Chapter 01: Leading, Managing, and Following

After assessing an older adult patient in long-term care who has been slowly deteriorating for weeks, the nurse manager calls the family and asks them to come in, as the patient is dying. What is the most likely basis for the nurse manager's request? a. An established clinical pathway b. Confirmatory scientific evidence c. Unit protocol d. Experience

ANS: D The nurse manager is employing knowledge and experience in determining that the patient is dying, because the course of dying is not standardized and cannot be determined by clinical pathways.

The manager calls the staff together to assess a situation in which the family of a seriously ill patient is anxious and is absorbing a great deal of staff time in consultation, discussion, and questioning of treatment decisions. Staff members are becoming distanced from the family. After inviting the concerns of staff, the manager explains that the organization values patient-centered care and that evidence supports that acting as an advocate and a listener is helpful to families. The manager asks the staff for ideas and strategies that are effectively patient-centered in dealing with families in similar situations. What is the role of the nurse manager in this situation? a. Leadership b. Management c. Follower d. Visionary

ANS: A As a leader, the manager is providing and communicating vision and direction based on evidence and experience. The manager is engaging others in decision making that moves them toward the vision with a reasonable level of risk taking.

A family is keeping vigil at a critically ill patient's bedside. Distant family members call the unit continuously asking for updates and expressing concern. The nurse speaks with the distant family members and states she is referring them to the hospital social worker, whose role is to work with family in this situation. What role is the nurse assuming through this action? a. Manager b. Leader c. Follower d. Laissez-faire

ANS: A As a manager, you are concerned with managing and coordinating resources to achieve outcomes in accordance with established clinical processes. Referral to a social worker alleviates demand on staff time and is consistent with hospital procedures.

A charge nurse on a busy 40-bed medical/surgical unit is approached by a family member who begins to complain loudly about the quality of care his mother is receiving. His behavior is so disruptive that it is overheard by staff, physicians, and other visitors. The family member leaves the unit abruptly, and the nurse is left feeling frustrated. Which behavior by the charge nurse best illustrates refined leadership skills in an emotionally intelligent practitioner? a. Reflect to gain insight into how the situation could be handled differently in the future. b. Try to catch up with the angry family member to resolve the concern. c. Discuss the concern with the patient after the family member has left. d. Notify nursing administration of the situation.

ANS: A Goleman suggests that emotional intelligence involves insight and being able to step outside of the situation to envision the context of what is happening as well as being able to manage emotions such as frustration effectively.

The manager of a surgical area has a vision for the future that requires the addition of RN assistants or unlicensed persons to feed, bathe, and ambulate patients. The RNs on the staff have always practiced in a primary nursing-delivery system and are very resistant to this idea. What would be the best initial strategy for implementation of this change? a. Exploring the values and feelings of the RN group in relationship to this change b. Leaving the RNs alone for a time so they can think about the change before it is implemented c. Dropping the idea and trying for the change in a year or so when some of the present RNs have retired d. Hiring the assistants and allowing the RNs to see what good additions they are

ANS: A Influencing others requires emotional intelligence in domains such as empathy, handling relationships, deepening self-awareness in self and others, motivating others, and managing emotions. Motivating others recognizes that values are powerful forces that influence acceptance of change. Leaving the RNs alone for a period of time before implementation does not provide opportunity to explore different perspectives and values. Avoiding discussion until the team changes may not promote adoption of the change until there is opportunity to explore perspectives and values related to the change. Hiring of the assistants demonstrates lack of empathy for the perspectives of the RN staff.

A dispute arises between an RN and an LPN over a patient issue. The tension continues between the two and begins to affect other staff members, who are drawn into the conflict. Over time, the team becomes polarized toward either the RN or the LPN. How might this situation be prevented? a. Expediency in responding to the initial dispute, once it became apparent that it could not be resolved by the two parties themselves b. Asking other staff members what the real issues were in the dispute between the RN and the LPN c. Reassigning one of the parties to another unit when it became apparent that the two individuals could not resolve the dispute themselves d. Calling a staff meeting at the onset of the dispute to allow the team and the RN and LPN to discuss the initial dispute

ANS: A The initial step in conflict resolution should have involved an expedient response to the issues and putting a focus on the issues involved in the dispute between the LPN and RN through negotiation involving the two parties, before the dispute involved others.

