membership in professional nursing organizations, such as the American Nurses Association (ANA) or National League for Nursing (NLN), nurses can collectively have a voice and be recognized by legislators. The individual nurse can become involved as well, simply by writing letters to legislators regarding important issues, and by staying current on pending legislation that directly or indirectly relates to nursing. These issues could be important, as they could affect licensure, practice, and health care in general. Current legislation can be viewed on the U.S. Congress website (www.congress.gov) by using the search term “nurse” (Cardillo, 2016). An explanation of pending legislation should be shared with the health care team so members are well educated regarding how the health care environment might be impacted by proposed legislation (AONE, 2015).
The nurse leader should understand the credentialing and fiduciary responsibilities of the organization’s governing body or board. It may be necessary to represent patient care issues, participate in strategic planning, or represent nursing or other disciplines at board meetings. The nurse leader should be well educated on organizational structure and design when the opportunity presents itself to discuss the value of nursing care for the organization. For example, a nurse leader may present to the board requesting additional resources, such as staff or supplies, and would need to know the organization’s payer base to determine where possible funds may be available.
When decision making as a nurse leader, the use of evidence-based data is necessary for creating standards, protocols, policies, and patient care models within the organization. Supporting the organization’s safety program by monitoring clinical activities, for example, can help to identify risk factors and potential liabilities. The nurse leadership role can be vital in creating teams to improve systems and processes that effect patient safety (AONE, 2015; Marquis & Huston, 2017).
Service and Levels of Care
The purpose of various nursing care delivery systems is to organize ways of providing a service to a select group of patients. Models of patient care vary to meet the needs of patients and nurses. Traditionally, models of care have included total patient care , team nursing , and primary nursing . One model is not superior to another, and all offer advantages and disadvantages to patient care.
Total patient care is an original model in which a registered nurse (RN) is responsible for all aspects of care or service to the patient. This is the oldest form of organized patient care still used in hospitals and home health agencies today (Marquis & Huston, 2017). Advantages include autonomy for the RN and holistic, unfragmented care for the patient. A disadvantage to this model is that it is not cost-effective for RNs to be performing tasks that could be performed by unlicensed assistive personnel (UAPs).
Team nursing, as the name implies, consists of a team of nursing staff that provides total patient care for a group of patients under the direction of a professional nurse. The team typically consists of RNs, licensed practical nurses (LPNs), and UAPs. To ensure duplication of services does not occur, strong communication skills are required for this model to be effective. As an advantage, team nursing allows the nurse leader to recognize the expertise and skills of individual team members and assign responsibilities to them to best utilize the skills of each. Disadvantages include potential confusion of roles and responsibilities resulting in fragmented care and possibly errors.
In primary nursing, the value of the role of the RN in professional practice is not simply as a performer of task-based sets of skills, but implemented so that all care is provided by RNs. In other words, primary nursing requires an all-RN staff. Because of the high cost of implementing this model, it is not operational in many hospitals today (Sullivan, 2012). This form of nursing typically produces high job satisfaction for RNs because they receive a feeling of satisfaction and reward. A disadvantage to this type of care can be seen if the RN providing care is inexperienced or incompetent and does not properly care for the patient with complex medical needs.
Other models of patient care include practice partnership , case management , and critical pathways . These models combine different modalities of care to meet patient care needs. The practice partnership was designed in 1989 by Marie Manthey (Sullivan, 2012). In this model, an RN joins forces with an LPN or UAP to practice as partners with the same schedules and groups of patients. Advantages of this model include efficiency of skill mix and varied levels of expertise (Sullivan, 2012). A disadvantage to the practice partnership would occur if the partners were not compatible or were not able to agree upon plans of care for patients.
Case management organizes patient care by patient population and specific diagnoses. Clinical teams are established and determine appropriate care and interventions for the patient. This form of nursing care was formed after payment for care changed from cost-based reimbursement to a prospective payment model (Scott, 2014). The role of case manager is often an advanced practice nurse or RN with specialized training due to scope of knowledge required. A disadvantage to this type of care would be role confusion if roles were not specifically defined because the duties of each team member may vary from case to case.
