NRS 110 leadership midterm

7 steps of Problem-Solving Process

1. Define the problem. 2. Gather information. 3. Analyze the information. 4. Develop solutions. 5. Make a decision. 6. Implement the decision. 7. Evaluate the solution. 1. Define the problem. To define a problem, ask the following: § Do I have the authority to do anything about this myself? § Do I have all the information? Do I have enough time? § Who else has important information and can contribute? § What benefits can be expected? A list of potential benefits provides the basis for comparison and choice of solutions. The list also serves as a means for evaluating the solution. 2. Gather information. 3. Analyze the information. Analyze the information only when all of it has been sorted into some orderly arrangement, as follows: § Categorize information in order of reliability. § List information from most important to least important. § Set information into a time sequence. What happened first? Next? What came before what? What were the concurrent circumstances? § Examine information in terms of cause and effect. Is A causing B, or vice versa? § Classify information into categories: human factors, such as personality, maturity, education, age, relationships among people, and problems outside the organization; technical factors, such as nursing skills or the type of unit; temporal factors, such as length of service, overtime, type of shift, and double shifts; and policy factors, such as organizational procedures or rules applying to the problem, legal issues, and ethical concerns. § Consider how long the situation has been going on. Because no amount of information is ever complete or comprehensive enough, critical-thinking skills help the manager examine the assumptions, evidence, and potential value conflicts. 4. Develop solutions. 5. Make a decision. 6. Implement the decision. 7. Evaluate the solution.

The seven steps of the decision-making process

1. Identify the purpose. Why is a decision necessary? What needs to be determined? State the issue in the broadest possible terms. 2. Set the criteria. What needs to be achieved, preserved, and avoided by whatever decision is made? The answers to these questions are the standards by which solutions will be evaluated. 3. Weigh the criteria. Rank each criterion on a scale of values from 1 (totally unimportant) to 10 (extremely important). 4. Seek alternatives. List all possible courses of action. Is one alternative more significant than another? Does one alternative have weaknesses in some areas? Can these be overcome? Can two alternatives or features of many alternatives be combined? 5. Test alternatives. First, using the same methodology as in step 3, rank each alternative on a scale of 1 to 10. Second, multiply the weight of each criterion by the rating of each alternative. Third, add the scores and compare the results. 6. Troubleshoot. What could go wrong? How can you plan? Can the choice be improved? 7. Evaluate the action. Is the solution being implemented? Is it effective? Is it costly?

rational decision making model

A step-by-step approach to making decisions that is designed to maximize outcomes by examining all available alternatives The rational decision-making model is a series of steps that managers take in an effort to make logical, well-grounded rational choices that maximize the achievement of objectives. First, identify all possible outcomes, examine the probability of each alternative, then take the action that yields the highest probability of achieving the most desirable outcome. Not all steps are used in every decision, nor are they always used in the same order. The rational decision-making model is thought of as the ideal, but often cannot be fully used. Individuals seldom make major decisions at a single point in time, and often are unable to recall when a decision was finally reached. Some major decisions are the result of many small actions or incremental choices the person makes without regarding larger issues. In addition, decision processes are likely to be characterized more by confusion, disorder, and emotionality than by rationality. For these reasons, it is best to develop appropriate technical skills and the capacity to find a good balance between lengthy processes and quick, decisive action.

Quality Management

A total commitment by everyone in an organization to improve the quality of procedures and products by reducing waste, errors, and defects. Quality management is a preventive approach designed to address problems before they become crises. Although quality management was originally designed for manufacturing, the healthcare industry has adopted various quality management strategies from the airline industry and other fields. Good management techniques can often be transferred from one use to another.

Activities can be identified according to the following: · Urgent and important · Important but not urgent · Urgent but not important · Busywork · Wasted time

Activities that are both urgent and important must be completed. Activities that are important but not urgent may make the difference between career progression and maintaining the status quo. Urgent but not important activities must be completed immediately but are not considered important or significant. Busywork and wasted time are self-explanatory.

Decision making vs problem solving

Although decision making and problem solving appear similar, they are not synonymous. Decision making may or may not involve a problem, but it always involves selecting one of several alternatives, each of which may be appropriate under certain circumstances. Problem solving, on the other hand, involves diagnosing a problem and solving it, which may or may not entail deciding on one correct solution. Most of the time, decision making is a subset of problem solving. However, some decisions are not of a problem-solving nature, such as decisions about scheduling, equipment, or in-services.

positive interruption

An interruption that is more important and urgent than the activity in which you are involved is a positive interruption: It deserves immediate attention. An emergency or crisis, for instance, may cause you to interrupt daily rounds.

Benchmarking

Benchmarking is a comparison of an organization's data with similar organizations. Outcome indicators are compared across disciplines or organizations. Once the results are known, healthcare organizations can address areas of weakness and enhance areas of strength (Nolte, 2011).

Humanistic Theory as a Bridge

Between reductive and adaptive organizational theory development is a movement from the 1930s that addresses how people respond to working in large organizations brought on by the industrial revolution. A major premise of humanistic theory is that people desire social relationships, respond to group pressure, and search for personal fulfillment in work settings. researchers concluded that the social attention and interactions created by the research itself—that is, the special human attention given to workers participating in the research—met a social need that enhanced productivity. This tendency for people to perform in an expected manner because of special attention and focused, unintentional interactions became known as the Hawthorne effect, a term now used most commonly in research but which emanated from organizational science. Although the findings are controversial, organizational theorists shifted focus to the social aspects of work and organizational design. One important assertion of this theory was that individuals cannot be coerced or bribed to do things they consider unreasonable; formal authority does not work without willing participants.

To incentivize hospitals to reduce medical mistakes, the _________________________________, the agency that oversees government payments for care, changed its reimbursement policy to no longer cover costs incurred by medical mistakes. If medical mistakes occur, the hospital must absorb the costs. Thus, pay for performance became the norm, and performance is now measured by the quality of care

Centers for Medicare & Medicaid Services (CMS)

Satisficing

Choosing an option that is acceptable, although not necessarily the best or perfect. Satisficing is not a misspelled word; it is a decision-making strategy whereby the individual chooses an alternative that is not ideal but either is good enough (suffices) under existing circumstances to meet minimum standards of acceptance or is the first acceptable alternative. Many problems in nursing are ineffectively solved with satisficing strategies.

