LM 2

Sarah determines, in partnership with her patient, that current medications are not enabling her patient, a married account executive with fibromyalgia, to continue with her employment and family responsibilities. After searching for additional information on fibromyalgia, Sarah finds nonpharmacologic interventions that are supported through credible evidence. Sarah suggests that the patient, her physician, and she meet to discuss the medications and possible options and a plan of care for the patient's discharge. This action exemplifies which of the four historical concepts identified by Lewis and Batey? a. Authority b. Responsibility c. Communication of conflict d. Autonomy

ANS: A Authority refers to the use of professional status and power to act in the patient's best interests. In this example, Sarah is using her professional status and power to set up a conference in which her patient, the prescribing physician, and she can discuss what is not working for the patient and potential options. REF: Page 349 TOP: AONE competency: Professionalism

A Magnet™ hospital surveys the staff about job satisfaction. This type of environment, in which nurses have authority and autonomy, is linked with: a. Client satisfaction with the healthcare organization. b. Organizations with a limited number of nurse managers. c. Private, specialty organizations in urban areas. d. Sophisticated academic health sciences universities.

ANS: A Autonomy and authority in decision making that is consistent with scope of practice are linked both to higher job satisfaction and to higher patient satisfaction with care. Job satisfaction is an important indicator of the quality of patient care. REF: Page 350 TOP: AONE competency: Business Skills

The Emergency Department staff decides to use a collective bargaining model for negotiation rather than a traditional trade union model. A traditional trade union model is characterized by: a. Positional conflict. b. Management support of labor's initiatives. c. A spirit of trust between management and labor. d. An ability to resolve complaints.

ANS: A Collective bargaining encompasses management support of labor's initiative, a spirit of trust between labor and management, and resolution of problems. It replaces the positional conflict that has been associated with traditional trade unions. Models such as the interest-based problem solving (IBPS) model seek to avoid positional conflicts such as those between labor and management that do not take into account the opposing party in any way. REF: Page 354 | Page 357 TOP: AONE competency: Business Skills

Sandra, an RN on the surgery unit, is assisting with a procedure in the patient examination room. The physician orders a medication to be given through IV. Sandra questions the order, based on her knowledge of the patient's history and of other medications that the patient has been given. The physician reiterates the order and Sandra refuses to give it. In this instance, Sandra is demonstrating: a. Autonomy. b. Accountability. c. Authority. d. Best practice.

ANS: A In this situation, Sandra is exemplifying autonomy, which is the act of making independent decisions in the best interests of the patient, based on her knowledge and experience. This is analogous to the example in the text where the workers on the manufacturing floor have the independence to say "Stop the line" when something is wrong. Key to the concept of autonomy is decision making and the level of independence that is given. Accountability refers to achievement of outcomes, and authority refers to the capacity to make decisions. REF: Page 349 TOP: AONE competency: Knowledge of the Health Care Environment

You are hired as a new manager. When the offer of employment is made, you agree to at-will employment. Later, you become very concerned about the policies and practices of your organization and their impact on patient care. You speak with your supervisor several times about your concerns, but no action is taken. In considering your next steps, you: a. Consider your increased vulnerability under the terms of your employment. b. Recognize that your supervisor is more vulnerable than you are because of her more senior position. c. Are more likely as a leader to take action because you are well protected from repercussions by federal and state regulations. d. Contact your union to discuss your concerns and review your options.

ANS: A Managers of at-will employees have greater latitude in selecting disciplinary measures for specific infractions. State and federal laws do provide a level of protection; however, an at-will employee may be terminated at any time for any reason except discrimination. At-will employees, in essence, work at the will of the employer. Nurses in these positions need to know their rights and accountability. REF: Page 356 TOP: AONE competency: Business Skills

As a new nurse manager who has "inherited" a unit with high nurse turnover and complaints of patient dissatisfaction, your first course of action would be to: a. Determine levels of nurse engagement on the unit. b. Review the personnel files of nurses who have resigned. c. Interview upper management about their vision for the unit. d. Meet with your staff to clarify your vision for the unit.

ANS: A Multiple studies demonstrate that a healthcare organization that provides a climate in which nurses have authority and autonomy has better patient outcomes, retains nurses at a higher rate, is more cost-effective, and has evidence of greater patient satisfaction than an organization in which such a climate does not exist (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Dunton, Gajewski, Klaus, & Pierson, 2007). Organizational assessment assists in identifying the reasons for high nurse turnover and patient complaints. REF: Page 349 | Page 350 TOP: AONE competency: Knowledge of the Health Care Environment

Senior executives at Hospital A determine that the hospital will engage in a strategic planning process after changes in healthcare funding and concerns expressed in the community about care that is being delivered at the hospital. The senior executives decide on a participatory process in which staff are widely consulted regarding input about the organization and the external environment and are actively invited to be part of decisions related to the mission statement, goals, and objectives. For true shared governance to be seen as part of this approach: a. It must be evident in the outcomes of the process that staff and senior executives have partnered on the decisions. b. Stakeholders must be assured of the value of their input even though final decisions rest with senior executives. c. Publications must clearly outline how staff input was solicited and obtained. d. Staff must be reassured that significant concerns will be kept in mind even if they have not been addressed in planning documents.

ANS: A Shared governance demands participation in decision making. When partnership, equity, and ownership are not involved, then shared governance has not occurred, and publication and expressions of appreciation for input will not be seen as representative of shared governance. REF: Page 351 | Page 352 TOP: AONE competency: Knowledge of the Health Care Environment

Nursing labor management partnerships: a. Engage nurses at all levels in problem solving for better patient care. b. Require unions and management to negotiate in good faith regarding hours of work and wages. c. Have been shown to have negligible effects on nurse turnover and patient outcomes. d. Have typically resulted in increased polarization of nurses and management, leading to formation of collective bargaining units.