The unit is shifting from primary nursing to a team model in an effort to contain costs. Staff members are upset about the change and ask for a meeting to discuss the new model. After hearing their concerns related to reduction in professional autonomy, what is the initial response by the manager to address the concerns? a. Acknowledge the loss. b. Explain the reasons for change, emphasizing the need to reduce costs. c. Repeat the information several times, giving detailed budget overviews. d. Adjourn the meeting and provide explanation through e-mail.

ANS: A Visioning involves engaging with others to assess the current reality, specify the end point, and then strategize to reduce differences. This requires trusting relationships that acknowledge the differences in values and ideas. When done well, the nurse manager and the nurses within a unit experience creative tension that inspires working in concert to achieve desired goals.

A new graduate nurse wonders about the directions that her preceptor has given her regarding management of incontinent, confused patients. The new nurse brings the preceptor evidence-based information she located regarding incontinence interventions for confused patients and asks to talk about the guidance that given after the preceptor reviews the information in the article. What is the new nurse demonstrating in this situation? (Select all that apply.) a. Assertiveness b. Followership c. Management d. Insubordination

ANS: A, B This is an example of followership in which a staff nurse is demonstrating assertive behavior and presenting evidence that may influence the decision making of her nurse leader and manager.

During a staff meeting held to discuss developing a mission statement for the unit, the idea of placing patient needs first is discussed. What is considered when the suggestion by the manager is for the unit mission to be derived from the organization mission? a. Empowering b. A leadership tag c. A symbol d. A management task

ANS: B According to complexity theory, leadership tags, which are similar to values, reflect the patient-centered philosophies and values-driven characteristics that define an organization and give it personality.

You overhear a new graduate RN telling a nurse colleague that leadership and management belong to the unit manager, not to her. As a nursing colleague, what do you know to be true in regard to the statement? a. The statement is correct. Leadership is not the role of the staff nurse. b. The new graduate would benefit from further understanding of her role as a professional, whose influence may affect the decision making of patients, colleagues, and other professionals. c. The new graduate has been influenced by nurse leaders and managers who leave for other positions. d. The general perception is that nurse leaders and managers are not satisfied in their jobs.

ANS: B Care coordination that involves the intersection of individual, family, and community-based needs requires that nurses have self-confidence, knowledge of organizations and health systems, and an inner desire to lead and manage. There is often a view that leadership is isolated to those holding managerial positions, and that a direct care nurse is subject to following by adhering to the direction of others. Such views fail to acknowledge that to be a nurse requires each licensed individual to lead, manage, and follow when practicing at the point-of-care and beyond.

As a leader on a rehab unit, the manager encourages all staff members to see themselves as having a role in decision making and quality care. The manager sees their role as involving particular responsibilities in decision making but not as a hierarchal role. What is this view of the role consistent with in this situation? a. Trait theories b. Complexity theory c. Situated theory d. Emotional intelligence

ANS: B Complexity theory involves envisioning each member of the team involved in decision making, management, and leadership, with the leader not seen in a hierarchal relationship to other team members.

A nurse manager of a 20-bed medical unit finds that 80% of the patients are older adults. She is asked to assess and adapt the unit to better meet the unique needs of the older adult patient. Using complexity principles, what would be the best approach to take for implementation of this change? a. Leverage the hierarchical management position to get unit staff involved in assessment and planning. b. Engage involved staff at all levels in the decision-making process. c. Focus the assessment on the unit and omit the hospital and community environment. d. Hire a geriatric specialist to oversee and control the project.

ANS: B Complexity theory suggests that systems interact and adapt and that decision making occurs throughout the systems, as opposed to being held in a hierarchy. In complexity theory, every voice counts, and therefore, all levels of staff would be involved in decision making.

As the RN charge nurse on the night shift in a small long-term care facility, you've found that there is little turnover among your LPN and nursing assistant (NA) staff members, but they are not very motivated to go beyond their job descriptions in their work. Which of the following strategies might motivate the staff and lead to greater job satisfaction? a. Ask the director of nursing to offer higher wages and bonuses for extra work for the night LPNs and NAs. b. Allow the LPNs and NAs greater decision-making power within the scope of their positions in the institution. c. Hire additional staff so that there are more staff available for enhanced care, and individual workloads are lessened. d. Ask the director of nursing to increase job security for night staff by having them sign contracts that guarantee work.

