Leadership \ 4

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.

To maintain patient safety, studies suggest that scheduling should avoid: a. rotating shifts. b. weekends. c. 8-hour shifts. d. mandatory overtime.

ANS: A Rotating shifts and overtime past 12 hours (mandatory or not) are being shown to increase nurse error and jeopardize patient safety.

Complex change situations require that the change leader promote ongoing visioning among staff members. One strategy is to: a. consciously evaluate invisible mental models. b. allow for individual outcomes. c. encourage cooperative activities. d. operate between order and disorder.

ANS: A Senge theory on change suggests that each individual or organization bases activities on a set of assumptions, or a set of beliefs, or mental pictures about the way that the world should work. When these invisible models are uncovered and consciously evaluated, it is possible to determine their influences on work accomplishment.

Which of the following are examples of application of the Leadership Rounding Tool? (Select all that apply.) a. "What is working well for you during bedside reporting?" b. "What has not worked for you today?" c. "Is there someone on your team who deserves special recognition for her efforts in the implementation?" d. "Did you have a good vacation?"

ANS: A, B, C, D The Leadership Rounding Tool suggests establishing and maintaining rapport and asking what is working well, what was a barrier, and who should be recognized, as well as answering tough questions.

A particular classification system assigns revenue according to the functional capacity of patients and the progression of patients during their stay in rehabilitation units. More independent patient activities, such as prompted voiding, require higher staff utilization than dependent activities but do not result in increased staff resources. This is an example of: a. bureaucracy. b. concern related to the validity of classification systems. c. inadequate reliability of classification systems. d. inappropriate subjectivity in making judgments about staffing.

ANS: B Validity of categories and implications for staffing levels are in question in this situation because staffing levels are not reflective of the levels of activity required for patient care.

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. US 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.

To effectively achieve a change goal/outcome in a change situation, the wound care specialist will: a. preserve the status quo. b. diminish facilitators and reinforce barriers. c. weigh the strength of forces. d. strengthen facilitating forces.

ANS: D For change to be effective, the facilitators must exceed the force of the barriers; thus, strengthening the facilitating forces would achieve this aim.

To reduce reliance on overtime hours, an organization develops a strategy for floating nurses during staff shortages. To maximize patient safety and reduce costs, the healthcare organization: a. develops a centralized pool of float nurses. b. assigns nurses from less busy units to ones with increased acuity levels. c. floats nurses only between units on which the nurses have been cross-trained. d. assigns float nurses to basic care only.

ANS: A A centralized pool usually includes experienced nurses who maintain a broad range of competencies. Other approaches are less satisfying for nurses, are less efficient, and may be less safe.

A busy neurologic ICU and step-down unit most likely would use which patient-classification system? a. Factor evaluation b. Prototype evaluation c. Hybrid system d. AHRQ system

ANS: A A factor evaluation system is considered more objective than a prototype evaluation system. It gives each task, thought process, and patient care activity a time or rating. Some patient types with a single healthcare focus, such as maternal deliveries or outpatient surgical patients, would be appropriately classified with a prototype system. Patients with more complex care needs and a less predictable disease course, such as those with pneumonia or stroke, are more appropriately evaluated with a factor system.

As a new manager, you are shocked to learn that your unit is still using heparin in heparin locks. You are aware of evidence related to this practice and want to change this practice as quickly as possible on your unit. You are in which stage of Lewin's stages of change? a. Unfreezing b. Experiencing the change c. Moving d. Refreezing

ANS: A Although you may be at a higher level of change in relation to your individual practice and knowledge of the use of change, in this situation, you are recognizing the need for change in relation to practice on the unit that you are managing. This phase is the initial phase in first-order change and will involve listening to staff to see if they perceive a similar problem.

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? 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.

The nurse manager frequently interacts with staff and other hospice facility employees. Communication is purposeful because the manager assesses current issues, such as specific satisfactions and dissatisfactions with the newly implemented computerized documentation system. Informally, the manager gathers available staff members to address similar learning needs. Many times, staff members are found coaching other staff about improving use of the new system. According to Senge (1990), the activities demonstrated in this example are: a. dialogue, team learning. b. resilience, personal mastery. c. shared vision, systems thinking. d. mental models, teachable moments.

ANS: A Building shared vision occurs when leaders involve all members in moving personal visions of the future into a consolidated vision common to members and leaders.