ANS: A The development of a nursing labor management partnership is an approach that can be used in most professional nursing environments. This process recognizes nurses as leaders on all levels and provides formal and informal mechanisms for professional nurses to work together to achieve shared goals through collaboration and shared decision making or decentralized decision making. A study of a nursing labor management partnership suggested that nurse satisfaction was higher, turnover was lower, and more time was available for patient care. REF: Page 355 TOP: AONE competency: Business Skills

Nurses in an Emergency Department, in an inner-city neighborhood characterized by high levels of violence, are concerned with low levels of security presence in their department. Security levels have recently been decreased and the nurses question why this has occurred. An appropriate action would be to: a. Provide nurses with information about rationale for recent changes in security staffing. b. Refer the matter to the head of security and let her deal with it. c. Provide mentors who can help nurses diffuse aggressiveness. d. Accept the security levels as a consequence of funding realities.

ANS: A Workplace advocacy is an umbrella term encompassing activities within the practice setting. Workplace advocacy includes an array of activities undertaken to address the challenges faced by nurses in their practice settings. The focus of these activities is on career development, employment opportunities, terms and conditions of employment, employment rights and protections, control of practice, labor-management relations, occupational health and safety, and employee assistance. The objective of workplace advocacy is to equip nurses to practice in a rapidly changing environment. One manifestation of workplace advocacy is ensuring that relevant information is shared about decisions that affect practice so that further data gathering and decision making (in this instance about security levels and nurse safety) is informed. REF: Page 352 TOP: AONE competency: Communication and Relationship-Building

In opening a new dialysis unit, the nurse manager has to develop a philosophy for the unit. This philosophy needs to: a. reflect the culture of the unit and its values. b. be developed by the nursing manager on the unit. c. identify the clients that will be served on the unit. d. replicate the organization's philosophy.

ANS: A A philosophy expresses the values and beliefs that members of the organization hold about the nature of their work, about the people to whom they provide service, and about themselves and others providing the services.

"Georgia Hospital will provide care that is a national example of consumer service" is a: a. vision statement. b. statement of philosophy. c. mission statement. d. rationale for care.

ANS: A A vision statement is an articulated goal that provides an inspirational target to which the organization aspires at some future time. A statement of philosophy expresses values and beliefs, and a mission statement provides the reason for the existence of the organization.

A nurse manager in a for-profit environment finds it difficult to recruit staff. This difficulty may be most related to aggressive profit goals and: a. lower salary compensation for staff. b. rising expectations of impoverished and indigent individuals for services. c. poor orientation and retention practices for staff. d. an overwhelming emphasis on accepting learners from health disciplines.

ANS: A For-profit hospitals tend to have lower wage and salary costs that are most likely connected to aggressive goals for profit.

A facility that provides care for patients whose average length of stay is less than 30 days and to patients whose average length of stay is longer than 30 days, and who require inpatient and ambulatory care for addictions, through a spectrum of wellness and illness services and providers, would be considered: a. a healthcare network. b. a tertiary care institution. c. rehabilitative. d. long-term care.

ANS: A Healthcare networks embrace and provide wellness and illness services, including primary, secondary, and tertiary care, through a network of providers.

A merger has occurred between a hospital and a local home health agency, creating new roles for the nursing staff in both agencies. The nurse managers of both systems begin to evaluate and revise patient care processes and systems. With the merger, the healthcare organization's changes are: a. creating more jobs in the community for registered nurses. b. resulting in an overall loss of jobs for registered nurses. c. controlled by the federal and state governments. d. controlled by the insurance agency.

ANS: A Home care agencies staffed appropriately with adequate numbers of professional nurses have the potential to keep older adults, those with disabilities, and persons with chronic illnesses comfortable and safe at home. Home care is the fastest growing segment in health care and the volume of home health care may have a subsequent impact on the numbers of nurses required.

While making rounds, a night supervisor finds a unit with a low census and too many staff members. The night supervisor is performing as a statutory supervisor when he or she: a. Assigns nurses to care for specific clients. b. Develops a protocol for unlicensed personnel. c. Recommends transferring a nurse to another service. d. Teaches a nurse to use a new piece of equipment.

ANS: C The night supervisor is acting in accordance with the National Labor Relations Act, which would enable the supervisor to assign nurses to care. REF: Page 349 TOP: AONE competency: Business Skills

Taylor Hospital has well-defined organizational units that provide maintenance, financial services, care for cardiac patients, care for surgical patients, and so on. The organizational chart indicates that surgical units report to a surgical manager and all nursing units report to a vice president of nursing; financial services to an accountant and then to a business executive; and so on. The primary disadvantage of this organizational structure is: a. breakdown in function and communication across specialties. b. lack of congruence in culture and organizational values. c. highly centralized decision making and authority. d. wide span of control.

ANS: A In a functional organizational structure, departments and services function according to specialty. This model supports professional expertise but can lead to silos in communication and decision making and discontinuity in patient services.

The hospital administration gives approval to the chief nursing officer to hire clinical nurse specialists in staff positions rather than in administrative positions. A clinical specialist who has staff authority but no line authority typically is able to: a. function through influence. b. take complete responsibility for the care of clients. c. interview and hire staff nurses for designated nursing units. d. be granted functional authority to determine standards of nursing care and enforce them.

ANS: A Staff positions provide support to line positions but have no direct accountability for staff or patient outcomes and therefore function through influence.