Coaching

Coaching is a strategy that helps the recipient focus on solving a specific problem or conflict (Thorn & Raj, 2012). Coaches are often nurses or human resources staff within the organization prepared to help resolve conflicts. Conflicts could be occurring between two nurses, between a nurse and a patient, or between a nurse and a physician. In a confidential environment, the coach helps the staff member explore the exact nature of the problem, consider various alternatives (e.g., transfer, quit, do nothing), delve into embedded issues (e.g., values conflict with organization, unmatched expectations), discover links (e.g., working with friends), and identify the disadvantages of leaving (e.g., start over with vacation time, benefits, leave friends). The goal is to reduce turnover from issues that can be resolved.

Content Theories

Content theories emphasize individual needs or the rewards that may satisfy those needs. Content theories are less useful today because they specify neither what rewards would motivate an individual nor how people vary in perceiving the importance of the reward.

Creativity stages

Creativity has four stages: preparation, incubation, insight, and verification. Even people who think they are not naturally creative can learn this process (see Figure 9-2). 1. Preparation. A carefully designed planning program is essential. First, acquire information necessary to understand the situation. Individuals can do this on their own, or groups can work together. The process follows this sequence: § Pick a specific task. § Gather relevant facts. § Challenge every detail. § Develop preferred solutions. § Implement improvements. 2. Incubation. After all the information available has been gathered, allow as much time as possible to elapse before deciding on solutions. 3. Insight. Often solutions emerge after a period of reflection that would not have occurred to anyone without this time lapse. 4. Verification. Once a solution has been implemented, evaluate it for effectiveness. You may need to restart the process, or go back to another step and create a different solution.

Creativity

Creativity is an essential part of the critical-thinking process. Creativity is the ability to develop and implement new and better solutions. Creativity demands a certain amount of exposure to outside contacts, receptiveness to new and seemingly strange ideas, a certain amount of freedom, and some permissive management. Most nurses, however, are employed in bureaucratic settings that do not foster creativity. Control is exercised over staff, and rigid adherence to formal channels of communication jeopardizes innovation. In addition, there is little room for failure, and when failures do occur, they are not well tolerated. When staff are afraid of the consequences of failure, their creativity is inhibited and innovation does not take place. Maintaining a certain level of creativity is one way to keep an organization alive. New employees who are not encumbered with details of accepted practices often can make suggestions based on their prior experiences or insights before they get set in their ways or have their innovative ideas "turned off." The advantages offered by new employees should be explored because all staff gain from such use of valuable human resources. Creativity has four stages: preparation, incubation, insight, and verification. Even people who think they are not naturally creative can learn this process (see Figure 9-2). Figure 9-2 The creative process. 1. Preparation. A carefully designed planning program is essential. First, acquire information necessary to understand the situation. Individuals can do this on their own, or groups can work together. The process follows this sequence: § Pick a specific task. § Gather relevant facts. § Challenge every detail. § Develop preferred solutions. § Implement improvements. 2. Incubation. After all the information available has been gathered, allow as much time as possible to elapse before deciding on solutions. 3. Insight. Often solutions emerge after a period of reflection that would not have occurred to anyone without this time lapse. 4. Verification. Once a solution has been implemented, evaluate it for effectiveness. You may need to restart the process, or go back to another step and create a different solution.

Critical thinking

Critical thinking is the process of examining underlying assumptions, interpreting and evaluating arguments, imagining and exploring alternatives, and developing a reflective criticism for the purpose of reaching a conclusion that can be justified. Critical thinking is not the same as criticism, though it does call for inquiring attitudes, knowledge about evidence and analysis, and skills to combine them. Critical-thinking skills can be used to resolve problems rationally. Identifying, analyzing, and questioning the evidence and implications of a problem stimulate and illuminate critical thought processes. Critical thinking is also an essential component of decision making. However, compared to problem solving and decision making, which involve seeking a single solution, critical thinking is a higher level cognitive process that includes creativity, problem solving, and decision making (see Figure 9-1).

Delegation

Delegation is the process by which responsibility and authority are transferred to another individual. It involves assigning tasks, determining expected results, and granting authority to the individual expected to accomplish these tasks. Delegation is perhaps the most difficult leadership skill for a nurse or a manager to acquire. Today, when more assistive personnel are being used to carry out the nurse's work and when the manager's span of control has expanded, appropriate delegation skills are essential for both nurses and nurse managers to be successful.

______________________ is the expansion of an organization into new arenas. It provides another strategy for survival in today's economy. Two types of __________________ are common: concentric and conglomerate.

Diversification

Evidence-based practice (EBP)

Evidence-based practice (EBP) has emerged as a strategy to improve quality by using the best available knowledge integrated with clinical experience and the patient's values and preferences to provide care. Similar to the nursing process, the steps in EBP are as follows: 1. Identify the clinical question. 2. Acquire the evidence to answer the question. 3. Evaluate the evidence. 4. Apply the evidence. 5. Assess the outcome.

Affordable Care Act (ACA)

Federal legislation passed in 2010 that includes a number of provisions designed to increase access to healthcare, improve the quality of healthcare, and explore new models of delivering and paying for healthcare. Designed to provide quality, affordable healthcare for all Americans. Its emphasis is on preventing disease and coordinating care, and it provides mechanisms for the uninsured to acquire health insurance by enrolling in state or federal exchanges of health insurance companies. Through incentives and penalties, the ACA encourages healthcare organizations to establish accountable care organizations (ACO), consisting of hospitals and healthcare providers who agree to provide care to a designated population. Also changed is how primary care providers offer care via a health home (previously called a medical home). Instead of serving as gatekeepers to specialty care in order to contain costs, primary care providers facilitate access to specialty care when needed and monitor that care using electronic health records (Russell, 2014). Regular follow-ups by care providers monitor chronic health conditions and reinforce treatment regimens. Patients, too, have access to their medical records and are encouraged to participate in decisions about their care.