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.

As the unit manager, you post the staffing plan and compliance reports. This initiative is aimed at: a. maintaining unit morale. b. complying with national requirements. c. demonstrating patient outcomes. d. inviting staff participation in decision making.

ANS: A Hospitals are responsible for monitoring the extent to which actual staffing matches the staffing plans, making revisions as necessary. The Joint Commission accreditation reviews staffing plans against any obvious staffing deficiencies and patient care concerns. Posting of the staffing plan is required in some states so that staff may view it. Adequate staffing, as demonstrated through a staffing plan, and compliance reports contribute to staff morale.

To engage your staff in awareness of their current practice and how it is affirmed or not by evidence, you plan a short series of learning presentations on evidence and use of heparin and saline to maintain IV patency. You meet with the educator to plan out the goals for each session with the overall purpose of increasing knowledge and awareness of staff in readiness to consider questions related to the IV practice. This learning approach is an example of which change management approach? a. Linear b. First-order c. Facilitative d. Integrative

ANS: A In the second stage, the moving or changing stage of Lewin's first-order, planned change process, planned interventions and strategies are executed to support the implementation of the change. One commonly used method is educating staff about the need for the change.

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.

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.

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. Organizational assessment assists in identifying the reasons for high nurse turnover and patient complaints.

The difference between staffing and scheduling is that staffing: a. puts the right person in the right position. b. puts the right person in the right time and place. c. refers to the number of nursing hours per patient per day. d. looks after interpretation of benefits and compensation.

ANS: A Nursing staffing involves planning for hiring and deploying qualified human resources to USNT meet the needs of a group of patients. Scheduling, on the other hand, is a function of implementing the staffing plan by assigning unit personnel to work specific hours and days of the week.

Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because "the unit has been using heparin for years and there has never been any adverse effects." You follow up with Elizabeth and discover that she is really quite angry about the information sessions because she feels that you are implying that "what she has been doing all these years means that she is incompetent and doesn't care about her patients." After speaking with Elizabeth, a few days later you discover that she is now fine with the change but is concerned that other areas of the organization might resist the change because of perceptions related to patient safety and cost. She suggests that it is important to bring pharmacy on board as they have had previous concerns about the use of heparin. In relation to change theory, this is indicative of: a. systems level thinking. b. linear thinking. c. interprofessional collaboration. d. first-order change.

ANS: A Senge complexity theory, Bevan Seven Change Factors, and general systems theory all highlight connectivity and the idea that changes are not isolated events.

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.

A nurse manager must also consider a number of internal variables that will affect staffing patterns. An internal variable to be considered is: a. organizational staffing policies. b. state licensing standards. c. American Nurses Association. d. consumer expectations.

ANS: A State licensing standards outline what a nurse can do. Internal policies determine what a nurse may do in a particular setting as well as the amount of flexibility that is allowed to manage times of high and low volumes, as well as changes in acuity. Organizational policies can put the nurse manager in a situation where patient safety cannot be maintained or financial obligations met.

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.

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.

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 When management accountability for activities is not accepted, then relationships suffer, professional practice is diminished, and self-esteem suffers.

In reviewing the job description of a nurse manager, the staff becomes aware that a nurse manager's role is complex. Which of the following duties are required of a nurse manager? (Select all that apply.) a. Ensure unit productivity reports. b. Develop policy and legislation to protect nurses' well-being. c. Plan staffing of UNPs only. d. Prepare a unit budget that reflects unit staffing needs. e. Monitor nurse-sensitive indicators such as falls and incidence of infections.

ANS: A, D, E A nurse manager manages financial resources by developing business and staffing plans.

A small rural hospital has been designated as a critical access hospital. It has 40 beds and an average occupancy of 34 beds. To prepare the staffing, the chief nursing officer computes the occupancy as being: a. 90% b. 85% c. 75% d. 60%

ANS: B A way to assess a unit's activity level is to calculate the percentage of occupancy. Formula: daily patient census (rounded) divided by the number of beds in the unitThe occupancy level is calculated as 34/40, or 85%.

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.

Based on Elizabeth's insights and suggestions, you involve pharmacy, only to discover that the change in practice involves practice committees, a medical practice committee, and concerns from administration about potential costs and safety of the proposed change to the IV protocols. The change process at this point is: a. linear. b. nonlinear. c. sabotaged. d. neutralized.

