Leadership Exam 2

Limitations in organization charts

does not show informal structure; every institution has a dynamic informal structure that an be powerful & motivating; knowledgeable leaders never underestimate its importance - can either facilitate or sabotage planned change Informal leaders: ~ long-term employees ~ gatekeeping positions (i.e., CNO's secretary)

Span of Control

# of people directly reporting to any one manager represents that manager's span of control & determines the # of interactions expected Inverse relationship with # of levels in organization ~narrower (less) span of control = greater # of levels Too many people reporting to a single manager delays decision making, whereas too few results in an inefficient, top-heavy organization Flattening the organization: ~ increased financial pressures & electronic communication technology advances, health-care organizations have increased their span of control & reduced the # of administrative levels

Authoritarian/Autocratic

*Theory X* - Strong control maintained - Centralized (tall) leader making decisions (does not involve others) - Others are motivated by coercion & directed with commands (external drives) (THINK: large bureaucracies- Armed Forces) - Communication flows downward - Emphasis on difference in status - "I" & "you" - Criticism is punitive (coercive power- punishment) Outcomes: well-defined group actions that are usually predictable, reducing frustration in the work group & giving members feeling of security High productivity Low creativity, self-motivation, autonomy *often used in emergencies or when staff is inexperienced or new

Increase Nursing's Power Base

1) Right timing: ~errors reported in medical system, # of uninsured, & shortcomings of current health-care system = reasons consumers & legislators are willing to listen to nurses as an attempt to fix the health-care crisis 2) Size of nursing profession: ~#'s are very important in politics, size is greatest asset 3) Nursing referent power: ~high degree of trust & credibility the public places in nurses 4) Increasing knowledge base & education for nurses: ~masters, doctoral, advanced practice (NP's, clinical nurse specialist, certified nurse midwives, RN anesthetist, clinical nurse-leaders) ~knowledge = power = influence others, gain credibility 5) Nursing's unique perspective: ~strong caring component + recent surge in scientific knowledge & critical thinking = blend of art & science 6) Desire of consumers & providers for change ~Health-care restructuring & downsizing have sparked increasing concern among consumers; public wants quality care

Action Plan to Increase Power of Nursing Profession

1) place more nurses in positions that influence public policy 2) stop nurses from acting like victims 3) increase level of nurses' understanding regarding all health-care policy efforts ~Changing nurse's view of both power & politics is perhaps the most significant key to proactive rather than reactive participation in policy setting 4) build coalitions within & outside of nursing ~Success comes not only with whom you know, but also, with who knows you! 5) promote greater research to strengthen EBP 6) support nursing leaders 7) pay attention to mentoring future nurse-leaders & leadership succession

Centralized (TALL) Organization

A few managers at the top of the hierarchy make the decisions & emphasis is on top-down control Vision/thinking of one or few individuals guides the organizations goals & how those goals are accomplished execution of decision-making is fairly rapid

Primary care Nursing

AKA relationship-based nursing Organized so that the patient is at the center of the structure. One health-care provider (RN) has 24-hr responsibility for care planning & coordination from admission to discharge Associate nurse follows care plan when primary nurse is not on duty Combo of clear interdisciplinary group communication & consistent, direct pt care by relatively few nursing staff allow for holistic, high-quality care Job satisfaction high Difficult to implement d/t degree of responsibility & autonomy required of primary nurse However, once nurse develops skill in primary nursing, feelings of challenge & reward Disadvantages = inadequately prepared or incompetent primary nurse may be incapable of coordinating multidisciplinary team or identifying complex pt needs & condition changes Difficult to recruit & retain all RN staff

Reward power

Ability to grant favors Positive leadership through rewards tends to develop a great deal of loyalty & devotion toward leaders