_____________ ___________ helps relate current behavior, activities, or operations to the long-range goals of an organization or individual.

Goal setting Without this future orientation, activities may not lead to the outcomes that will help achieve the goals and meet the ideals of the individual or organization. The focus should be to develop measurable, realistic, and achievable goals.

Brainstorming

In brainstorming, group members meet together and generate many diverse ideas about the nature, cause, definition, or solution to a problem without consideration of their relative value. With brainstorming, a premium is placed on generating lots of ideas as quickly as possible and on coming up with unusual ideas. Most important, members do not critique ideas as they are proposed. Evaluation takes place after all the ideas have been generated. Members are encouraged to improve on each other's ideas. These sessions are enjoyable but are often unsuccessful because members inevitably begin to critique ideas, and as a result, meetings shift to the ordinary interacting group format. Criticisms of this approach are the high cost factor, the time consumed, and the superficiality of many solutions.

Functional Structure

In functional structures, employees are grouped in departments by specialty, and groupings of similar tasks are performed by groups of like-minded or trained individuals operating out of the same department along with similar types of departments reporting to the same manager. In a functional nursing structure, all nursing tasks fall under nursing service. Functional structures tend to centralize decision making because the functions converge at the top of the organization. A functional nursing structure enjoys the benefit of having like individuals performing common work close together, but coordination between and among other functional areas, such as the pharmacy or laboratory, may be limited. Decision making can become too centered on a single manager who may lack a broad perspective of organizational dynamics.

Robotics

In the hospital, supplies can be ordered electronically. Next, laser-guided robots fill orders in the pharmacy or central supply and deliver them to nursing units via dedicated elevators—and do so more efficiently, accurately, and in less time than individuals can. Robot functionality will continue to expand, limited only by resources and ingenuity.

Innovation

Innovation is a strategy to bridge the gap between an existing state and a desired state. Organized nursing has recognized the importance of innovation to solve healthcare's many problems The following are several techniques to stimulate innovation: · Simulations—high-tech mannequins or actors representing standardized patients · Case studies—participants using critical thinking to analyze actual patient situations · Problem-based learning—information being added to a case study over time · Debate—participants examining an issue from more than one viewpoint (Lachman et al., 2009) Critical thinking, creativity, and innovative thinking, along with the appropriate tools and techniques, will enable nurses and their managers to make decisions and solve problems in the least time and with the best outcomes.

__________ ____________ occurs when a flatter organizational structure causes positions to be combined and results in managers having more employees to supervise, a situation common today.

Job enlargement Less complex organizations have flat structures; authority is decentralized, with several managers supervising large work groups.

________ ____________ places emphasis on ensuring that time is spent wisely, and that the right individual is correctly assigned the responsibility for tasks.

Job redesign

Mentoring

Mentors play a greater role than preceptors in developing staff. Precepting usually is associated with orientation of staff, whereas mentoring occurs over a much longer period and involves a bigger investment of personal energy. A mentor is a wiser and more experienced person who guides, supports, and nurtures a less experienced person. Mentors are usually the same sex as the protégé, 8 to 15 years older, highly placed in the organization, powerful, and willing to share their experiences. They are not threatened by the mentee's potential for equaling or exceeding them. Mentees are selected by mentors for several reasons: good performance, loyalty to people and the organization, a similar social background or a social acquaintance with each other, appropriate appearance, an opportunity to demonstrate the extraordinary, and high visibility. Mentor-mentee relationships typically advance through several stages. The initiation stage usually lasts 6 months to a year, during which the relationship gets started. During the mentee stage, the mentee's work is not yet recognized for its own merit but, rather, as a by-product of the mentor's instruction, support, and encouragement. The mentor thus buffers the mentee from criticism. A breakup stage may occur between 6 months and 2 years after a significant change in the relationship, usually resulting from the mentee taking a job in another department or organization so that a physical separation of the two individuals occurs. It also can occur if the mentor refuses to accept the mentee as a peer or when the relationship becomes dysfunctional for some reason. The lasting friendship stage is the final phase and will occur if the mentor accepts the mentee as a peer or if the relationship is reestablished after a significant separation. The complete mentoring process usually includes the last stage.

Service-line Structure

More common in healthcare organizations today are service-line structures (Nugent, Nolan, Brown, & Rogers, 2008). Service-line structures also are called product-line or service-integrated structures. In a service-line structure, clinical services are organized around patients with specific conditions (see Figure 2-3). For instance, there may be an oncology, cardiac, or mother-infant service line. Service-line structures are sometimes preferred in large and complex organizations because the same activity (e.g., hiring) is assigned to several self-contained units. In theory, service lines respond rapidly to the service's patient populations because nursing, pharmacologic, diagnostic, and other services work in tandem. This structure is appropriate when environmental uncertainty is high, the populations serviced are high volume and have specific needs, and the organization requires frequent adaptation and innovation to distinguish itself. A service-line structure designs its resources for rapid response in a changing environment. Because each service line specializes and strategically aligns resources, its outputs can be tailored to keep patient satisfaction high. Service lines coexist with functional structures. A nurse may work in a service line as an oncology nurse but also have ties to the functional area of nursing. This requires coordination across function settings (nursing, dietary, pharmacy, and so on) and takes effort among leaders to ensure that functional and service goals are achieved. Service goals receive priority under this organizational structure because employees see the service outcomes as the primary purpose of their organizational position. As in all structures, organizations with multiple service lines face challenges, including possible duplication of resources (such as duplicating advertisements for new positions), lack of identity with one's professional discipline, and inconsistent or duplicative process design across services, creating multiple demands on support service areas, such as pharmacy or environmental services where expectations can differ enough to create confusion and inefficiencies in those areas. In addition, some service lines (e.g., pediatrics, obstetrics, bariatric surgery, and transplant centers) present special challenges due to low usage or the need for specialized personnel Service-line structures are the most common structures found in academic health science centers and larger urban organizations (Kaplow & Reed, 2008). As noted, this type of structure can present a challenge to nurse leaders to maintain nursing standards across service lines (Hill, 2009).