ANS: B Hygiene factors such as salary, working conditions, and security are consistent with Herzberg's two-factor theory of motivation; meeting these needs avoids job dissatisfaction. Motivator factors such as recognition and satisfaction with work promote a satisfying and enriched work environment. Transformational leaders use motivator factors liberally to inspire work performance and increase job satisfaction.

At a second negotiation session, the unit manager and staff nurse are unable to reach a resolution. What is the appropriate next step? a. Arrange another meeting in a week's time so as to allow a cooling-off period. b. Elevate the next negation session to the next manager, one level above. c. Insist that participants continue to talk until a resolution has been reached. d. Back the unit manager's actions and end the dispute.

ANS: B Part of leadership is understanding conflict resolution and ability to negotiate and manage for resolution of issues and concerns. This situation has failed a second negotiation session, elevation to a manager with additional training to facilitate conflict resolution is important at this point.

The manager of a unit is finding it difficult to work with a new graduate nurse. The new nurse has many ideas; however, his manner of presenting them irritates the manager. After reflection and discussion with others, the manager recognizes that she feels threatened by his behavior. She comes to understand that the new nurse is trying to establish his own role on the unit; is not trying to challenge her; and needs guidance, coaching, and affirmation. What is the nurse manager demonstrating in this situation? a. A positive self-concept b. Deepening self-awareness c. Leadership d. Acquiescence

ANS: B Stepping outside oneself to envision the situation while assuming ownership is a component of emotional intelligence. This is an example of self-awareness to identify the resolve to self-conflict in this situation.

Chart audits have revealed significant omissions of data that could have legal and financial guideline ramifications. The unit manager meets with the staff to discuss audit findings and to find approaches that will address the gaps in charting and achieve desired goals. What is the manager demonstrating? a. Leadership b. Management c. Decision making d. Vision

ANS: B The process of guiding others to meet established goals, outcomes, and procedures is management. This can require collaborative decision making to determine how best to reach predetermined goals and follow established practices.

A staff nurse has been recently promoted to unit manager. During the time on the unit, the nurse formed a strong social network among staff, has promoted the development of relationships between staff and workers in other areas of the organization, and has formed relationships that generate ideas from patient organizations and the local nursing education program. According to complexity theory, what principle is being engaged? a. Empowerment b. Systematic thinking c. Development of networks d. Bottom-up interactions

ANS: C According to complexity theory, social networks evolve around areas of common interest and are able to respond to problems in creative and novel ways.

The nurse manager wants to increase motivation by providing motivating factors for the nurse on the unit. What action would be appropriate to motivate the staff? a. Collaborate with the human resource/personnel department to develop on-site daycare services. b. Provide a hierarchical organizational structure. c. Implement a model of shared governance. d. Promote the development of a flexible benefits package.

ANS: C Complexity theory suggests that systems interact and adapt and that decision making occurs throughout systems, as opposed to being held in a hierarchy. In complexity theory, every voice counts, and therefore all levels of staff would be involved in decision making. This principle is the foundation of shared governance.

A grievance brought by a staff nurse against the unit manager requires mediation. At the first mediation session, the staff nurse repeatedly calls the unit manager's actions unfair, and the unit manager continues to reiterate the reasons for the actions. What would be the best course of action at this time? a. Send the two disputants away to reach their own resolution. b. Involve another staff nurse in the discussion for clarity issues. c. Ask each party to examine their own motives and issues in the conflict. d. Continue to listen as the parties repeat their thoughts and feelings about the conflict.

ANS: C For resolution of conflict, one should address the interests and involvement of participants in the conflict by examining the real issues of all parties.

A family is keeping vigil at a critically ill patient's bedside. The nurse approaches the unit manager with concern over the family dynamics for the patient concerned there are patient-family conflicts based on patient's wishes. The nurse suggests that the patient's provider may need to discuss the treatment plan with the family. The unit manager states he will arrange a discussion with the patient's provider and ask the nurse to support the provider's decisions. What is the role of the nurse in this situation? a. Leadership b. Management c. Follower d. Evidence-based

ANS: C In the followership role, you bring to the manager your concerns about concerns for patients and the outcomes and accept the direction given by the manager in response to your concerns.