Performance Appraisals

Actual performance, not intent, is eval If employees believe that the appraisal is based on their job description rather than on whether the manager approves of them, they are more likely to view the appraisal as relevant A performance appraisal wastes time if it is merely an excuse to satisfy regulations & the goal is not employee growth When ongoing anecdotal notes are not maintained throughout the evaluation period, the appraiser is more apt to experience the recency effect, where recent issues are weighed more heavily than past performance A competence assessment Evans whether an individual has the knowledge, education, skills, or experience to perform the task, whereas a performance eval examines how well that individual actually completes that task Some employees look on their annual performance review as an opportunity to receive positive feedback from their supervisor, esp if the employee receives infrequent praise on a day-to-day basis The concept of collegial evaluation of nursing practice is closely related to maintaining professional standards Indirectness & ambiguity are more likely to inhibit communication than enhance it, and the employee is left unsure about the significance of the message Day-to-day feedback regarding performance is one of the best methods for improving work performance & building a team approach

Decentralized (FLAT) Organization

Allows decision-making/problem-solving to be done at the lowest practical managerial level Problems can be solved at level in which they occur, although some delays may occur in decision making if problem must be transmitted through several levels to reach the appropriate individual to solve the problem Larger organization = greater need to decentralize decision making ~complex questions that must be answered can best be addressed by a variety of people with distinct areas of expertise Shared governance - most innovative & empowering organization - collaborative decision-making

Referent power

Association with others When one gives another person feelings of personal acceptance or approval Others perceive as powerful (personal charisma, way leader talk/acts, organizations he/she belongs to, people he/she associates with) People who are accepted as role models Physicians use very effectively - society as a whole views physicians as powerful, and they carefully maintain this image

Communication

Begins the moment that two or more people become aware of each other's presence Effective communication requires the sender to validate what receivers see & hear Differences in gender, power, and status significantly affect the types & quality of organizational & unit-level communication Although info & communication are different, they are interdependent Grapevine communication is subject to error & distortion bc of the speed at which it passes & bc the sender has little formal accountability for the message Because nonverbal communication indicates the emotional component of the message, it is generally considered more reliable than verbal communication Effective leaders are congruent in their verbal & nonverbal communication so that followers are clear about the messages they receive Assertive communication is not rude or insensitive behavior, rather it is having an informed voice that insists on being heard As in nonverbal communication, the verbal communication skills of the leader-manager in a multicultural workplace requires cultural sensitivity The leader who actively listens gives genuine time & attention to the sender, focusing on verbal & nonverbals Even the most advanced communication technology cannot replace the human judgment needed by leaders & managers to use that technology appropriately Confidentiality can be breached legally only when one provider must share info about pt so that another provider can assume care Meaningful use refers to capturing the right data to improve patient outcomes Managers must be well grounded in group dynamics & group roles bc of the need to facilitate group communication & productivity within the organization

Power & Authority

Both are necessary components of leadership & management Power: enables one to accomplish goals; capacity to act or the strength & potency to accomplish something ~having power gives one the potential to change the attitudes & behaviors of individual people & groups ~frequently misunderstood - management-subordinate relationship are often influenced by how power was used in the family unit & the often unacknowledged impact of gender upon power in family dynamics Authority: the right to command; accompanies any management position & source of legitimate power

Transformational Leadership

Coach or mentor - Committed, has a vision for future, able to empower others with this vision - Inspires commitment to the good of the group - Focuses on management tasks - Uses trade-offs to meet goals - Uses contingency reward (motivation-based system, rewards for meeting identified goals; positive reinforcement) - Provides supportive climate - Promotes creativity *best used in self-governing situations *must be coupled with transactional qualities of the day-to-day managerial role or the leader will fail

Case Management

Collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates opinions & services to meet an individuals health needs through communication & available resources to promote quality & cost-effective outcomes Use of critical pathways - if pt deviates from normal plan, variance is indicated Variance = anything that occurs to alter a pt's progress through the normal critical path

Conflict

Conflict is neither good nor bad, and it can produce growth or destruction, depending on how it is managed Some level of conflict in the organization appears desirable, although the optimum level for a specific person or unit at a given time is difficult to determine Violence & workplace aggression are increasingly being recognized as epidemic in health-care workplace The aftermath of conflict may be more significant than the original conflict if the conflict has not been handled constructively The optimal goal in resolving conflict is creating a win-win solution for all involved Although conflict is a pervasive force in health-care organizations, only a small % of time is spent in true collaboration The very least for which a person will settle is often referred to as the bottom line Managers who protest too strongly that they do not have a hidden agenda appear defensive & vulnerable Negotiation is psychological & verbal. The effective negotiator always appears calm & self-assured Destructive negotiation tactics are never a part of collaborative conflict resolution