Decision Making Under Uncertainty and Risk

Most critical decision making in organizations is done under conditions of uncertainty and risk. The individual or group making the decision does not know all the alternatives, attendant risks, or possible consequences of each option. Uncertainty and risk are inevitable because of the complex and dynamic nature of healthcare organizations. For example, if the weather forecaster predicts a 40% chance of snow, the nurse manager is operating in a situation of risk when trying to decide how to staff the unit for the next 24 hours. The key element in decision making under conditions of risk is to determine the probabilities of each alternative as accurately as possible. The nurse manager can use a probability analysis, whereby expected risk is calculated or estimated.

Objective Probability

Objective probability is the likelihood that an event will or will not occur based on facts and reliable information

clinical ladder program

One example of a career advancement development strategy is the clinical ladder program. It uses a system of performance indicators to advance an employee within the organization. The following are the key components: · Horizontal promotion · Clinical ladder · Clinical mentee Horizontal promotion rewards the excellent clinical nurse without promoting the nurse to management. A clinical ladder, based on Benner's (2000) novice-to-expert concepts, includes the following: · Clinical apprentice—new nurse or nurse new to the area · Clinical colleague—a full partner in care · Clinical mentee—demonstrates preceptor ability · Clinical leader—demonstrates leadership in practice · Clinical expert—combines teaching and research with practice The strength of the system is that superb, clinical nurses can remain at the bedside, clinical excellence can be rewarded, and nurses can move back and forth among the levels based on their personal and professional goals and needs.

Leapfrog Group

Organization that promotes healthcare safety by giving consumers the information they need to make better-informed choices about the hospitals they choose. The Leapfrog Group is a consortium of public and private purchasers that uses its mammoth purchasing power by rewarding healthcare organizations that demonstrate quality outcome measures. Today, the Leapfrog Group compares hospitals' performance on preventing errors, accidents, injuries, and infections.

Integrated healthcare networks

Organizational healthcare structures that deliver a continuum of care, provide coverage for a group of individuals, and accept fixed payments for that group Integrated healthcare networks originally emerged as organizations sought to survive in today's cost-conscious environment. The results of the Affordable Care Act have led to even further integration as the health of populations must not be managed across the continuum of care services (Soto, 2013). The earliest definition for population health was based on health outcomes distributed over a group of individuals. Today this includes interventions around lifestyle, prevention, and risk avoidance, all aimed at reducing the need for acute care services. Integrated systems encompass a variety of model organizational structures, but certain characteristics are common. Network systems provide the following: · A continuum of care · Geographic or population coverage for the buyers of healthcare services · Acceptance of the risk inherent in taking a fixed payment in return for providing healthcare for all persons in the selected group, such as all employees of one company To provide such services, networks of providers evolved to encompass hospitals and physician practices. Most important, the focal point for care is primary care and care management rather than using the hospital for the continuum of services. The goal is to interact with and keep patients in the setting that incurs the lowest cost, promotes health, and reduces expensive hospital stays. A variety of other arrangements have emerged, varying from loose affiliations or collaborations between hospitals and hospital systems to complete mergers of hospitals, clinics, and physician practices. As changes in healthcare reimbursement unfold, nurses are playing expanded roles in primary care, transitional care, and community-based wellness initiatives.

Parallel Structure

Parallel structure is unique to healthcare. The field of medicine contends that it requires its own organizational structure because of the complexity of its field and the desire to self-monitor its own members. Most hospitals today continue to have hospital structures while the medical staff has its own structural unit, with its own leaders and departments that coexist with the hospital's structures, with both structures reporting to the board of trustees. For a department like nursing, this poses the dilemma of being exposed to two lines of authority—to the hospital and the medical governance structure. Parallel structures are becoming less successful as healthcare organizations integrate into newer models that incorporate physician practice under the organizational umbrella.

Ownership of Healthcare Organizations can be either private or government, voluntary (not for profit) or investor owned (for profit), and sectarian or nonsectarian (see Figure 2-4).

Private organizations are usually owned by corporations or religious entities, whereas government organizations are operated by city, county, state, or federal entities, such as the Indian Health Service. Voluntary organizations are usually not-for-profit, meaning that surplus monies are reinvested into the organization. Investor-owned, or for-profit, corporations distribute surplus monies back to the investors, who expect a profit. Sectarian agencies have religious affiliations.

Magnet Recognition Program

Recognition by the American Nurses Credentialing Center that an organization provides quality nursing care. The Magnet Recognition Program was designed to recognize excellence in nursing. The purpose was to improve patient care by focusing on nurses' qualifications, work life, and participation within the organization. The program designated 14 factors that indicated a culture of excellence, resulting in an environment for quality patient care. Institutions that met the stringent guidelines for nurses were credentialed by the American Nurses Credentialing Center (ANCC) as Magnet-certified hospitals. In 2007, the Magnet program was redesigned to provide a framework for the future of nursing practice and education (American Nurses Credentialing Center, 2008). To focus on outcome measures, the 14 factors from the original program were reconfigured into five components: · Transformational leadership · Structural components · Exemplary professional practice · New knowledge, innovations, and improvement · Empirical outcomes Magnet hospitals are those organizations that are recognized for "quality patient care, nursing excellence and innovations in professional nursing practice." (American Nurses Credentialing Center, 2016). To qualify for recognition as a Magnet hospital, the organization must demonstrate that they are achieving the following: · Promoting quality in a setting that supports professional practice · Identifying excellence in the delivery of nursing services to patients/residents · Disseminating "best practices" in nursing services (ANCC, 2015)

______________ theory uses the mission of the organization to structure and design work, which is then subdivided into parts. The traditional design of medicine is based on this model, where a primary care physician oversees the holistic concerns of the patient, but specialists are called in to detail each subcomponent part of medical treatment. Similarly, most hospital organizations still orchestrate their clinical services and departments using this model. This classical view of organizations has strength, but also real limitations. The way clinical work is carried out is dependent upon bureaucratic work design, yet clinicians often create work-arounds when necessary to achieve patient care objectives.