Critical pathways are expected outcomes designated by a collaboration of medical professionals. Critical pathways offer direction for managing care of a patient during a specified time period. Case managers often manage care using critical pathways. Advantages to this model include reduced length of stay and reduced cost due to appropriate use of resources for care needed (Marquis & Huston, 2017).
The Robert Wood Johnson Foundation along with the Institute for Healthcare Improvement created a program called Transforming Care at the Bedside (Lavizzo-Mourey & Berwick, 2009). The goal of the program was to support hospitals by making long lasting, sustainable improvements to care. The patient-centered care model was created. This model enhances the role of the nurse to include a multidisciplinary team of caregivers. This team includes admission and discharge staff as well as diagnostic, treatment, and support services, including nutrition, custodial staff, and medical records. The goals of this model are efficiency, quality, and cost-containment. Simply put, this model decreases the number of caregivers by increasing the responsibilities of each. It has received high marks in current literature because of successful patient-centered care and lower mortality (Sullivan, 2012).
The American Association of Critical-Care Nurses (AACN) developed the synergy model of care based on patient characteristics matched with nurse competencies. When patient characteristics and nurse competencies match, they create synergy by working together. Examples of patient characteristics include resiliency, vulnerability, stability, and resource availability. Examples of nurse competencies include clinical judgment, systems thinking, caring practices, and response to diversity.
Patient-centered medical homes are the most recently created health care delivery system. This model ensures that appropriate care is provided to a specific population of patients and is supported by the Affordable Care Act of 2010. In this model, the primary care provider is considered the patient’s “medical home.” The primary care provider coordinates care with other providers to ensure that care is not duplicated or omitted. This is an ideal role for advanced practice nurses who are well suited to lead a patient-centered medical home team as independent practitioners (Marquis & Huston, 2017; Sullivan, 2012).
It is important to remember that all levels and models of care differ and are not permanent models. As health care continues to adapt to changing reimbursement systems, technological advances, and varying patient demands, so too will health care delivery services.
Leadership and Power
It is important for the nurse leader and manager to use power on behalf of other people,
rather than over them (Marquis & Huston, 2017). Merriam-Webster’s dictionary defines power (2018) in several ways:
· The ability to act or produce an effect,
· Possession of control, authority, or influence over others,
· Political control or influence, and
· Physical might.
The figure depicts a procession of traditional "nurse caps," with a larger blue hat leading a number of smaller white hats, calling to mind a group of boats following a lead ship. The image symbolizes the concept of authority, with a leader and followers.
Power perceived by others may be feared, honored, worshiped, or mistrusted. The nurse leader and manager should consider that individual experiences can greatly affect a person’s ability to accept or deal with power systems as an adult. This can be related to adverse events that may have occurred during childhood (Knudson-Martin, 2013).
The nurse leader and manager should use power wisely to be successful. Power in organizations is necessary to achieve organizational goals and personal goals as well. It is important to remember that the nurse leader and manager should serve as a role model to others, empowering others in an entrusted role. Allowing staff members to have opportunities for success and advancement can raise morale and increase team effort across the department (Huston, 2017).
Organizational structure requires the use of leadership and management functions , such as use of authority , establishment of personal power, and empowerment of others. Organizational politics exists in all facilities and may have an influence on power. Organizational politics are unofficial, behind-the-scenes efforts to influence the organization or increase power. The nurse leader or manager should have an awareness of organizational politics and use appropriate political strategies when necessary. Understanding the power in politics is one of the first steps a nurse leader and manager should take to develop personal and professional empowerment.