Building Personal Power Base

Maintain personal energy ~power & energy go hand in hand ~you must take care of yourself before you can take care of others Present a powerful picture to others ~stand tall, poised, assertive, articulate, and well groomed - exude confidence Pay the entry fee ~newcomers who stand out & appear powerful are those who do more, work harder, and contribute to organization ~attend meetings & in-service opportunities ~night shifts & weekend & holiday assignments without complaining Determine the powerful in the organization ~know names & faces of those with both formal & informal power ~look for similarities & shared values & avoid focusing on differences Learn organizations language & symbols ~culture is "the story" in which people are embedded, values & rituals that reinforce that narrative Learn how to use organizations priorities ~use priorities & goals to meet management needs Increase professional skills & knowledge ~performance must be extraordinary to enhance power & credibility Maintain a broad vision ~vision is one of the most powerful tools that a leader has in his/her toolbox ~when communicated effectively, serves as the driving force for goal attainment Use experts & seek counsel ~seek out role models as newcomer & observe/imitate positive role model ~by looking for advice & counsel, demonstrates willingness to be team players & cautious & want expert opinion before proceeding, not rash newcomers who think they have all the answers Be flexible ~someone who can compromise Develop visibility & a voice in organization ~become active in committees or groups that are recognized by the organization as having clout ~develop observational, listening, and verbal skills ~attempt to interact with everyone Learn to toot your own horn ~accepting compliments is an art ~be gracious but not passive Maintain sense of humor ~ability to laugh at oneself & not take too seriously is most important power builder ~humor often relieves stress or tension Empower others ~share knowledge, maintain cohesiveness, valuing the profession, supporting each other

Transactional Leadership

Maintains status quo - Traditional manager, concerned with day-to-day operations - Identifies common values - Caretaker - Inspires others with vision - Has long-term vision - Looks at effects - Empowers others

Matrix Structure

Designed to focus on both product & function Function- all the tasks required to produce the product, & the product is the end result of the function ~ex: good pt outcomes are the product, staff education & adequate staffing may be the functions necessary to produce the outcome ~less formal rules & fewer levels of the hierarchy ~slow decision making d/t necessity of info sharing (complexity of communication) can produce confusion & frustration bc of its dual-authority hierarchical design

Organizational chart

Defines formal relationships within the institution Formal relationships, lines of communication, and authority are depicted on chart by unbroken (solid) lines. Line positions: (i.e., RN's) ~ solid horizontal or vertical lines Solid horizontal lines = communication btwn people with similar spheres of responsibility & power but different functions Solid vertical lines = denote the official chain of command (formal paths of communication & authority) Top = greatest decision-making authority Staff positions: (i.e., infection control) Dotted/broken lines = advisory in nature, no inherent legitimate authority Unity of command: Vertical solid line btwn positions = one person/boss (manager) in which employees report to ~ greatly simplifies the manager-employee relationship bc the employee only need to maintain minimal # of relationships & accept the influence of only one person as his/her immediate supervisor ~ difficult to maintain in some large health-care organizations bc the nature of health-care requires an interprofessional approach --additional individuals a nurse may be accountable to includes the immediate supervisor, the pt, pt's family, central administration, and the physician (all have some input in directing the nurse's work) --lack of unity of command results in some conflict & lost productivity

Formal structure

Emphasis on organizational positions & formal power Generally, highly planned & visible Through departmentalizations & work division, provides a framework for defining managerial authority, responsibility, and accountability Functions are defined & systematically arranged, different people have different roles, and rank & hierarchy are evident

Stakeholders

Entities that play a role in organizations health & performance or that are affected by organization Examples- Internal: ~nurse in hospital ~dietitian in nursing home External: (in acute care hospital) ~local school of nursing ~home health agencies ~managed care providers who contract with consumers in the area ~Chamber of Commerce in city *every organization should be viewed as being part of a greater community of stakeholders