ANS: B Complex change involves nonlinear processes and a variety of strategies to negotiate influences on change. Complexity theories alter the traditional systems thinking approach by asserting that system behavior is unpredictable. This theory views change as emergent, nonlinear, and highly influenced by all individuals and subsystems in an organization.

An example of one strategy used to improve participation in the change process by staffing fitting the behavioral description of innovators and early adopters is to: a. repeat the benefits of the change. b. share change experiences early in the process. c. initiate frequent interactions among staff. d. provide select information to the staff.

ANS: B Connecting innovators and early adopters to new ideas and with new peers keeps them at the cutting edge.

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.

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 wide spread 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.

A nurse staffing plan takes into account: a. specific nurse-to-patient ratios per shift. b. participation of nurses in projecting staffing needs. c. compensation and benefits for each level of staff. d. the occupancy load of a unit.

ANS: B Nurse staffing plans employ nursing judgment and flexibility that is based on acuity, nurse experience, and unit configuration rather than set nurse-to-patient ratios. The American Nurses Association has opted to support the nurse staffing committee as the approach to ensure safe staffing. In 2013, national legislation was introduced that requires all acute care hospitals to establish a committee made up of 55% direct care RNs.

Nurses on the dialysis unit notice that changes in labeling of fluids have meant several alarming near miss 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. 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.

To engage your staff in awareness of their current practice and how it is affirmed or not by evidence, you plan a short series of learning presentations on evidence and use of heparin and saline to maintain IV patency. You meet with the educator to plan out the goals for each session with the overall purpose of increasing knowledge and awareness of staff in readiness to consider questions related to the IV practice. Staff nurses who gain information on current IV therapy practices are engaging in which phase of Rogers' decision-making process? a. Persuasion b. Knowledge c. Confirmation d. Decision

ANS: B Rogers' innovation—decision-making process involves five stages for change in individuals, the first of which is knowledge.

To project staffing needs and to avoid understaffing, it is important that nurse managers consider which of the following? a. Maximum productive hours b. Average non-productive hours c. Minimum benefit hours d. Maximum vacation time

ANS: B To avoid understaffing, average non-productive or benefit hours need to be taken into account, so the unit is properly staffed when staff members are off.

When goals/outcomes are somewhat unclear in early preparation for a complex change, the manager and the change management team develop several acceptable goals/outcomes. This change in management approach is termed: a. unfreezing. b. nonlinear. c. cybernetic. d. linear.

ANS: B While Lewin theory was designed to describe planned or first-order changes, many scholars think the theory is too simplistic to address how unplanned or second-order change occurs. In complex situations with an uncertain change environment, a nonlinear approach that involves flexibility improves overall outcomes. Linear change is appropriate to stable, less complex, and more predictable situations.

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.

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.

Staff members on your unit raise concern that there is rising acuity on the unit and lack of responsiveness in addressing these needs through appropriate staffing. They point to increased incidences of adverse and sentinel events on the unit. To address this concern, your hospital organization would do best to: a. implement a patient-classification system immediately. b. participate in databases that compare the outcomes and staffing levels versus those of similar institutions. c. provide increased numbers of staff to the unit. d. ignore such concerns because acuity is variable.

ANS: BStaff morale suffers both when acuity models indicate a gap between staffing and acuity and when there is no model but perceived acuity that is not being addressed. A truer approach is to monitor patient outcomes and participate in national databases that measure staffing levels through comparison with like institutions.

A factor evaluation system: a. utilizes financial data to determine number of staff-to-patient ratios. b. utilizes DRGs to determine acuity on a unit. c. combines interventions and time required for interventions to determine levels of care required. d. combines financial resources and nursing interventions to determine patient contact hours.

ANS: C A factor evaluation system considers tasks, thought processes, and patient care activities and gives them a time or rating. These are then used to determine the number of patient care hours required.

An important aspect of managing the costs on a unit is to plan accurately for staffing needs. Nurse managers use staffing plans to: a. assign staff on the unit on a daily basis. b. ensure that days off are planned for the staff. c. outline the number of individuals by classification on a per-shift basis. d. predict the numbers and classifications of float staff needed to augment regular staff.