As a nurse manager in a hospital, you would expect what to be the major contributor to funding and revenues in your organization? a. The federal government b. Medicare c. Medicaid d. Blue Cross/Blue Shield

ANS: A The federal government is responsible for both Medicare and Medicaid and is the largest and most influential health insurance program in the United States. The federal government is the primary payer of healthcare costs in the United States.

The chief nursing officer is given the task of reviewing and proposing revision of the organization's mission, philosophy, and technology. In reviewing them, the chief nursing officer understands that they should be reflected in: a. the organizational structure. b. line and staff responsibilities. c. the policies and procedures. d. government regulations.

ANS: A The mission statement is an important foundation for the organizational structure and defines technology and human resources required for the organization.

With the help of a federal grant, the local school nurse has established a spreadsheet that contains relevant nursing data so that she can analyze children's health. School health programs are: a. increasingly seen as primary care sites for children. b. providing only health education programs for children and their parents. c. capable only of providing referrals for health problems to primary care providers. d. funded exclusively by local authorities.

ANS: A Traditionally, school health programs were organized to control infectious disease outbreaks, treat and control on-site injuries, and educate parents and children about basic health. Increasingly, schools are being seen as primary healthcare sites for children.

With revenue reductions and cost-saving measures, the number of managers has been reduced, this has increased the number of team leaders supervised by managers by as many as three. This change may result in: a. decreased patient satisfaction. b. increased efficiency in costs. c. a more positive perception of managers. d. little change to manager-staff relationships.

ANS: A When a span of control becomes too large, supervision can become less effective, which can have a negative effect on staff-manager relationships and on the overall quality of patient care.

In the Unity Healthcare organization, communication flows: a. laterally. b. bottom to top. c. top to bottom. d. intermittently.

ANS: C In a bureaucratic organization, communication flows vertically top to bottom.

Martin, the unit manager, receives complaints from community agencies that patients who have been discharged from his unit seem to lack understanding about their disorder and immediate strategies for managing elements of their care. Martin checks the patient teaching sheets and notes that the sheets are initialed by staff. He calls the agencies and indicates that teaching has been done. Potential outcomes of Martin's actions include (select all that apply): a. Poor morale on the unit. b. Disruption in community relationships. c. Corruption of patient-staff relationships. d. Patient outcomes for quality care are met.

ANS: A, B, C Kupperschmidt (2004) points out that when accountability is not accepted, then relationships suffer, professional practice is diminished, and self-esteem suffers. REF: Page 350 TOP: AONE competency: Professionalism

As a nurse manager in a for-profit hospital, you are interested in promoting teaching programs for physicians, because evidence suggests that hospitals with teaching programs tend to promote better care for patients. Your administration indicates that it cannot support your ideas or proposal because of: (Select all that apply.) a. increased salary costs. b. duplication of tests and procedures. c. graduate medical education. d. potential damage to reputation through learner error.

ANS: A, B, C Teaching hospitals tend to incur higher costs because of the salaries required for supervision of physicians, duplication of tests and procedures through the learning process, longer times required to process patients, costs of state-of-the art technology, biomedical research, and stand-by capacity of specialized care. Because of the additional costs, few for-profit agencies and organizations support teaching programs.

Organizational culture includes: (Select all that apply.) a. norms. b. traditions. c. behaviors. d. values.

ANS: A, B, C, D Organizational culture, the reflection of the norms or traditions of the organization, is exemplified in behaviors that illustrate values and beliefs.

Martin, the unit manager, receives complaints from community agencies that patients who have been discharged from his unit seem to lack understanding about their disorder and immediate strategies for managing elements of their care. Martin checks the patient teaching sheets and notes that the sheets are initialed by staff. He calls the agencies and indicates that teaching has been done. Martin's follow-up to complaints from the community is: a. Appropriate and indicates that he has assumed accountability for the actions of his staff. b. Indicative that he does not clearly understand the concept of accountability. c. Indicative of strong support for his staff and their autonomy. d. Important in clarifying the difference between his accountability and that of the community in patient care.

ANS: B Accountability refers to the achievement of desired outcomes. If community agencies are noticing that limited or no change in patient behavior has occurred despite teaching on the unit, then the staff has not achieved accountability, and he is not holding his unit responsible for the outcomes. Martin is also demonstrating lack of accountability. REF: Page 350 TOP: AONE competency: Professionalism

Government and third-party payers announce reduction of compensation for the delivery of patient services. Hospital STV has a flat organizational structure. After the funding announcements, senior officials at the hospital meet and make decisions regarding cost containment of new revenue streams. This action is consistent with: a. The practice of leaving financial decisions with senior officials who understand the total context of funding. b. A tendency to concentrate decision making during economic downturns at the top administrative level. c. A need to make expedient decisions that are likely to be poorly received by staff. d. Ensuring that decisions with regard to cost are made equitably across all departments.

ANS: B During times of economic downturn, decisions tend to become very centralized to avoid risk. History demonstrates that increasing the breadth of input during these times is more effective than narrowing it. REF: Page 351 TOP: AONE competency: Knowledge of the Health Care Environment

In accomplishing the goal of breakfast for children in elementary school, Leanne is particularly effective in approaching businesses with the needs that the group has determined and articulating the ways that the group has found for businesses to participate. Leanne is exemplifying: a. Leadership. b. Followership. c. Professionalism. d. Knowledge of context.

ANS: B Effective followership involves active and loyal involvement in an agenda that has been established. In this role, Leanne is supporting and operationalizing the agenda and strategies that have been established within the group. REF: Page 349 TOP: AONE competency: Communication and Relationship-Building

On Unit 62, the nurses and the unit manager have been involved in shared decision making related to the model of nursing care delivery that the unit will adopt. All individuals have participated and been involved in decision making and implementation of changes. When issues arise during implementation, it is expected that: a. Accountability resides entirely with the unit manager. b. Individual expertise will be utilized to provide solutions, but that responsibility for the change is shared. c. No one really has any accountability or responsibility for the changes. d. This will contribute to widespread skepticism among the staff about the probability of success.