Coercive power

Fear of punishment (if manager's expectations are not met) Obtain compliance through threats of transfer, layoff, demotion, or dismissal Shuns or ignores employee Berates or belittles employee

Informal structure

Focus is on employees, their relationships, and the informal power that is inherent within those relationships Generally, a naturally forming social network of employees Fills the gaps with connections & relationships that illustrate how employees work with one another to get work done Typically based on camaraderie, often result in a more immediate response from individuals, saving people's time & effort Relied upon if the formal structure has stopped being effective (occurs when organizations grows or changes but does not reevaluate its hierarchy or work groups) *informal authority (leaders) & lines of communication exist in every group, even when they are never formally acknowledged Communication channel: Grapevine - the conversations that occur in the break room, down the halls, during carpool, and in between work that allows the relationships of informal groups to develop. ~ fast & can facilitate info upward, downward, horizontal but difficult to control or stop ~ sender has little accountability for message, often becomes a source for rumor/gossip

Great Man Theory/Trait Theory

Great Man Theory from Aristotelian philosophy - some people are born to lead, whereas others are born to be led. Suggests that great leaders will arise when the situation demands it Trait theories assume that some people have certain characteristics or personality traits that make them better leaders than others.

Organization Climate

How employees perceive an organization (i.e., employee may perceive as fair, friendly, and informal or as formal & very structured) Perception may be accurate or inaccurate

Authentic/Congruent Leadership

In order to lead, leaders must be true to themselves & their values & their conviction to act accordingly is what inspires followers - authentic followers realize their own true nature ~Ex: some nurse-leaders experience intrapersonal value conflicts between what they believe to be morally appropriate & a need to deliver results in a health-care system increasingly characterized by pay for performance & rewarded by cost containment 1) Purpose: understand own purposes & passions as a result of ongoing self-reflection & self-awareness 2) Values: link btwn purpose & passion by having congruence in beliefs & actions 3) Heart: care for themselves & the people they lead, & their compassion is genuine 4) Relationships: value building relationships & est connections with others, not to receive rewards but rather to strengthen the human connection 5) Self-discipline: practice self-discipline by incorporating balance into their personal & professional lives

Leadership

In the front, moving forward, taking risks, attempting to achieve shared goals, inspiring others to action, and challenging the status quo *a job title alone does not make a person a leader - only persons behavior determines role

Multidisciplinary Team

Increases likelihood that care will be comprehensive & holistic, although the responsibility for team leadership still typically falls to the nurse Mutual respect & collaboration is not a given Requires efficient means of communication about pt goals, progress, and problems; hard to find opportunities for whole team to meet bc of work shift patterns or other commitments

Empowerment

Individuals may be born average, but staying average is a choice Complex process that consists of responsibility for the individual desiring empowerment as well as the organization & its leadership Creates & sustains a work environment that speaks to values, such as facilitating the employee's choice to invest in & own personal actions & behaviors that result in positive contributions to the organization's mission

Expert power

Knowledge & skill Gain power over others who need that knowledge - limited to specialized area (i.e., Florence Nightingale used research to demonstrate expertise in health needs of wounded soldiers by proving when nurses were present, less soldiers died)

Manager vs Leader

Manager: person who brings things about - the one who accomplishes, has the responsibility, and conducts. ~ Have greater formal responsibility & accountability for rationality & control than leaders ~ Legitimate Power d/t the delegated authority that accompanies position ~ Assigned position with formal organization ~ Direct willing & unwilling subordinates Leader: person who influences & guides direction, opinion, and course of action. ~ Often do not have delegated authority, but obtain power through other means, such as influence (Reference Power) ~ Wider variety of roles than managers do ~ May or may not be part of the formal organization ~ Direct willing followers

Communication difficulties in organization

Messages may not be received clearly bc of the sender's hierarchical position; status & power also often influence the receivers ability to hear info accurately "Principal syndrome": when school-aged child, if summoned to principals office causes panic thinking "what did i do?" - adults find discomfort in communicating with certain people who hold high status