Reductionist theory

Reductive Theory

Reductive theory, or classical approaches to organizations, focuses heavily on (a) the nature of the work to be accomplished, (b) creating structures to achieve the work, and (c) dissecting the work into component parts. The premise is to enhance people's efficiency through thoughtfully designed tasks. Leaders who use this model aim to subdivide work, specify tasks to be done, and fit people into the plan. Reductive theory has four elements: division and specialization of labor, organizational structure, chain of command, and span of control

Types of decisions

Relatively well-defined, common problems can usually be solved with routine decisions, often using established rules, policies, and procedures. For instance, when a nurse makes a medication error, the manager's actions are guided by policy and the report form. Routine decisions are more often made by first-level managers than by top administrators. Adaptive decisions are necessary when both problems and alternative solutions are somewhat unusual and only partially understood. Often they are modifications of other well-known problems and solutions. Managers must make innovative decisions when problems are unusual and unclear, and when creative, novel solutions are necessary

Subjective probability

Subjective probability is the likelihood that an event will or will not occur based on a manager's personal judgment and beliefs.

Telehealth

Telehealth has evolved as technologies to assess, intervene, and monitor patients remotely continue to improve. The technology to diagnose and treat patients from a distance, along with patient-accessible EHRs and mobile devices such as smartphones, enables providers to interact with patients regardless of their location. Nurses, for example, can watch banks of video screens miles away from the hospital monitoring ICU patients' vital signs. Electronic equipment, such as a stethoscope, can be accessed by a healthcare provider in a distant location. Such systems are especially useful in providing expert consultation for specialty care. This technology, too, is expected to grow.

Institute of Medicine's Recommendations for Nursing

The IOM's report on the future of nursing makes sweeping recommendations for the profession, including that "nurses should be full partners, with physicians and other healthcare professionals, in redesigning healthcare in the United States" (IOM, 2010, p. 3). Also, the IOM posits that today's healthcare environment necessitates better-educated nurses and recommends that 80% of nurses be prepared at the baccalaureate or higher level by 2020. In addition, the report recommends that barriers limiting the scope of practice for advanced practice nurses be eliminated, and that racial, ethnic, and gender diversity among the nursing workforce should be increased to better care for a diverse patient population. While nurses are consistently ranked as the most trusted profession in the United States (Gallup, 2014), few nurses hold positions of leadership in healthcare, and the IOM recommends an increase in their numbers. Progress on meeting the recommendations of the IOM report is substantial and ongoing (Hassmiller & Reinhard, 2015).

The critical-thinking process

The critical-thinking process seems abstract unless it can be related to practical experiences. One way to develop this process is to consider a series of questions when examining a specific problem or making a decision, such as the following: · What are the underlying assumptions? Underlying assumptions are unquestioned beliefs that influence an individual's reasoning. They are perceptions that may or may not be grounded in reality. · How is evidence interpreted? What is the context? Interpretation of information also can be value laden. Is the evidence presented completely and clearly? Can the facts be substantiated? Are the people presenting the evidence using emotional or biased information? Are there any errors in reasoning? · How are the arguments to be evaluated? Is there objective evidence to support the arguments? Have all value preferences been determined? Is there a good chance that the arguments will be accepted? Are there enough people to support decisions? · What are the possible alternative perspectives? Using different basic assumptions and paradigms can help the critical thinker develop several different views of an issue. Compare how a nurse manager who assumes that more RNs equal better care will deal with a budget cut with a manager who is committed to adding assistive personnel instead. What evidence supports the alternatives? What solutions do staff members, patients, physicians, and others propose? What would be the ideal alternative? Critical-thinking skills are used throughout the nursing process (see Table 9-1). Nurses can build on the knowledge base they began acquiring in school to make the critical-thinking process a conscious one in daily activities. Learning to be a critical thinker requires a commitment over time, but the skills can be learned.

The descriptive rationality model

The descriptive rationality model, developed by Simon in 1955 and supported by research in the 1990s (Simon, 1993), emphasizes the limitations of the rationality of the decision maker and the situation. It recognizes three ways in which decision makers depart from the rational decision-making model: · The decision maker's search for possible objectives or alternative solutions is limited because of time, energy, and money. · People frequently lack adequate information about problems and cannot control the conditions under which they operate. · Individuals often use a satisficing strategy.

interruption log

The log should show who interrupted, the nature of the interruption, when it occurred, how long it lasted, what topics were discussed, the importance of the topics, and time-saving actions to be taken.

Matrix Structure

The matrix structure integrates both service-line and functional structures into one overlapping structure. In a matrix structure, a manager is responsible for both the function and the product line. For example, the nurse manager for the oncology clinic may report to the vice president for nursing and the vice president for outpatient services. Matrices tend to develop where there are strong outside pressures for a dual organizational focus on product and function. The matrix is appropriate in a highly uncertain environment that changes frequently but also requires organizational expertise (Galbraith, 2009). A major weakness of the matrix structure is its dual authority, which can frustrate and confuse departmental managers and employees. Respect and strong interpersonal skills are required from the leaders in this structure, who will spend extra time in joint problem solving and conflict resolution. These leaders must share organizational vision beyond their individual functional areas and be willing to act based on this broader vision. If this does not happen, one function may become more dominant.

Reinforcement theory (behavior modification)

The motivational theory that views motivation as learning and proposes that behavior is learned through a process called operant conditioning Reinforcement theory (behavior modification) views motivation as learning (Skinner, 1953). According to this theory, behavior is learned through a process called operant conditioning, in which a behavior becomes associated with a particular consequence. In operant conditioning, the response—consequence connection is strengthened over time—that is, it is learned. Consequences may be positive, as with praise or recognition, or negative. Positive reinforcers are used for the express purpose of increasing a desired behavior. Negative reinforcers are used to inhibit an undesired behavior. Punishment is a common technique. Because punishment is negative in character, an employee may instead fail to improve and also may avoid the job. Undesirable behavior will be suppressed only as long as the employee is monitored and the threat of punishment is present. Conversely, positive reinforcement is the best way to change behavior.