ANS: C A nurse manager needs to manage financial resources by developing staffing plans. Staffing plans plan for minimum number of professional nurses required on a unit at a given time or to the amount of minimum staffing in an extended-care facility or prison, based on regulatory guidelines.

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.

Scheduling is a function of implementing the staffing plan by assigning unit personnel to work specific hours and specific days of the week. To retain nursing staff, the nurse manager must incorporate into the schedule plan: a. all weekends off. b. all holidays off. c. a variety of scheduling options. d. rotating shifts.

ANS: C Creating a flexible schedule with a variety of scheduling options that leads to work schedule stability for each employee is one mechanism likely to retain staff, which is within the control of nurse managers.

Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because "the unit has been using heparin for years and there has never been any adverse effects." You follow up with Elizabeth and discover that she is really quite angry about the information sessions because she feels that you are implying that "what she has been doing all these years means that she is incompetent and doesn't care about her patients." Which of the following would be the most effective response to Elizabeth? a. "I understand how you feel, but you are going to have to change." b. "It is unfortunate that you feel this way. Others seem quite excited about the new information." c. "It is difficult sometimes to change what we know very well. Sometimes it can be frightening." d. "Perhaps I can arrange some more information sessions for you, so you can see just how important this change is to patient safety."

ANS: C Dialogue can reveal areas where individuals feel inept or overwhelmed, providing the leader with an understanding of what programs need to be developed to increase personal ability to change and what educational initiatives need to be implemented to support change. To promote dialogue, leaders must serve as facilitators, promoting the sharing of ideas, fears, and honest reactions to the change proposal.

You anticipate that your region will soon move toward an e-health record system. You begin to discuss this with your staff and are disappointed that you receive little positive response from the staff about this possibility. One staff member, in particular, seems to sum it up by saying "e-health? Won't happen in my working life! There are too many problems with it, like privacy issues." This response is most likely motivated by: a. lack of urgency regarding the need to change. b. lack of evidence to support importance of technology. c. deficits in education and experience. d. lack of organizational support for change.

ANS: C For leaders to inspire change, they must have intimate knowledge of what matters to the people they manage. Kotter (2012) characterizes this as establishing a sense of urgency, and this involves overcoming complacency his is especially hard when there doesn't seem to be any visible crisis, or the crisis seems irrelevant to the people being asked to change (Kotter, 2012).

The clinical coordinator expects the position description of the new wound care specialist to change nurses' responsibilities in caring for clients with skin integrity problems. The best approach to address this need for change, yet to have the best outcomes for clients, staff nurses, and the organization, is to: a. select one of the change models. b. use Lewin's model and principles of change. c. apply both planned and complexity theory approaches. d. form a task force of nursing staff and wound care specialists.

ANS: C In the second stage, the moving or changing stage of Lewin theory, planned interventions and strategies, such as education, vision building, and incremental steps towards the change, are executed to support the implementation of the change. This situation potentially also involves complexity theories that recognize that change involves engagement of individuals and subsystems throughout the unit and organization.

As the unit manager on the unit that is leading changes to heparin locks, you find that Elizabeth is very valuable in terms of her observations about other units and her knowledge of organizational processes, and now in discussing the new procedure with others. Elizabeth might be considered an: a. engager. b. innovator. c. informal change agent. d. informant.

ANS: C Informal change agents are those who do not have formal, positional power but who have credibility through expertise and can model the new way of thinking, or who offer suggestions, ideas, and concerns.

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.

Elizabeth is an example of a(n): a. early adopter. b. late majority. c. laggard. d. resister.

ANS: C Laggards prefer keeping traditions alive ("We have always done it this way") and openly express their resistance to ideas (speaking out against the change). Late majority individuals are openly negative but will engage with new ideas when most others adopt the change.

To prepare staffing schedules, a nurse manager needs to calculate paid non-productive time. When calculating paid non-productive time, the nurse manager considers: a. work time, educational time, and holiday time. b. paid hours minus worked hours. c. vacation time, holiday time, and sick time. d. paid hours minus meeting time.

ANS: C Non-productive hours are hours of benefit time and include vacation, holiday, and personal or sick time.

In a job interview for a staff position, which of the following indicates your knowledge of patient safety? a. "Will I be able to get overtime hours on your unit?" b. "If there is an opportunity to work extra shifts, I would really like that." c. "Is there a strategy in place to reduce the number of overtime hours on the unit?" d. "I see no reason why I wouldn't be able to work overtime."