Leadership and Influence
Proverbs 14:28 states, “The mark of a good leader is loyal followers; leadership is nothing without a following” (Peterson, 1993). Effective leaders have the ability to influence staff to accept ideas and share common goals. This ability is considered a strength for leaders, and it begins with building relationships. Rath and Conchie (2008) determined that effective leaders have the ability to understand their followers’ needs. Through a research study, followers were asked to choose three words that describe the effect a leader has made in his or her life. The four most common responses from participants were trust, compassion, stability, and hope (Ambler, 2015). Remember that both leaders and followers contribute to the effectiveness of their shared relationship.
Nurse leaders and managers can influence others in a positive way by utilizing the following power points:
· Practice patience over impatience,
· Be open-minded instead of close-minded,
· Practice integrity over dishonesty,
· Practice compassion over confrontation, and
· Practice persuasion over coercion. (Sullivan, 2012, p. 123)
Formal Authority
Formal authority is the official power to act within an organization. The success of nurse leaders and managers relies on the effective use of authority to accompany their role within the organization. Managers may use their authority to ensure that goals are met. Leaders, on the other hand, recognize when it is appropriate to question authority, and should use their power with thought and consideration. Ultimately, nurse managers who uses power, authority, and organizational politics wisely will be more effective at meeting goals set for the organization, the unit, and themselves.
Formal and Informal Power
Information provided by organizational charts is typically limited in that it does not identify the informal power structure of the organization, or each position’s level of authority. The informal power structure consists of interpersonal relationships, groups, and group leaders without formal authority. With authority being defined as the formal power to act, organizations may give authority related to degree of status. Status can be defined as skill, education, specialization, level of responsibility, autonomy, or salary assigned to a position. It is also common for employees to have status in an organization without given authority. In some organizations, managers have the authority to discipline, hire, and fire staff (Marquis & Huston, 2017).
Leadership may be formal or informal. Formal leadership is officially assigned by the organization with duties outlined by a job description. Keep in mind, a job title alone does not define whether a nurse is a leader. Informal leaders do not have a specified title; however, they influence others through their leadership skills. Often, others recognize a person’s leadership behavior through guiding, offering opinions, and recommending courses of action. Leaders have a wider variety of roles than managers, without a single definition. Leaders obtain power through influence gained by empowering others and directing followers who are willing. This power and influence may or may not be formally recognized by the organization. Leaders may have goals that are not those of the organization.
In many cases, sources of authority, power, and influence, are specific to the organization and must be used appropriately in each situation to be effective.
Nursing Leadership and Management
Nurses are considered leaders in the health care industry, and nursing is one of the most honest and ethical professions (Brenan, 2017). Leading and managing in nursing impact not only other staff members but also potentially every patient under the staff’s care. Leadership and management are informally practiced by all nurses without specified roles. By directing the work of both professional and nonprofessional staff to achieve patient outcomes, persuading and guiding patient care is a daily task of all nurses. It is important to develop both leadership and management skills and learn how to intertwine both into the role of the nurse. At some level, every nurse is a leader and a manager. The combined role as leader-manager should include the following characteristics:
· Nurse leader-managers are visionary and futuristic; they think long term.
· Nurse leader-managers are not narrowly focused; they think about the organization as a whole.
· Nurse leader-managers influence others, not only their own group.
· Nurse leader-managers are sensitive to others and to different situations by emphasizing the organization’s vision, values, and motivation.
· Nurse leader-managers are politically aware.
· Nurse leader-managers are change agents. They accept the current structure and processes of the organization, but are aware of the need for change according to ever-changing realities and desire organizational growth as needed (Gardner, 1990; Marquis & Huston, 2017, p. 53).
Although there are many similarities between the nurse leader and manager role, there are differences that distinguish the two as well. Leadership without management can be described as a failure, and vice versa. What is most important is that the skills necessary for any given situation are recognized and applied appropriately.
Typical managerial tasks for the professional nurse include planning, organizing, staffing, evaluating, supervising, negotiating, and representing. The degree of power that a nurse manager holds is assigned by the organization. The nurse manager role entails making assignments and coordinating tasks to be completed, developing and motiving staff as needed by encouraging professional development, defining goals, evaluating outcomes, and offering feedback to staff.