Political decision making model

The political decision-making model describes the process in terms of the particular interests and objectives of powerful stakeholders, such as hospital boards, medical staffs, corporate officers, and regulatory bodies. Power is the ability to influence or control how problems and objectives are defined, what alternative solutions are considered and selected, what information flows, and, ultimately, what decisions are made

Group Decision Making

The widespread use of participative management, quality improvement teams, and shared governance in healthcare organizations requires every nurse manager to determine when group, rather than individual, decisions are desirable, and how to use groups effectively. A number of studies have shown that professional people do not function well in a micromanaged environment. As an alternative, group problem solving of substantial issues casts the manager in the role of facilitator and consultant. Compared to individual decision making, groups can provide more input, often produce better decisions, and generate more commitment. One group decision-making technique is brainstorming.

Short-term goals should be set for the next 6 to 12 months, but they should be related to long-term goals.

To manage time effectively, answer five major questions about these goals: 1. What specific objectives are to be achieved? 2. What specific activities are necessary to achieve these objectives? 3. How much time is required for each activity? 4. Which activities can be planned and scheduled for concurrent action, and which must be planned and scheduled sequentially? 5. Which activities can be delegated to others?

Process Theories

Whereas content theories attempt to explain why a person behaves in a particular manner, process theories emphasize how the motivation process works to direct an individual's effort into performance. These theories add another dimension to the understanding of motivation and help predict employee behavior in certain circumstances. Examples of process theories are reinforcement theory, expectancy theory, equity theory, and goal-setting theory.

Shared governance

a flat type of organizational structure with decision making decentralized Shared governance is a nursing response to organizational structures that represents the voice of the nursing profession in healthcare agencies. It can be considered a modified parallel structure to that of medicine, ensuring that matters of clinical practice are influenced by those who are closest to care delivery. One key difference in shared governance is that its structures complement organizational design. Shared governance gives nurses a forum in which to shape nursing practice within the healthcare organization. Shared governance requires nurses to be accountable to the latest standards and knowledge in the field. Nurses gain experience in using their voice in decision making at the organizational level. So important is this structure that Magnet standards require shared governance and—as part of its review process, including peer review—examine the influence of nursing in organizational decision making. Nurses participate in unit-based councils that interface with divisional councils, specialty councils, and a leadership council, consisting of nurse managers and administrators (Hafeman, 2015). In this structure, decisions are made by consensus rather than by the manager's order or majority rule, allowing staff nurses an active voice in problem solving. Unit councils make decisions for that unit, while divisional councils address issues impacting multiple units, with a hospital-wide council addressing profession-wide issues linked to patient care standards. Appropriate councils address clinical quality and safety issues, professional competencies and development, and the implementation of evidence-based practices into the organization. Although nursing practice councils have operated for several decades, changes in healthcare and in organizational structures have led to council modifications, a process not without difficulty (Moore & Wells, 2010). Staffing shortages, patient demands, and unfamiliarity with shared governance concepts or its benefits may discourage participation. In addition, not all shared governance models are successful (Ballard, 2010). Human factors—such as lack of leadership, lack of staff or manager understanding of shared governance, or the absence of knowledgeable mentors—can impede implementation of the model. Structural factors—such as a known structure for decision making, time available for meetings, and staffing support for attendance—also affect the success of shared governance. Still, as a Magnet standard, shared governance will continue into the future (McDowell et al., 2010).

Quality and Safety Education for Nurses (QSEN)

addresses the challenge to prepare nurses with the competencies needed to continuously improve the quality of care in their work environments. Based on recommendations of the Institute of Medicine (IOM, 2003), a national advisory board of experts developed quality and safety competencies, designating targets of knowledge, skills, and attitudes (KSAs) for nursing education known as Quality and Safety Education for Nurses. The six prelicensure KSAs are as follows: · Patient-centered care · Teamwork and collaboration · Evidence-based practice · Quality improvement · Safety · Informatics These competencies are being used as guides for nursing education, to assist nurses transitioning to practice, and for nurses continued lifelong learning.

Systems Theory

an adaptive theory stating that an organization is a managed system that changes inputs into outputs An open-system organization draws on resources—known as inputs—from outside its boundary. Inputs can include materials, money, and equipment as well as human capital with particular expertise. These resources are transformed when processes are designed, animated, and coordinated with the mission of the organization in mind—a process known as throughputs—to create the goods and services desired, which are called outputs.

The term _____________ is defined as the ideal, intentionally rational, most efficient form of organization.

bureaucracy

The term _________ refers to the perception that an individual has used up all available energy to perform the job and does not have enough energy to complete the task (Epstein, 2010). __________ is a combination of physical fatigue, emotional exhaustion, and cognitive weariness. As a result, the individual may reduce hours worked or change to another profession.

burnout

The _______________ is depicted on a table of organization (called the organizational chart) through job titles listed in magnitude of authority and responsibility. Those jobs that ascend to the top reflect increased authority and represent the right or power to direct the activities of those of lesser rank. Those depicted at the lower end of the chart have the obligation to perform certain functions or responsibilities and yield less authority and power. The organizational chart gives the appearance of orderliness and clarity around who is in charge. Positions with line authority are depicted in boxes on the organizational chart, with the person holding supervisory authority over other employees located at the top. Another type of authority is known as staff authority, in which individuals yield considerable expertise to advise and influence others; they possess influence that, without supervisory power, provides important direction and persuasion, minus supervisory status. In Figure 2-1, the nurse managers and acute care nurse practitioner possess staff authority with one another. This means that no nurse is responsible for the work of the others, yet they respect and collaborate to improve the efficiency and productivity of the unit for which the nurse manager bears responsibility.

chain of command

The final adaptive theory, known as __________ theory, is linked to the field of complexity science, inspired by quantum mechanics. _________ theory challenges us to look at organizations through a lens that strips away notions of the command and control structures found in reductive theories. Complexity scientists observe in nature that nonlinear problems cannot be solved with the linear approaches tied to reductionism. The concept of cause and effect is rarely predictable in work settings where the stakes are high, multiple variables interact, and predictive outcomes are not feasible. Complexity science informs organizational leaders that all systems will self-regulate over time, that change is plausible from the bottom-up or through the organization, and that leadership aims to establish simple rules that promote adaptation in concert with environmental agents, rather than believing that the command and control methods found in reductionist models are sufficient (Ray, Turkel, Cohn, 2011). ______________ theory and complexity science refute permanent organizational structures as useful. Rather, principles that ensure flexibility, fluidity, speed of adaptability, and cultural sensitivity are emerging, such as those found in virtual organizations (Norton & Smith, 1997). In social media, Facebook is an example of a leaderless organization, created and managed by its communities of interests, serving its users through a broad set of principles that are self-monitored.