Laissez-Faire/Permissive

Non-leadership - Non-directive - Little or no control; relinquishes control & direction to staff; disperses decision making throughout group - Motivates by support when requested - Uses upward & downward communication - Does no criticize *best used with experienced, expert, mature staff who know roles; when all group members are highly motivated & self-directed, can result in much creativity & productivity *appropriate when problems are poorly defined & brainstorming is needed to generate alternative solutions Disadvantage: can be frustrating d/t non-directional style; group apathy & disinterest can occur

Functional Nursing

Scientific Management ~ efficient management of time, tasks, energy & efficiency in use of staff - by using time & motion studies & the expertise of experienced workers, work could be scientifically designed to promote greatest efficiency of time & energy

Charismatic power

Personal Distinguished by some from referent power but more personal type (referent power gained only through assoc with powerful others)

Legitimate power

Position power; authority Gained by title or official position Inherent ability to create feelings of obligation or responsibility Socialization & culture of subordinates will influence to some degree how much power manager has

Interprofessional teams

Provide primary care in the form of primary health-care teams (PHCTs); teams typically include (but not limited to) physicians, NPs, nurses, PT, OT, and social workers working collaboratively to deliver coordinated patient care

Flat Organizational Designs

Remove hierarchical layers by flattening the chain of command & decentralizing organization Single layer of managers would oversee a large # of subordinates & have a wide span of control More authority & decision making can occur where the work is being carried out

Functional Nursing

Requires completion of specific tasks by different nursing personnel Major advantage = efficiency; tasks completed quickly its little confusion regarding responsibilities Allows care to be provided with minimal RNs (works well in places such as the operating room) May lead to fragmented care & possibility of overlooking pt priority needs May not be cost effective d/t need for many coordinators Employees often focus only on own efforts, with less interest in overall results *most nursing students begin clinical training by doing some form of functional nursing care then advancing to total patient care for a small # of pt's

Delivery Care Structure

Should facilitate meeting the goals of the organization, be cost-effective, satisfy the pt, provide role satisfaction to nurses, allow implementation of the nursing process, and provide for adequate communication among health-care providers Many nursing units have a history of selecting methods of organizing care based on the most current popular mode rather than objectively determining the best method for a particular unit or department ~not every nurse desires a challenging job, with the autonomy of personal decision making

Informational power

The need for information When people have info that others must have to accomplish their goals

Management

The process of leading & directing all or part of an organization through the deployment & manipulation of resources

Democratic/Participative

Theory Y - Shares responsibilities, authority delegated - Less control maintained - Decision making involves others - Emphasis on "we" - Communication is two-way; flows up & down - Economic & ego awards are used to motivate (internal drives) - Directs through suggestions & guidance - Draws & welcomes new ideas; encourages intercommunication & contributions - Uses role to motivate staff to achieve communal goals (shared governance) - Related to both positive nurse & patient outcomes (d/t emphasis on leader's ability to create positive relationships with the organization) - Increased staff satisfaction & motivation - Criticism is constructive *appropriate for groups who work together for extended periods, promotes autonomy & growth of individual staff ~particularly effective when cooperation & coordination between groups are necessary Disadvantage: many people must be consulted, so takes longer & may be frustrating for those who want decisions made rapidly

Servant Leadership

To be a great leader, one must be a servant, helper, & teacher first, then a leader ~ the belief that honestly sharing critical challenges with all parties & asking for their input is more important than personally providing solutions ~ always think before reacting ~ choose words carefully so as not to damage those being led ~ ability to use foresight & intuition ~ seeing things whole & sensing relationships & connections Conceptualization: a visionary for the organization providing a sense of the goals & directions; the "big picture"