Table 1.2 offers a comparison of traditional management and leadership characteristics.
Table 1.2
Management and Leadership Characteristics
Managers
Leaders
Assigned by the organization
Often lack authority but obtain power through influence
Definite source of power and authority through assigned role
Wider variety of roles than managers
Have specific duties and responsibilities
Goals may not reflect those of the organization
Direct willing and unwilling subordinates
Direct willing followers
Manipulate resources, such as people, financial, time, and environmental, to achieve organizational goals
Focus on interpersonal relationships and empowering others
Focus on control, decision making, evaluation, and results
Focus on group processes, gathering information and providing feedback
Note. Adapted from Leadership Roles and Management Functions in Nursing (9th ed.), by B. L. Marquis & C. J. Huston (pp. 40-41). Philadelphia, PA: Wolters Kluwer (2017).
Leadership Theories
There are many theories that attempt to define successful leadership. Founders such as Carlyle, Allport, Fielder, Hersey, Blanchard, and others list basic assumptions about identified theories that directly correlate with a person’s leadership potential. For example, the great man theory founded by Thomas Carlyle in the 19th century is based on the assumption that leaders are born with or without the ability to lead (Cherry, 2018). Table 1.3 lists several leadership theories, including founders, basic assumptions, and applications.
Table 1.3
Leadership Theories
Theory
Founder/Date
Basic Assumptions
Application
Great Man Theory
Thomas Carlyle, 19th Century
1. Great leaders are born with specific traits that allow them to rise up and lead others.
2. Great leaders can rise up when the need for them is great.
(Bisk Education, 2018).
Carlyle stated, “the history of the world is but the biograph of great men,” such as Julius Caesar, Alexander the Great, and Abraham Lincoln, to name a few (Cherry, 2017).
Trait Theory
Gordon Allport, 1936
1. Traits are inborn.
2. Certain traits are linked with certain behavior patterns.
3. These behavior patterns prove to be consistent in various situations.
(Cherry, 2018)
Traits that have been identified as characteristic of leaders include the following: knowledge of business, emotional maturity, strong analytical abilities, creativity, flexibility, charisma, knowledge of technology and industry, self-confidence, honest and trustworthy, intense desire to lead others, high level of energy and effort to reach shared goals (“Trait Theory of Leadership,” n.d.).
Contingency Leadership Theory
Fred Fielder, 1960s
1. There is not a leadership style that is considered the best; instead, a leader’s success is dependent upon the situation (“Fiedler’s Contingency Model,” n.d.).
2. This theory also suggests that managers adapt their style of leadership in response to changing situations.
This theory supports the idea that success is not due to characteristics of the leaders’ personality, but rather, external factors that influence the leader in certain situations.
Situational Leadership Theory
Paul Hersey and Ken Blanchard, 1960s
As followers mature, the leadership style needed becomes less task-oriented and more relationship-oriented (Marquis & Huston, 2017; Webster & Webster, n.d.).
This theory relies on adapting leadership styles based on the situation and predicts the most appropriate leadership style based on the situation and the follower’s maturity level.
Leader-Member Exchange Theory
(Two-way theory also known as the Vertical Dyad Linkage)
Dansereau, Graen, and Haga, 1970s
Leaders do not treat all subordinates equally.
Theory focuses on the relationship between leader and follower with the aim of maximizing the success of the organization through leadership effectiveness (“Leader Member Exchange (LMX) Theory,” n.d.).
Transformational Leadership Theory
James Burns,
1970s
Both leaders and followers have the ability to “raise each other to the highest levels of motivation and morality” (Marquis & Huston, 2017, p. 50).
· A leader who empowers others
· Inspiring
· Focuses on long-term success
· Vision-oriented
· Takes care of followers
· Identifies commonalities with followers
· Humanitarian ideals
Servant Leadership
Robert Greenleaf, 1970
The premise of servant leadership is that through serving others, one may be called to lead (Sullivan, 2012).