chaos theory

___________________ diversification occurs when an organization complements its existing services by expanding into new markets or broadening the types of services it currently has available. For example, a children's hospital might open a daycare center for developmentally delayed children or offer drop-in facilities for sick child care.

concentric diversification

__________________ diversification is the expansion into areas that differ from the original product or service. The purpose of conglomerate diversification is to obtain a source of income that will support the organization's product or service. For example, a long-term care facility might develop real estate or purchase a company that produces durable medical equipment.

conglomerate diversification

Motivational Theories The usefulness of motivational theories depends on their ability to explain motivation adequately, to predict with some degree of accuracy what people will actually do, and, finally, to suggest practical ways of influencing employees to accomplish organizational objectives. Motivational theories can be classified into at least two distinct groups: _____________ _____________

content theories and process theories

Another adaptive theory is _______________ theory, which was developed to explain that organizational performance is enhanced when leaders attend to and interact directly with the unique characteristics occurring in a changing environment. Through these interactions leaders match an organization's human and material resources in creative ways to respond quickly to social and clinical needs. The environment defined here includes the people, objects, and ideas outside the organization that influence or threaten to destabilize the organization. Although some environmental factors are easily identified in healthcare organizations (regulators, competitors, suppliers of goods, and so on), the boundaries become blurred when a third-party payer or a physician controls a patient's access to care. In these cases, the physician or payer appears to be the customer, or gatekeeper.

contingency theory

Reductive theory has four elements:

division and specialization of labor, organizational structure, chain of command, and span of control

___________ theory suggests that a person perceives that one's contribution to the job is rewarded in the same proportion that another person's contribution is rewarded. Job contributions include such things as ability, education, experience, and effort, whereas rewards include job satisfaction, pay, prestige, and any other outcomes an employee regards as valuable (Adams, 1963, 1965).

equity theory

Like reinforcement theory, _____________ theory (Vroom, 1964) emphasizes the role of rewards and their relationship to the performance of desired behaviors. ___________ theory regards people as reacting deliberately and actively to their environment.

expectancy theory In an effort to improve the amount of delegation by the nurses on her unit, Andrea approached the situation from an expectancy theory perspective. She identified that the nurses wanted to assign more duties to assistive personnel but were reluctant because of concerns about liability. Once Andrea was able to clarify liability issues, the nurses were eager to delegate tasks that could be performed by nonlicensed staff in order to devote more time to their professional responsibilities. Expectancy theory also considers multiple outcomes. Consider the possibility of a promotion to nurse manager. Even though a staff nurse believes such a promotion is positive and is a desirable reward for competent performance in patient care, the nurse also realizes there are possibly some negative outcomes (e.g., working longer hours, losing the close camaraderie enjoyed with other staff members). These outcomes may influence the staff nurse's decision.

______________ is another technique used to eliminate negative behavior. By removing a positive reinforcer, undesired behavior is extinguished. Jasmine was a chronic complainer. To curb this behavior, her manager chose to ignore her many complaints and not try to resolve them. Initially, Jasmine complained more, but eventually she realized her behavior was not getting the desired response and stopped complaining.

extinction

Unlike expectancy theory and equity theory, ______________ theory suggests that it is not the rewards or outcomes of task performance per se that cause a person to expend effort but, rather, the goal itself (Locke, 1968).

goal-setting theory Timothy was new to a home care hospice program. An important skill in care with the terminally ill is therapeutic communication. Timothy and his manager recognized that he needed help to improve his skills in communicating with these patients and their families. His manager asked him to write two goals related to communication. Timothy expressed a desire to attend a communications workshop and also indicated he would try at least one new communication technique each week. Within a month, Timothy's therapeutic communication skills had already improved. As a result, Timothy was more satisfied with his position, his patients received more compassionate care, and Timothy found his work more rewarding.

Electronic health records (EHRs)

health records that allow real-time communication, reporting, and record keeping through electronic transmission. Electronic health records (EHRs) reduce redundancies, improve efficiency, decrease medical errors, and lower healthcare costs. Continuity of care, discharge planning and follow-up, ambulatory care collaboration, and patient safety are just a few of the additional advantages of EHRs. Furthermore, fully integrated systems allow for collective data analysis across clinical conditions and between and among healthcare organizations, and they support evidence-based decision making. Federal incentives (e.g., reimbursement and grants) encourage the expanded use of EHRs, which is expected to continue

Arrangements between or among organizations that provide the same or similar services are examples of ____________ integration. For instance, all hospitals in the network provide comparable services

horizontal integration

Both academic teaching and nonteaching hospitals have made greater use of a new physician specialty known as _______________. A _______________ manages the care of hospitalized patients on behalf of the primary care provider while that patient is hospitalized or works to complement the private physician by being available for emergency care.

hospitalists

A major premise of _________________ theory is that people desire social relationships, respond to group pressure, and search for personal fulfillment in work settings. researchers concluded that the social attention and interactions created by the research itself—that is, the special human attention given to workers participating in the research—met a social need that enhanced productivity. This tendency for people to perform in an expected manner because of special attention and focused, unintentional interactions became known as the _____________ effect, a term now used most commonly in research but which emanated from organizational science.

humanistic Hawthorne effect

Another type of diversification common to healthcare is the _________ _____________. A ___________ ___________ is a partnership in which each partner contributes different areas of expertise, resources, or services to create a new product or service. In one type of joint venture, one partner (general partner) finances and manages the venture, whereas the other partner (limited partner) provides a needed service. Joint ventures between healthcare organizations, physicians, researchers, and others are becoming increasingly common. Integrated healthcare organizations, hospitals, and clinics seek physician and/or practitioner groups they can bond (capture) in order to obtain more referrals. The healthcare organization as financier and manager is the general partner, and physicians are limited partners.

joint venture

The ______________ of an organization is a broad, general statement of the organization's reason for existence. Developing the ____________ is the necessary first step to forming an organization.

mission "Our mission is to provide comprehensive emergency and acute care services to the people and communities within a 200-mile radius" is an example of a mission statement that guides decision making for the organization. Purchasing a medical equipment company, therefore, fails to meet the current mission, nor does it contribute to the vision of improving the community's health.