ANS: B High-performing organizations provide for participation by all stakeholders, and each stakeholder shares responsibility and risk. This kind of environment is more satisfying for nurses and is characterized by optimism and trust. REF: Pages 350-352 TOP: AONE competency: Knowledge of the Health Care Environment

In Hospital STV, senior administration is strongly oriented toward fiscal and social conservatism. The nursing department is deeply concerned with the provision of quality to the community, which includes a high number of poor and unemployed. To accomplish the goals of the nursing department, resources need to be allocated that administration is not able to allocate. Nursing and administration: a. Are engaged in shared governance. b. Are involved in an irreconcilable conflict of interests. c. Represent separate subcultures in the institution. d. Represent union and nonunion conflict.

ANS: C Institutions can have several subcultures, which are represented by unique features and distinct ideologies. Subcultures can be congruent and can support healthy relationships in the organization, or they may be separated and characterized by tensions that may be irreconcilable and destructive. From the information given in this scenario, it is not evident that shared governance, union presence, or irreconcilable differences are present. REF: Page 351 TOP: AONE competency: Knowledge of the Health Care Environment

Nurses on the dialysis unit notice that changes in labeling of fluids have meant several alarming near misses in terms of wrong administration of fluids. They take this concern to the unit manager. As an advocate of nurse autonomy, the most appropriate response in this situation would be to: a. Ensure that the nurses are aware of the reasons for the change and how the decision was made about the new labels. b. Discuss concerns about the labels and develop potential solutions that take into account changes that can be made at the local level and those that need system intervention. c. Suggest that the staff wait until they have become more familiar with the labels before taking further action. d. Tell the staff that you will notify the pharmacy about these concerns and leave it up to the pharmacy to decide what should be done.

ANS: B Participation in decision making regarding one's practice is an appropriate expectation for professional nurses, provides for greater autonomy and authority over practice decisions, contributes to supporting the professional nurse, and is a major component of job satisfaction (Kramer et al., 2008; Pittman, 2007). Autonomy is encouraged through supportive management and through unit-level support of changes without the need for complex, multilevel approval of changes that can be made locally. REF: Page 348 | Page 349 TOP: AONE competency: Leadership

The Emergency Department staff members are concerned that working long hours without rest puts patient safety at risk. One staff member decides that she will risk her job and become a whistleblower. Whistle-blowing is an appropriate recourse when management: a. Disregards due process when disciplining a nurse. b. Delays responding to repeated efforts to provide safe care. c. Hires nurses who are not a part of the union during a strike. d. Refuses to bargain in good faith with the elected bargaining agent.

ANS: B Whistle-blowing is often a result of organizational failure, including failure of the organization to respond to serious danger or wrongdoing created within the environment, which, in this instance, involves conditions that put the patient at risk. REF: Page 349 TOP: AONE competency: Business Skills

The chief nursing officer utilizes the hospital's workplace advocacy to help the overwhelmed Emergency Department staff. Workplace Advocacy is designed to assist nurses by: a. Creating professional practice climates in their institutions. b. Equipping them to practice in a rapidly changing environment. c. Negotiating employment contracts. d. Representing them in labor-management disputes.

ANS: B Workplace advocacy encompasses a number of activities that enable nurses to control the practice of nursing and to address challenges that they face in the practice setting. These activities include career development, employment rights, employment opportunities, and the labor-management relationship. The aim of workplace advocacy is to proactively equip nurses to practice within a rapidly changing environment, rather than to negotiate contracts or provide representation in employment disputes. REF: Page 352 TOP: AONE competency: Business Skills

The chief nursing officer and the dean of the School of Nursing create a partnership based on belief that by establishing rules and regulations and controlling the environment, this partnership will: a. promote professional medical authority, autonomy, and responsibility. b. need a degree of flexibility to engender success. c. be essential for self-governance. d. provide for the establishment of medical committees.

ANS: B Bureaucratic structures have a centralized command structure (chain of command) with a clear division of labor and well-articulated and commonly accepted expectations for performance. Rules, standards, and protocols ensure uniform actions and limit individualization of services and variance in workers' performance. Although bureaucracy enhances consistency, by nature, it limits employees' autonomy and thus the potential for innovations.

The local health department nurse manager has developed and implemented a disaster readiness plan as part of a community service. Community services: a. care for the specific needs of individual families in the community. b. focus on the treatment of community-wide problems rather than on individual health problems. c. do not include services provided by public health departments. d. provide personal health follow-up for all acute care hospitalizations.

ANS: B Community services, including public health departments, are focused on the treatment of the community rather than that of the individual. These funds provide personal health services, care for communicable diseases, services for children with birth defects, mental health care, investigation of epidemiology, and treatment of bioterrorism threats and attacks. Monies are allocated also for environmental services and for health resources.

At Hospital XYZ, staff members on Y3 Unit have dealt with the third charge nurse in 3 years. Donna, the current charge nurse, lacks confidence in patient-nurse relationships, and scheduling and other processes are routinely left to the last minute. Staff members approached Donna first and then administration with their concerns about Donna's effectiveness as a leader. The staff was told that the problem is likely staff related, that it is simply an unhappy group, and that there is nothing that will be done further about their concerns. The philosophy of the organization indicates that "open, transparent communication between staff and management is desired and supported," and that "innovation and creative thinking are the foundation of the organization's progress." In assessing this situation as a newly hired senior executive, you anticipate that: a. staff members will resolve the conflict on their own. b. the situation will lead to ongoing disgruntlement and attrition. c. no further discussion or concerns will come out of the situation. d. the head nurse will be able to resolve the conflict on her own.