This theory calls for leaders to act in a Christ-like manner, while listening to others without judgment, thinking before reacting, using foresight and intuition, and choosing words wisely.
Leadership Styles
A nurse manager’s leadership style can affect many in the health care organization. They can significantly influence staff productivity, morale, and turnover rates, which can also indirectly influence patient care. Just as health care environments require new and creative methods of health care delivery, the same is true regarding approaches to leadership (Sullivan, 2012). These varied leadership styles (see Table 1.4) result from the many leadership theories previously discussed (see Table 1.3).
Table 1.4
Leadership Styles
Autocratic or Authoritarian
· Reflected by the leader making all decisions without consulting other staff members.
· Can be found in very large organizations, such as the armed forces (Marquis & Huston, 2017).
· When rules are not followed, staff members are often punished and given negative reinforcement.
· Questioning the leader’s direction or orders is strongly discouraged.
· Trust, communication, and teamwork are not promoted in this style of leadership (Frandsen, 2014).
· Creativity, self-motivation, and autonomy are nonexistent; however, productivity is very high.
· Favorable for quick completion of group-actions that are well defined and predictable. It can be useful when enforcing policies and procedures that need to be strictly adhered to, such as those that protect health and safety, during emergencies, or in organizations that are highly structured in which performance of specific step-by-step operations must be followed (“Different Nursing Leadership Styles,” 2018).
Laissez-Faire
(Also known as nondirectional style or hands-off approach)
· Allows staff members to function with little or no guidance.
· Nurse leaders give minimal direction with little or no supervision.
· Authority is given to staff members who are their own decision-makers, goal-setters, and problem-solvers.
· Quality improvement using this leadership style is seen as reactive rather than proactive.
· Feedback and input are provided by effective laissez-faire leaders when ideally they are leading a group of educated, skilled, and self-motivated staff members with many years of experience.
· Most often used by novice leaders or those at the end of their career who are soon to be replaced (“Different Nursing Leadership Styles,” 2018; Frandsen, 2014).
· Frustration, group apathy, and disinterest can result unless all team members are self-motivated and independent workers (Marquis & Huston, 2017).
Participative
(Also known as democratic leadership)
· Appropriate for groups of staff members that work together for long periods of time.
· A participative leader, rather than making autocratic decisions, involves other staff members in the process.
· Exceptionally effective with a cooperative group, with coordination between groups when multiple groups are necessary.
· Effective when employees put forth much effort because they feel valued as a decision-making team member.
· Can be time-consuming, and difficulties can arise when dealing with staff members who are very vocal vs. those who choose to refrain from voicing their opinion.
Transactional
· Operates on the assumption that staff are motivated only by using discipline and rewards. An outward organizational focus does not exist; rather, the focus is on day-to-day operations only.
· Authoritative leadership is utilized for this type of management.
Transformational
· Empowers others by building relationships and motivating staff through a committed visionary leader.
· Focuses on the positive, encourages teambuilding, and builds self-motivation of team members (“Different Nursing Leadership Styles,” 2018; Frandsen, 2014; Marquis & Huston, 2017).
Characteristics of Exceptional Leaders
Effective nursing leadership is critical to the long-term success of organizations and, more importantly, to the efficiency and quality of patient care. In a system undergoing constant change, nursing leaders must be prepared to adjust and be flexible. Organizations with leaders and managers who are highly qualified, possess exceptional leadership characteristics, and are forward thinkers will lead the way.