ANS: C Overtime, whether voluntary or mandatory, to fill staff vacancies is seen as a risk to both patients and nurses because it is more likely to lead to compromised decision making and technical skills because of fatigue.

In evaluating weekend mortality rates, the head nurse on the cardiac unit is surprised to find that they are higher than on weekdays. In exploring the reasons for this apparent anomaly, the head nurse focuses on: a. availability of diagnostic personnel. b. availability of physicians c. communication with on-call providers. d. acuity level of patients.

ANS: C Studies to date of off-peak hours (weekends and nights) are limited, but those that have been done indicate increased mortality during weekends and nights, when staff work with fewer and often less experienced staff and when there may be strained communication among on-call healthcare providers.

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.

The oncology clinical manager and the educational coordinator asked nursing staff to complete a brief written survey to assess their attitudes and knowledge related to having used the new infusion equipment for 6 weeks. The stage of change in this situation is: a. developing awareness. b. experiencing the change. c. integrating the change. d. perceiving awareness.

ANS: C This particular initiative assesses the success with which the change has been integrated into everyday practice after it has been experienced, or the degree to which staff members have accepted using the new infusion equipment.

The home health agency hired an expert in financial management to evaluate and propose a plan for reversing growing expenses and decreasing revenues. The expert is well respected, both personally and professionally, by members living in this small community. To be effective, staff will need to perceive this change agent as: a. trusted, quiet. b. flexible, informal. c. credible, enthusiastic d. communicative, personable

ANS: C To influence the decision, the expert must be seen as having knowledge of what matters to the people that they lead and of the change area itself. The expert also must be enthusiastic and communicative and have referent power.

The number of adverse events such as falls and pressure ulcers on the unit is increasing. An ideal staffing plan to address this issue would include which of the following? Increasing the: a. total number of staff on the unit. b. staff and RN hours per patient. c. total number of staff and implementing 12-hour shifts. d. number of RNs and number of RNs with experience on the unit.

ANS: D A number of studies have identified that adverse events such as falls and pressure ulcers can be reduced by increasing the number of RNs on a unit (relative to other personnel) and utilizing experienced RNs. Overtime and 12-hour shifts are linked to greater incidence of errors.

The American Nurses Association has advocated for the Registered Nurse Safe Staffing Act. This legislation is based on ANA Safe Staffing Principles and takes what factors into consideration for planning staffing on a nursing unit? a. Patient acuity and complexity b. Education and training of the nurses c. Technology available and use on the unit d. All factors listed are to be considered

ANS: D ANA has opted to support the nurse staffing committee as the approach to ensure safe staffing. For the last decade, the ANA has advocated for a Registered Nurse Safe Staffing Act. The legislation is based upon the ANA Safe Staffing Principles (Box 13-2) and considers the following:

An example of one strategy to improve participation in the change process by staff fitting the behavioral descriptions of laggards, early majority, late majority, and rejecters is to: a. encourage teamwork. b. transfer to a different unit. c. require attendance at staff meetings. d. delegate the roles and tasks of change.

ANS: D According to Rogers's work, the individual's decision-making actions pass through five sequential stages. The decision to not accept the new idea may occur at any stage. However, peer change agents and formal change managers can facilitate movement through these stages by encouraging the use of the idea and providing information about its benefits and disadvantages.

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.

Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because "the unit has been using heparin for years and there has never been any adverse effects." You follow up with Elizabeth and discover that she is really quite angry about the information sessions because she feels that you are implying that "what she has been doing all these years means that she is incompetent and doesn't care about her patients." Your response to her indicates that: a. Elizabeth will never adopt the change. b. Elizabeth is insecure in her practice. c. Elizabeth requires more information about the practice. d. change involves emotions.

ANS: D Change, whether proactively initiated at the point of change or imposed from external sources, affects people. Responses to all or part of the change process by individuals and groups may vary from full acceptance and willing participation to outright rejection or even rebellion. It is critical to be able to "read" people and to recognize that communication should involve people's emotions and feelings.