ANS: B Lack of congruence between the stated philosophy of the hospital and the experienced organizational culture does not support either the staff or the charge nurse and likely will result in ongoing frustration, confusion, and morale, which could result in increased attrition.

In matrix organizational structures, a nurse manager understands that this type of structure: a. is a simplified organizational structure. b. has both a functional manager and a service or product-line manager. c. arranges departments strictly according to function. d. promotes harmony in organizational decision making.

ANS: B Matrix structures are complex, integrated organizational structures that involve both functional and service or product-line managers. In this structure, team members or teams from various functional departments may combine to complete a project or program, thereby becoming responsible to both their functional department manager and their product-line manager.

"At Thoroughcare, we provide health care for women and children in transition" is an example of a: a. vision statement. b. mission statement. c. goal statement. d. statement of philosophy.

ANS: B Mission statements provide a reason or rationale for the existence of the organization and are indicative of the structure of the organization and of who consumes the services provided.

Tracy is an RN case manager who interfaces between the Centers for Medicare & Medicaid. Tracy's responsibilities most likely would include: a. managing physician-led research. b. monitoring physician documentation of the need for medical care. c. determining which services are designated fee-for-service. d. identifying errors in physician diagnoses.

ANS: B Nurse case managers serve as interfaces for the Centers for Medicare & Medicaid Services (CMS) and are key in monitoring compliance with Conditions of Participation (CoP) elements. The case managers routinely monitor for appropriate physician documentation of medical necessity and other required CoP elements

A local hospital has formed a corporate partnership with a reputable HMO (health maintenance organization). The nurse manager has had to educate staff and personnel about the financial implications of this partnership. An HMO: a. provides more expensive care than other types of insurance plans. b. has a centralized administration that directs and compensates physician services. c. pays physicians on a fee-for-service basis. d. does not pay as much for acute care as other practice plans.

ANS: B The HMO is a configuration of healthcare agencies that provide basic and supplemental health maintenance and treatment services to voluntary enrollees who prepay a fixed periodic fee without regard to the amount of services used. HMOs have a centralized administration that directs and pays salaries for physician practice (e.g., HMOs).

As a nurse manager, you have been offered a position at a Veterans Administration hospital. In accepting the position, it is important for you to understand that Veterans hospitals provide: a. primary care and are privately funded. b. a range of services and are responsible to government and taxpayers. c. secondary care only and are publicly administered and funded. d. services to Veterans under an HMO.

ANS: B Veterans Administration hospitals provide a range of services to Veterans and are responsible to government and thus to taxpayers, who support the hospitals.

In an inner-city area, a group of nurses meet and develop a plan to negotiate with local businesses to support a breakfast program for young elementary schoolchildren. This is an example of: a. Community development. b. Collective bargaining. c. Collective action. d. Shared governance.

ANS: C Collective action refers to activities undertaken by a group of people with common interests and, in this example, by a group of nurses who are interested in the welfare of children in their community. REF: Page 347 TOP: AONE competency: Communication and Relationship-Building

The Emergency Department nurses' decision to organize for the purpose of collective bargaining is being driven by a desire to: a. Establish the staffing pattern that will be used. b. Determine the hours that one is willing to work. c. Create a professional practice environment. d. Protect against arbitrary discipline and termination.

ANS: C Historically, nurses were reluctant to unionize. However, concern with safety of care and quality of care, especially when tension is present in a work environment, makes unionization more desirable. U.S. Supreme Court rulings have provided for RN-only units and protection to practice according to what the profession and licensure status require nurses to do. REF: Page 356 TOP: AONE competency: Business Skills

In reviewing the current delivery model, the nurse manager is aware that a demographic change that will have a significant effect on healthcare delivery systems of the future is: a. changes in staffing patterns. b. increasing reports of violence in the workplace. c. the increasing percentage of the population that will be over age 65. d. escalations in the cost of health care.

ANS: C A demographic change that will significantly impact the healthcare system of the future is the increasing proportion of individuals 65 years and older. By 2025, more than 18% of the population is expected to be 65 years and older, which means that new healthcare organizations will evolve as the system attempts to maintain older adults in the community for as long as possible.

In what situations would you expect low morale and frustration? a. Statement of philosophy indicates "We value our staff." When staff members leave, careful evaluation is done to determine whether staff should be replaced by full- or part-time employees. b. Practices include annual staff recognition celebrations. During times of change, staff members are actively included in issue identification and solution finding. c. Recruitment ads promise opportunities for advancement for everyone. Promotions are given only to individuals with long-standing service and entrenched relationships. d. The vision indicates that there is strong commitment to lead in research. The organization has tried to implement a strong campaign to attract leading nurse researchers but has experienced difficulty in doing so.

ANS: C Although frustration may occur with external factors that affect ability to act on values and aspirations, lack of congruence between what is espoused as a value within the organization (such as promising advancement as an incentive to join the organization) and what is actually done (such as restricting advancement to internal candidates with much organizational history) can cause low morale and confusion.

The facilities department is experiencing some challenges and is undergoing reorganization. Because of your familiarity with systems theory, you: a. know that this challenge is their issue and that it has nothing to do with your unit. b. understand that such events are localized and do not have an impact on the organizational culture. c. know that the nature of challenges and reorganization in facilities will have an impact on other areas. d. anticipate that your prior experiences with facilities have no effect on the current situation.

ANS: C By nature, a system such as an organization is an interacting collection of parts that together make up the whole. Changes to one part will affect other parts and the system as a whole.