The skills necessary to propel a leader into the exceptional category of leadership include self-awareness, self-management, social awareness, and relationship management (Watson, 2004). Carson Dye and Andrew Garman (2005) asserted that the following competencies can be used by organizations as a foundation for leadership development, coaching, assessment, selection, and planning for future leaders:
1. Communicate the organizational vision.
2. Encourage adaptability.
3. Use group decision techniques in a skillful way.
4. Think long-term by visualizing the organization in the future.
5. Recognize personal strengths and weaknesses.
6. Be aware of emotional intelligence.
7. Know and represent your values and beliefs.
8. Set a strong example of work ethic and motivation.
9. Mentor others.
10. Develop teams that include strong team players.
11. Understand organizational informal and formal power.
12. Be mindful when making decisions.
13. Encourage creativity.
14. Be direct and truthful.
15. Have a calm and approachable demeanor.
16. Be an active listener.
17. Set clear expectations and provide useful feedback.
18. Challenge staff by setting high standards.
As nurse leaders progress in their careers, so does the need to create a professional and positive image in the form of a resume. The resume is a personalized record of contact information, education, skills, strengths, and professional experience that can be used as a screening tool by employers. A well-prepared resume is a necessity to provide a quick, positive, impression that captures the reader’s attention and is memorable.
Management Principles, Characteristics, and Skills
Theorist Henri Fayol (1841-1925) was the first to identify five functions of management that include, planning, organizing, staffing, directing, and controlling (see Figure 1.3). These functions reflect a “proactive approach to management that is systematic” (Sullivan, 2012, p. 52).
Figure 1.3
Management Characteristics
Figure depicts five management characteristics in circular form – with Planning at the top and then in clockwise fashion: Organizing, Staffing, Directing, and Controlling – with arrows showing flow through the characteristics in clockwise fashion.
Planning includes determining goals, objectives, policies, and procedures. Implementing short-term goals and creating long-term projections are also included in the planning process. Once a plan of action is determined, managing planned change begins.
Organizing includes a way to implement the plans that are made. Specifically, this includes identification of work to be done, determining the appropriate type of patient care delivery, creating a chain of command, and assigning formal authority.
Staffing involves recruiting, interviewing, hiring, and orienting new staff. Other functions included with staffing are team-building and professional development.
Directing is the act of accomplishing the work of the organization while managing duties such as conflict among staff, delegation, communication, and facilitating collaboration among staff members.
Controlling functions include tasks such as evaluating staff performance, quality control, and issuing feedback (Marquis & Huston, 2017).
These functions accompany the principles included in the Figure 1.4. The principles define how managers should organize and interact with staff.
Figure 1.4
Fayol’s Principles of Management
Diagram shows Fayol’s 14 Principles of Management at the center with all 14 principles encircling the center. The principles are Division of Work, Authority and Responsibility, Discipline, Unity of Command, Unity of Direction, Organizational Needs Over Individual Needs, Fair Payment Centralization, Chain of Command, Order, Treat People Equally, Stability–Limited Turnover, Encourage Initiative, and Promote Harmony.
Note. Adapted from “Henri Fayol’s Principles of Management,” from the Mind Tools website at https://www.mindtools.com/pages/article/henri-fayol.htm.
Management Skills
Nurses need to exhibit a variety of management skills in order to manage effectively. Technical skills involve specific skill sets. Numerous technology systems can be used to problem-solve in the health care environment. Various tools, such as office software, Web designs, and written skills are put to use in the form of communication, data management and analytics, information technology, office skills, and technical writing.
Self-awareness is closely linked to successful leadership and can be defined as understanding one’s self by recognizing strengths and weaknesses, moral values, thought processes, character, emotions, motivations, desires, and goals. Awareness of self allows for greater control over interactions with others and aids in time management. This is important because of the need to balance work, personal, and family life. Increasing self-awareness can be achieved by keeping a journal documenting personal goals, practicing meditation and other mindfulness habits, performing daily self-reflection, recognizing emotions, redirecting destructive thought patterns, and accepting responsibility for one’s actions. There is tremendous value in developing leadership skills with an introspective look at self. Self-leadership is the foundation for effective leadership, and nurse leaders can develop leadership skills by cultivating personal wellness.