Organizational Culture

Total of organizations values, language, traditions, customs, & sacred cows - not open to discussion or change (i.e., hospital logo that had been designed by the original board of trustees - not considered for updating or change) System of symbols & interactions unique to each organization. It is the ways of thinking, behaving, and believing that members of a unit have in common Leader must take active role in creating kind of organizational culture that will ensure success - more entrenched the culture & pattern of actions, the more challenging the change process is for the leader Success in building a new culture may require new leadership &/or assistance by the use of outside analysis Example: Challenges est a culture where EBP is the norm. Often bc senior management or organization leaders have not taken active role in emphasizing the importance of change

Transactional vs Transformational

Transactional leaders focus on tasks & getting the work done. Transformational leaders focus on vision & empowerment

Leader Qualities

Understand human behavior: ~ have insight into its relationships to beliefs, values, feelings ~ be sensitive to others feelings & problems Use effective communication skills: ~ be clear & concise, avoid ambiguity ~ use appropriate format (verbal, written, formal, informal) ~ be aware of own nonverbal behavior Use power appropriately: ~ use power attained through place in table of organization (positional); do not abuse power ~ use power attained through knowledge & experience or perceived by staff (professional) Respond to staff needs: ~ listen attentively; attend to needs; provide positive feedback; avoid favoritism; set realistic expectations; avoid mixed messages ~ treat staff with respect; counsel privately; keep promises; avoid threats, superior attitude, criticism, or aggressive confrontation Delegate appropriately (leader retains accountability): ~ right person (competent subordinate) ~ right task (within scope of practice) ~ right situation (appropriate to abilities & patient acuity) ~ right communication (clear instructions, validate understanding) ~ right supervision (assess actions, evaluate outcomes) Provide opportunities for personal growth: ~ help less experienced nurse to increase knowledge, experience, responsibility (mentor/preceptor, continuing education, staff education) Use critical thinking & problem solving: ~ encourage staff to engage in critical thinking by involving in assessing, planning, & evaluating outcomes Recognize & address conditions conducive to change: ~ ensure that all staff have a stake in the outcomes ~ include all creatively in the process ~ focus on benefits ~ provide positive feedback ~ offer incentives ~ ensure change is planned, introduced gradually, initiated in a calm manner rather than chaotic atmosphere ~ best after a prior successful change ~ recognize & address resistance ~ identify causes of resistance: threatening; lack of understanding; disagreeing with purpose/approach, beliefs, values; increase in responsibility; content with status quo; fear of failure.

Situational/Contingency/Multicratic

Uses best of all 3 other styles - Leaders move dynamically along the continuum of leaderships styles in response to each new situation/individuals involved - Leader maintains concern for the people Hersey & Blanchard ~ developed tridimensional leadership effectiveness model that predicts which leadership style is most appropriate in each situation on the basis of the level of the followers maturity - As people mature, leadership style becomes less task focused & more relationship oriented

Modular Nursing

Uses mini-teams (RN & UAPs) to provide care to a small group of patients, usually centralized geographically Keeping team small & attempting to assign personnel to same team as often as possible should allow professional nurse more time for planning & coordinating team members Small teams requires less communication, allowing members better use of their time for direct pt care activities

Team Nursing

Uses nurse-leader (RN) who coordinates team members of varying educational prep & skill sets in the care of a group of patients Team leader responsible for knowing the condition & needs of all the pt's assigned to the team & for planning individual care Through extensive communication, comprehensive care can be provided for pt's despite a relatively high proportion of ancillary staff (work under direction of professional nurse) Associated with democratic leadership Team members given as much autonomy as possible when performing assigned tasks, although the team shares responsibility & accountability collectively Need for excellent communication makes difficult to implement team Nursing & requires great self-discipline of team members High job satisfaction Insufficient time for team care planning & implementation - leads to blurred lines of responsibility, errors, and fragmented care

Total Patient Care

Utilizes case method of assignment, oldest form of patient care organization & still widely used today Provides nurses with high autonomy & responsibility Assigning pt's is simple & direct & does not require the planning that other methods of patient care delivery require. Lines of responsibility & accountability are clear Pt receives holistic & unfragmented care during nurse's shift Pt can receive multiple approaches to care often resulting in confusion Requires highly skilled personnel & thus may cost more than other methods Greatest disadvantage = when nurse is inadequately prepared or too inexperienced to provide total care