The charge nurse walks into Mr. Smith's room and finds him yelling at the LPN. He is obviously very upset. The charge nurse determines that he has not slept for three nights because of unrelieved pain levels. The LPN is very upset and calls Mr. Smith an "ugly, old man." The charge nurse acknowledges the LPN's feelings and concerns and then suggests that Mr. Smith's behavior was aggressive but was related to lack of sleep and to pain. The charge nurse asks, "Can you, together with Mr. Smith, determine triggers for the pain and effective approaches to controlling his pain?" This situation is an example of what? a. Lack of empathy and understanding for Miss Jones b. Concern with placating Mr. Smith c. Leadership behavior d. Management behavior

ANS: C The situation between Mr. Smith and Miss Jones is a complex situation involving unrelieved patient symptoms and aggressiveness toward a staff member. Providing engaged, collaborative guidance and decision making in a complex situation where there is no standardized solution reflects leadership.

According to the complexity theory, what would be the focus of measurement? a. Cost per hospital day b. Bed utilization c. Infection rates d. Staff morale and budgets

ANS: D According to complexity theory and the principle "Think systematically," one cannot ignore objective data or nonmeasurable data, as both inform decisions.

The nurse manager has been asked to implement an evidence-based approach to teach ostomy patients self-management skills postoperatively. The program is to be implemented across the entire facility. What illustrates effective leadership in this situation? a. The training modules are left in the staff room for times when staff are available. b. The current approach is continued because it is also evidence-based and is more familiar to staff. c. You decide to implement the approach at a later date because of feedback from the RNs that the new approach takes too much time. d. An RN who is already familiar with the new approach of volunteers to take the lead in mentoring and teaching others how to implement it.

ANS: D Followership occurs when there is acquiescence to a peer who is leading in a setting where a team has gathered to ensure the best clinical decision making, and actions are taken to achieve clinical or organizational outcomes. Followership promotes good clinical decisions and use of clinical resources.

A unit manager of a 25-bed medical/surgical area receives a phone call from a nurse who has called in sick five times in the past month. He tells the manager that he very much wants to come to work when scheduled but must often care for his wife, who is undergoing treatment for breast cancer. According to Maslow's need hierarchy theory, what would be the best approach to satisfying the needs of this nurse, other staff, and patients? a. Line up agency nurses who can be called in to work on short notice. b. Place the nurse on unpaid leave for the remainder of his wife's treatment. c. Sympathize with the nurse's dilemma and let the charge nurse know that this nurse may be calling in frequently in the future. d. Work with the nurse, staffing office, and other nurses to arrange his scheduled days off around his wife's treatments.

ANS: D Placing the nurse on unpaid leave may threaten the nurse's capacity to meet physiologic needs and demotivate the nurse. Unsatisfactory coverage of shifts on short notice could affect patient care and threaten the needs of staff to feel competent. Arranging the schedule around the wife's needs meets the needs of the staff and of patients while satisfying the nurse's need for affiliation.

The chief nursing officer has asked the staff development coordinator to facilitate the development of a clinical competency program for the facility. While making rounds on the units, the staff development coordinator overhears RN staff complaining that they feel it is insulting to be required to participate in a competency program. What behavior by the staff development coordinator is most appropriate in this situation? a. Disregard staff concerns and continue with development of the program. b. Inform the nurses that this program is a requirement for JCAHO accreditation. c. Schedule a meeting with the chief nurse executive to apprise her of the situation. d. Facilitate a meeting so nurses can articulate their values and concerns about a competency program.

ANS: D The manager role involves guiding others through a set of derived practices that are evidence-based and known to satisfy preestablished outcomes such as participation in a competency program. This involves engagement of staff through sharing of concerns and ideas. A close analysis of the IOM report and the summary of the PPACA suggests that no health reform can unfold without active nursing engagement. Each document emphasizes that nurses must lead, manage, and behave as active collaborators with other members of the health team and with those being served.

As the head of a nursing program, you consistently invite the ideas of your team about innovations in teaching, community partnerships, and curriculum design and invite participation in decisions. Many of these ideas have been implemented successfully, and your staff members are keen to try on other ideas. What is the leadership you are employing? a. Situational b. Trait-based c. Contingency-based d. Transformational

ANS: D Transformational leadership involves attending to the needs and motives of followers, which results in creativity, improvement, and employee development.