As the unit manager, you spend a day performing direct patient care and work with a new system that is designed to capture patient documentation at the bedside. During discussions with staff while giving care, you discover that the number of screens that need to be opened during documentation makes charting more complex and time consuming than traditional manual charting approaches. On the basis of this feedback, you: a. assume that the system is doing what it needs to do. b. provide reassurance to staff that the unit has achieved its goals in implementation of the system. c. ask some of the staff if they have had similar experiences with the system. d. consult chart audit data and end user consultation reports to determine if errors and problems are occurring.

ANS: D In Kotter eight-step change model, removing obstacles means keeping alert for barriers in structure and processes that limit the ability to change and then removing those barriers once they have been found.

Your healthcare organization has a decentralized system for scheduling. As part of this process, after you have developed a draft schedule, you may need to: a. seek budgetary approval. b. balance personal schedules against institutional needs. c. negotiate the schedule with unit staff. d. submit the schedule to a centralized staffing office for review.

ANS: D In a decentralized model, you may be completely responsible for approving all schedule changes and for development of the schedule, or you may need to submit a draft to a centralized office for review and determination of supplemental staff. Balancing personal schedules and negotiation describes staff self-scheduling models.

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.

Sarah, RN, is one of your most enthusiastic staff members and has been to a workshop on preparing educational materials for patients. On the basis of this workshop, she would like to develop an information website for patients who are being admitted to the ward. An appropriate response to Sarah's suggestion would be: a. "That is a great suggestion, but we have no resources for such an expensive undertaking right now." b. "Perhaps you can keep that in mind as we redesign our charting system." c. "We have too many seniors as patients, and you know that they don't use technology." d. "There is a great group here that meets to look at technology pilots. Let's see if you can join them and discuss your idea further."

ANS: D Involving Sarah with others who enjoy new ideas and who are able to try out new ideas in pilot projects enables her to remain on the cutting edge and to try out innovative solutions with the least amount of disruption.

A nurse manager must consider a number of external variables when preparing the personnel budget and projecting the unit's staffing needs. An external variable to be considered is: a. organizational staffing policies. b. staffing models. c. changes in services that will be offered. d. department of Health licensing standards.

ANS: D Licensing regulations of the state can determine staffing models. Staffing regulations can dictate the number of professional nurses required on a unit at any given time.

In the past year, you have noticed an increase in patient falls on your unit. In reading studies related to staffing and patient outcomes, you realize that you will need to plan for: a. higher patient care hours. b. safer facilities. c. institution of a patient-classification system. d. an increased number of RN positions.

ANS: D Lower fall rates are shown to be related to higher total nursing hours and a higher percentage of nursing hours supplied by RNs.

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.

A strategy to increase RN staff retention at Valley Hospital includes: a. better compensation and benefits. b. clearer position descriptions. c. lay-offs of nursing assistants. d. adequate staffing to meet acuity levels.

ANS: D Over the past decade, a significant amount of research has been done in the United States to evaluate links among nursing staffing, workloads, skills mix, and patient outcomes. An analysis of this research demonstrates that ensuring adequate staffing levels has been shown, among other things, to improve nurse retention and job satisfaction.

Resistance is most likely when change: a. is not well understood. b. involves many layers in an organization. c. involves nonprofessional workers. d. threatens personal security.

ANS: D Resistance and reluctance commonly occur when personal security is threatened and may involve loss of confidence in abilities or loss of job or financial security.

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.

The wound care nurse decided to involve those to be affected by change early in the change management process. This can positively result in: a. coordination. b. resistance. c. anticipation. d. participation.

ANS: D Successful change means persistence and advancement of the change, which requires the undivided focus of all team members. Early involvement and participation are critical to capturing the undivided focus of team members.

Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because "the unit has been using heparin for years and there has never been any adverse effects." According to Havelock (1973), this comment may originate from failure in which phase of the six phases of planned change? a. Generating self-renewal b. Choosing the solution c. Diagnosing the problem d. Building a relationship

ANS: D The first phase of this model of planned change involves building a relationship as a basis for later phases, which include diagnosing the problem and choosing the solution. At this point, as a new manager, the relationship may not have yet developed sufficiently with Elizabeth.

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.

A nurse manager uses many sources of data when planning the unit's workload for the year. Which of the following data must be considered in the planning? a. Hours of operation of the unit b. Trends in acuity on the unit c. Maximum work stretch for each employee d. Weekend requirements

Answer B: Acuity levels are determined through classification systems, which determine the nursing resources required.