A hospital is working toward becoming a Magnet® hospital. The chief nursing officer is aware that professional nursing departments in Magnet® hospitals will: a. not be directed by nurses. b. be virtual organizations. c. be designed to maintain nursing standards of practice. d. be entitled to have client care departments.

ANS: C Hospitals that are successful in recruiting and retaining nurses have found that the major contributing characteristic to success is a nursing department that is structured to provide nurses the opportunity to be accountable for their own practice. Accountability is guided by nursing standards of practice and thus, successful nursing departments emphasize maintenance of these standards.

Collaborative partnerships between hospitals and schools of nursing are examples of hybrid organizational structures. A hybrid organizational structure: a. has many divisions of labor. b. best fits long-term care units. c. has a mixture of the characteristics of various organizational types. d. places the authority for decision making closest to the places where workers perform.

ANS: C Hybrid structures include characteristics of various organizational types and reflect the needs of the situation and the environment.

A primary care clinic is established in Pleasantville to provide comprehensive services to infants, children, and families within the community. The executive director of the clinic oversees physician and nursing services for infants, children, and families; a neurodevelopmental clinic; psychology, family counseling, and social work services; nutritional counseling; speech and hearing services; and physiotherapy. This type of organizational structure is known as: a. hierarchical. b. bureaucratic. c. service-line. d. matrix

ANS: C In service-line structures (sometimes called product lines), the functions necessary to produce a specific service or product are brought together into an integrated organizational unit under the control of a single manager or executive.

What would be the most appropriate focus in developing a business plan for a nurse-owned home healthcare service? a. Programs to educate the community on preparing healthy meals for a limited cost b. Reduction of injuries from alcohol-related accidents c. Pain management for patients with low back pain d. Reduction of falls among seniors

ANS: C Nurse-managed and nurse-owned healthcare services are part of a growing number of organizations that extend health care beyond that offered through traditional services. Growth in these organizations and services has been spurred by the implementation of the prospective payment system, which resulted in early discharge of many patients from acute care facilities. These nurse-managed and nurse-owned services focus on the care of individuals and families rather than on community-based outcomes for populations such as older adults, or on community-based issues such as injuries related to drunk driving.

In the Unity Healthcare organization, decisions, including those at the unit level, are made by a group of senior executives. Rules for employees are clear, and nursing care is delineated by procedures and protocols. This exemplifies: a. transformational leadership. b. transactional leadership. c. bureaucratic organization. d. Chaos theory.

ANS: C Organizational structure refers to the organization of a work group, rather than to its leadership, and includes where decisions are made and what the relationships are between groups. In the example given, power is centrally located, with all decisions regarding policies and procedures flowing from this central location, which is characteristic of bureaucratic organizations.

A new CEO has been hired at Valley Hospital who proposes to change the centralized organizational structure that was put in place 10 years ago, based on widespread consultation with staff. The proposed structure involves substantial flattening of the organizational structure, with significant decision making being made at the point-of-care and an emphasis on interprofessional collaboration. There is a great deal of discussion about the balance between hospital-wide budget decision making and unit-based decision making. This discussion represents: a. Chaos theory. b. organizational redesign. c. organizational reengineering. d. restructuring.

ANS: C Reengineering involves a total overhaul of an organizational structure. It is a radical reorganization of the totality of an organization's structure and work processes. In reengineering, fundamentally new organizational expectations and relationships are created. Redesign is a technique to analyze tasks to improve efficiency, and restructuring is a technique to enhance organizational productivity.

At Orangetown Hospital, the nursing department is developing a mission statement for nursing. What would be a suitable mission statement? a. "Nursing provides services for patients admitted to Orangetown Hospital." b. "To participate fully in the professional services offered by Orangetown Hospital." c. "To lead by the lamp; services for seniors." d. "At Orangetown, the nursing department provides caring services that recognize the diversity of clients and promote optimal health with clients through partnership, education, and interprofessional collaboration."

ANS: D A nursing mission statement within an organization needs to establish the reason for nursing within the organization and lays out relationships with clients, the community, and other disciplines.

A group of patients with early Alzheimer disease and their spouses approach you regarding help with the establishment of a local Alzheimer Society for the support and education of affected individuals and their families. As a manager in an ambulatory care clinic, what suggestion or advice would you offer this group? a. Self-help groups are, by nature, directed, funded, and led by those requiring help, and therefore, the patients and families should need no help from your clinic. b. Your healthcare organization would be pleased to help as long as your organization financially takes over responsibility for direction, leadership, and management. c. Through partnership, you will provide supports, if possible, that the patients and spouses themselves identify as necessary in the establishment of the group. d. The services that the patients and spouses are proposing are likely being offered somewhere else already.

ANS: C Self-help groups often are made up of, and are directed by, peers who have healthcare needs. A growing trend is the development of community-based geriatric organizations in partnership with healthcare organizations. The request of the patients and their spouses indicates that this service is needed in the community and that they are looking for assistance in setting up the Alzheimer Society rather than having your agency take over the management of the group.

Healthcare organization XYZ provides women's health services on an inpatient basis (average stay of less than 30 days). This facility would likely be considered: a. primary care, specialized. b. tertiary care, long-term. c. acute care, specialized. d. public care, specialized.

ANS: C The AHA defines an acute care hospital as a facility in which the average length of stay is less than 30 days. Because of the focus on women's health services, it would also be considered specialized.

A nurse manager at a home healthcare service has resigned to take a position at a local ambulatory care center. She has been hired because of her expertise in TJC accreditation. To initiate the changes, the nurse manager has to be knowledgeable about the differences between a home healthcare institution and an ambulatory care center, which is a primary care institution. Primary care institutions are facilities that provide: a. rehabilitative or long-term care. b. disease-restorative care. c. first access to care. d. only outpatient services.