Nurse managers have the power to influence the political process. It is important for nurse managers to be active participants in the legislative process concerning health care issues. According to Huston (2017), political strategies can be used to increase the nursing profession’s power base. Nurses should have a voice in decision-making processes. To explain, nurse leaders and managers should be present where decisions are made, such as on advisory committees and boards, to increase policymakers’ understanding of the nurse’s role in health care. Huston also held that nurses have the most experience, as a whole, in health care systems. This, along with the high amount of respect the public has for the nursing profession, makes the nurse leader an ideal candidate to seek out this role.
Critical thinking is more than decision making and problem solving; it is higher order reasoning and evaluation. Acts of insight, intuition, empathy, and motivation are also needed to identify patient problems and direct interventions to obtain positive outcomes. Research has concluded that there is a correlation between the critical thinking skills of RNs and their clinical competence (Ryan & Tatum, 2012). Nurse managers should build upon their current knowledge of the nursing process when attempting to build critical-thinking skills. For example, during the assessment process, critical thinkers would expand the nursing assessment process to include
observation, deciding whether data collected are relevant or not, validating data, and organizing and categorizing data (Wilkinson, 1992). It is common for most people to be quick decision makers, but it is important to make sure that the problem is fully examined before a solution is determined. Critical thinking can also be described as reflective thinking. Critical-thinking nurses are creative, knowledgeable, flexible, caring, observant, assertive, intuitive, resourceful—they think “outside of the box” (Marquis & Huston, 2017, p. 4). For example, critical thinking can be utilized in all areas of nursing, such as a nurse who is having a conversation with family members regarding resuscitation, interventions, and management of long-term conditions for a loved one. The nurse would do so by including critical thinking. Ideally, the nurse would discuss the situation as it relates to the individual patient, being caring and empathetic toward the family’s feelings, and by implementing interventions that are resourceful, intuitive, and creative to ease the patient’s transition and the family’s as well. It is often assumed that nurses are able to easily cope with events such as trauma and death. For some nurses, the ability to empathize or understand the feelings of patients and their families occurs naturally. For others, it is a skill that is learned over time. Acknowledging personal feelings and needs as not only nurses but human beings requires awareness and can be therapeutic. Taking time to grieve the loss of a patient, for example, is necessary.
Reflective Summary
Nursing leadership and management are both necessary roles that are vital to the long-term success of all health care organizations. The process needed to become an exceptional leader and manager includes developing personal leadership and management preferences, styles, characteristics, and skills that advance the role from novice to expert, and are vital to successful health care organizations as well. The nursing leader or manager with a good understanding of the levels of health care, types of service, and power and authority in organizations should achieve success in the health care environment.
Key Terms
Authority: The official power to act within an organization.
Case Management: Organizing patient care by patient population and specific diagnoses.
Critical Pathways: A set of expected outcomes designated by a collaboration of medical professionals.
Formal Authority: Official power to act within an organization.
Formal Power: Authority to act.
Influence: Ability to affect others so that they accept ideas and share common goals.
Informal Power: Level of authority of staff that is not documented.
Management Functions: An approach to management that includes planning, organizing, staffing, directing, and controlling.
Medical Homes: Ensures appropriate care is provided to a specific patient population.
Patient-Centered Care Model: Model that decreases the number of caregivers by increasing the responsibilities of each.
Power: Control, authority, or influence over others.
Practice Partnership: Registered nurses, licensed practical nurses, and unlicensed assistive personnel join forces and practice as partners with the same schedules and patient assignments.
Primary Nursing: All patient care is provided by registered nurses.
Status: Skill, education, specialization, level of responsibility, autonomy, or salary assigned to a position.
Synergy Model of Care: Developed by the American Association of Critical-Care Nurses, a model that matches nurse competencies with patient characteristics.
Team Nursing: A team of nursing staff provides total patient care for a group of patients under the direction of a professional nurse.
Total Patient Care: The registered nurse is responsible for all aspects of patient care.
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