ANS: C The spectrum of care services provided are typically described as primary care (first-access care), secondary care (disease-restorative care), and tertiary care (rehabilitative or long-term care). Ambulatory care centers are an example of primary care.

The staff members in a local Emergency Department are experiencing stress and burnout as the result of excessive overtime. The staff decides to unionize to negotiate for better working conditions. The increase in unionization within health care may be attributed to the: a. Movement from being "blue-collar workers" to being "knowledge workers." b. Excess profits in health care. c. Level of risk that exists for health care. d. Number of people who are involved in health care.

ANS: D As technology replaces unskilled workers, fewer workers are available for trade-union organizing, which has led to declines in union memberships. Nurses represent a large pool of workers who may be available for union organizing in the face of the declining pool available elsewhere. REF: Page 355 TOP: AONE competency: Business Skills

Collective action is effective in: a. Ensuring that needs of nurses are placed ahead of other disciplines. b. Defining nursing as a profession. c. Advising patients of the needs of nurses. d. Amplifying the influence of individuals.

ANS: D Individuals may have limited influence in achieving various purposes such as advancement of quality care or of the profession, whereas collective action helps to define and sustain individuals in achieving the desired purposes. REF: Page 348 TOP: AONE competency: Business Skills

In a nurse managers' meeting, strategies for ways to help retain staff are discussed. One strategy for assisting nurses in developing collective action skills is: a. Accepting the practice of "going along to get along." b. Attending as many workshops as practical. c. Spending as much time as possible in clinical settings. d. Taking the opportunity to work with a mentor.

ANS: D Mentoring facilitates development and adoption of positive interaction and other skills that facilitate good decision making. Optimism, trust, and decision making are important in collective action and shared decision making and contribute to job satisfaction and lower turnover in staff. REF: Page 351 | Page 353 TOP: AONE competency: Business Skills

Awareness and use of power have been challenging for nurses in general because of: a. Incidences of punishment by authority figures. b. Too little time in the workplace to collectively develop power strategies. c. Lack of cohesiveness and unity among nurses. d. A tradition of obedience to authority.

ANS: D Rituals and traditions such as the Nightingale Pledge have emphasized the need for the "good nurse" to be obedient to authority. This prevailing attitude has made it difficult for nurses, who typically spend considerable time in the workplace and who have opportunity through their work in teams to develop cohesiveness and unity, to develop awareness and use of power. REF: Page 348 TOP: AONE competency: Knowledge of the Health Care Environment

In looking at an organizational chart for her institution, Jennifer notes that nursing is led at the senior level by a non-nurse executive. Jennifer expresses concern that this is a reflection of how nursing is viewed within the organization. Jennifer's comments reflect: a. A concern that resource allocation will be made on a business and not a professional model. b. The dissatisfaction that occurs when lack of autonomy is given to nurses. c. Concern with the nonadvancement of nursing practice in the institution. d. An awareness of how organizational culture is reflected in organizational structure.

ANS: D The organizational chart reflects the formal structure of the organization and can reflect predominant beliefs, values, and relationships in the organization. Exclusion at senior executive levels of nurse leaders may reflect institutional beliefs about how resources are allocated, the degree of autonomy given to staff, and involvement of key groups in decision making. REF: Page 350 TOP: AONE competency: Knowledge of the Health Care Environment

As a nurse manager, you have been asked to assist in designing a subacute facility for open heart patients who require further complex care after hospitalization. In setting up the facility, what would require reassessment? a. Patients admitted to the facility must have adequate health insurance to cover the services provided. b. A local nurse education program asks you if nursing students can gain clinical experience with recovering surgical patients in the facility. c. Public funding will be provided to enable care of patients who have an ordinary course of recovery. d. The facility is an older house that is more than 30 minutes away from the acute care center.

ANS: D Because of the types of patients being accepted for care and the distance of the subacute facility from acute care, emergency response and seamless transfer issues in the event of an unanticipated crisis must be addressed. As a nurse manager, an important part of your position may be assisting to develop strategies to maximize the benefits and minimize the risks in this situation.

The Wellington Mental Health Institute is fully accredited by the AOA and not directly by the CMS. This means that the Wellington facility: a. cannot accept mental health patients who are Medicare beneficiaries. b. can care for only Medicaid and not Medicare beneficiaries. c. has not met the standards set by the CMS as determined by an external review panel. d. has been reviewed and accredited by the AOA, which is a deeming authority for CMS.

ANS: D CMS accreditation or external review of an organization's compliance with the standards set by the CMS can be conducted by the AOA, which is a deeming authority for CMS.

You are a nurse manager in a facility that is part of a national system of specialized hospitals that provide services to children and that is funded and managed through a religious charity organization. This system emphasizes compassionate, faith-based care. What level of consolidated system is represented in this example? a. First level b. Second level c. Fourth level d. Fifth level

ANS: D Consolidated systems tend to be organized into five levels. The fifth level involves special interest groups that own and operate units along religious lines, teaching interests, or related special interests that drive their activities. In this example, the facilities are funded and managed by a religious organization that provides care that is congruent with its particular faith-based values.

What is an example of an HMO? a. Nurse practitioners are paid promptly at discounted fees for each service rendered at a women's health clinic. b. Physicians in a large urban center are reimbursed for visits made to their clients. c. Physicians are paid for each service delivered to enrolled patients through a prepaid plan. d. Patients pay fixed annual fees for ambulatory care services, regardless of actual utilization of health services.

ANS: D Fee-for-service systems provide compensation to healthcare providers in group practices based on fee-for-service, which in PPQs means that fees are paid promptly but at a discounted rate. HMOs are configurations of healthcare agencies that provide health maintenance and services for enrolled patients for a fee that is preestablished regardless of utilization of service.

To prepare for the orientation of newly hired nurses, the nurse manager plans a presentation outlining the concept of healthcare networks. Healthcare networks are: a. units that provide only primary care services. b. owned by the institutions. c. a feature of all public institutions. `d. units that serve large populations.

ANS: D Healthcare networks are interconnected units. Their aim is serving large regional populations.

Sarah is a clinical nurse educator in the dialysis unit at Pines Health Center and provides education, consultation, and training support. Sarah has: a. direct responsibility for patient care. b. direct accountability for patient outcomes. c. an authority relationship to staff. d. an influence over patient outcomes.

ANS: D In a staff position, Sarah supports line positions in accomplishing the primary goals and objectives of the unit and provides support, counsel, and advice, but she has limited or no authority for decision making.

A new director of nursing in a small rural hospital wants to make changes from the traditional model of governance to a shared-governance model. Select the characteristic below that best describes the traditional organizational structure in which a staff nurse is assigned to carry out nursing tasks for clients but is not given the chance to provide input into forming the policies and procedures by which care is delivered or the standards by which care is evaluated: a. bureaucratic. b. decentralized. c. delegated authority and responsibility. d. delegated responsibility but no authority.

ANS: D In traditional structures, decision-making authority (right to act) is held by a centralized decision-making body, so that staff members have responsibility for certain functions but do not participate in decisions related to those functions.

Because of rapid turnover and the ongoing hiring of new graduates, the skill levels of staff in a busy CCU are varied. Senior staff are becoming burned out with the need to provide mentorship and guidance to new staff. As the manager, you propose the addition of a nurse in advanced practice to provide consultation and education for staff. What is this position considered? a. Hierarchical position b. Ancillary c. Line position d. Staff position

ANS: D Line personnel have authority for decision making, whereas personnel in staff positions provide education, support, advice, and counsel. The nurse in the advanced practice is providing advice and support through education as well as consultation.

A nursing informatics specialist hired by Blue Cross/Blue Shield Insurance System (a form of third-party payers benefit package for a prepaid fee that uses specific standards to approve a period of time for the use of inpatient and community health services) is participating in: a. critical pathways. b. healthcare networks. c. health maintenance organizations. d. managed care.

ANS: D Managed care strives to contain costs (e.g., through limitation of time in care) while maintaining quality. Managed care combines care delivery with financing and provides comprehensive services for a fixed prepaid fee. Group practice plans take various forms. One form has a centralized administration that directs and pays salaries for physician practice (e.g., HMOs).

What patients would most likely be covered under Medicare? a. Jim, who lives on the street and has occasional infections b. Alysha, who is on social assistance and has a 5-year-old daughter with frequent ear infections c. Karen, a housewife, 45 years of age, whose husband recently abandoned the family d. Dan, who is 68 years of age and in good health

ANS: D Medicare is a federal government program for individuals over 65 and with certain permanent illnesses, such as end-stage renal disease. Medicaid provides financing of health care for the medically indigent.

A nurse manager working for a not-for-profit organization should be familiar with the regulations that impact the organization. Not-for-profit organizations: a. pay dividends to stockholders. b. can refuse clients who are unable to pay. c. have no paid employees. d. pay no taxes.

ANS: D Not-for-profit organizations, often referred to as voluntary organizations, are controlled by voluntary boards and provide services to both paying and charity clients. Funds are redirected toward maintenance and growth as opposed to profit shares for stockholders. Historically, non-profit organizations have been exempt from paying taxes as they commit to providing an important community service.

A statement such as "We believe in the right of patients to make choices and to have care that is sensitive to their preferences and needs" is a _____ statement. a. mission b. goal c. vision d. philosophy

ANS: D Philosophy statements capture significant beliefs and values of the organization.

You are the nurse manager for a not-for-profit health service for the homeless and for drug users in an impoverished neighborhood. As the manager, your concern about sustainability is related to: a. the possibility of violence. b. an increase in prescription drugs available for abuse. c. decisions of the public board. d. an increase in uncompensated care events.

ANS: D Public and nonprofit hospitals are tax exempt and have a concomitant responsibility to provide mandated community service such as delivering care to the poor and indigent. To keep a nonprofit status, facilities must make a good-faith effort to provide community service and charity care. Nonprofit organizations located in impoverished urban and rural areas are often economically disadvantaged by the amount of uncompensated care that they provide.

What would be the most appropriate mission statement for a nursing center? a. "At Plentyville, we provide rehabilitative services for addicted adolescents." b. "Georgiatown provides treatment and prevention services for county residents." c. "At Heart, our aim is to provide services that lead the nation in health education and research." d. "At Coeur, we strive to achieve optimal pain management with patients who are experiencing chronic pain."

ANS: D The mission statements of nursing centers are oriented toward achieving optimal health status for a defined group of patients or consumers rather than being treatment or maintenance or social-support oriented.

As a nurse manager, you have been asked to be part of a design team for health services that have vertical integration. In planning for these services, your team will design a proposal that will: a. cluster like services together, such as outpatient clinics for the care of children with various developmental and medical needs. b. plan for the smooth transition of patients from the emergency services department to other units in the hospital. c. ensure that funding follows the patient from acute care to long-term care services. d. bring together acute care, ambulatory, home care, and palliative care services for the management of patients diagnosed with cancer.

ANS: D When organizations align to provide a full array or continuum of services, the arrangement is referred to as vertical integration. Benefits attributed to vertical integration include enhanced coordination of services, efficiency, and customer services.