Employee performance literature ultimately reveals two major dimensions as determinants of job performance

motivation and ability

______________ structures delineate work group arrangements based on the concept of departmentalization as a means to maintain command, reinforce authority, and provide a formal communication network. Stated earlier, structures evolve over time, especially as organizations grow in size.

organizational

When individuals come together to fulfill a common aspiration, ______________ are formed.

organizations

_________________ must be clarified before problem solving can occur.

perceptions

The _____________ is a sometimes written statement that reflects the organizational values, vision, and mission (Conway-Morana, 2009). Values are the beliefs or attitudes one has about people, ideas, objects, or actions that form a basis for the behavior that will become the culture. Organizations use value statements to identify those beliefs or attitudes esteemed by the organization's leaders.

philosophy

Time can be used ________________ or _______________.

proactively or reactively If you focus your energy on people and events over which you have some direct or indirect control, you are using a proactive approach. If, on the other hand, you spend most of your time on what concerns you most about other people and events, your efforts are less apt to be effective. For example, you can set and follow your goals and priorities, or you can spend your time worrying, blaming, or making excuses about what you do not accomplish.

People use ___________ ___________ when they perceive a gap between an existing state (what is going on) and a desired state (what should be going on).

problem solving

In an effort to ameliorate medical mistakes, a number of quality initiatives have emerged. These include..............

quality management, the Leapfrog Group, benchmarking, evidence-based practice, the Magnet Recognition Program, and Quality and Safety Education for Nurses.

Examples of process theories are ...... (4)

reinforcement theory, expectancy theory, equity theory, and goal-setting theory.

____________ ___________ involves clarifying roles and attempting to integrate or tie together the various roles that individuals play. If there is role conflict or ambiguity, it is important to confront others by pointing out conflicting messages. Role redefinition may also involve renegotiation of roles in an attempt to lessen overload.

role redefinition

_____________ structures are the most common structures found in academic health science centers and larger urban organizations

service-line structures

______________ involves selectively reinforcing behaviors that are successively closer approximations to the desired behavior. When people become clearly aware that desirable rewards are contingent on a specific behavior, their behavior will eventually change

shaping

_______________ addresses the issue of effective supervision expressed by the number of direct reports to someone with line authority.

span of control Complex organizations have numerous highly specialized departments; centralized authority results in a tall organizational structure with small differentiated work groups. Less complex organizations have flat structures; authority is decentralized, with several managers supervising large work groups.

Another type of authority is known as __________ authority, in which individuals yield considerable expertise to advise and influence others; they possess influence that, without supervisory power, provides important direction and persuasion, minus supervisory status. In Figure 2-1, the nurse managers and acute care nurse practitioner possess staff authority with one another. This means that no nurse is responsible for the work of the others, yet they respect and collaborate to improve the efficiency and productivity of the unit for which the nurse manager bears responsibility.

staff

__________ is the nonspecific reaction that people have to demands from the environment that pose a threat.

stress Stress results when two or more incompatible demands on the body cause a conflict. Recognized as the pioneer of stress research, Selye (1978) suggests that the body's wear and tear result from its response to normal stressors. The rate and intensity of damage increase when an organism experiences greater stress than it is capable of accommodating. Selye maintains that the physiological response to stress is the same whether the stressor is positive, eustress, or negative, distress. It is easy to see how negative events, such as job loss, can cause stress. However, positive events also may cause stress. A certain amount of stress is essential to sustain life, and moderate amounts serve as stimuli to performance; however, overpowering stress can cause a person to respond in a maladaptive physiological or psychological manner.

3 adaptive theories...

systems theory, contingency theory, chaos theory

3 adaptive theories:

systems theory, contingency theory, chaos theory

Complex organizations have numerous highly specialized departments; centralized authority results in a ________ organizational structure with small differentiated work groups. Less complex organizations have __________ structures; authority is decentralized, with several managers supervising large work groups.

tall flat

The term ___________ hospital commonly designates a hospital associated with a medical school that maintains physician or medical resident availability on-site 24 hours a day. ______________ hospitals, in contrast, have private physicians (not medical students) on staff.

teaching hospital nonteaching hospitals

Decision Making Under Certainty

the decision maker knows with reasonable certainty what the alternatives are and what conditions are associated with each alternative When you know the alternatives and the conditions surrounding each alternative, a state of certainty is said to exist. Suppose a nurse manager on a unit with acutely ill patients wants to decrease the number of venipunctures a patient experiences when an IV is started, as well as reduce costs resulting from failed venipunctures. Three alternatives exist: · Establish an IV team on all shifts to minimize IV attempts and reduce costs. · Establish a reciprocal relationship with the anesthesia department to start IVs when nurses experience difficulty. · Set a standard of two insertion attempts per nurse per patient, although this does not substantially lower equipment costs. The manager knows the alternatives (IV team, anesthesia department, standards) and the conditions associated with each option (reduced costs, assistance with starting IVs, minimum attempts and some cost reduction). A condition of strong certainty is said to exist, and the decision can be made with full knowledge of what the payoff probably will be.

Groupthink

the mode of thinking that occurs when the desire for harmony in a decision-making group overrides a realistic appraisal of alternatives Groupthink is a negative phenomenon that occurs in highly cohesive groups that become isolated. Through prolonged close association, group members come to think alike and have similar prejudices and blind spots, such as stereotypical views of outsiders. They exhibit a strong tendency to seek concurrence, which interferes with critical thinking about important decisions. In addition, the leadership of such groups suppresses open, freewheeling discussion and controls what ideas will be discussed and how much dissent will be tolerated. Groupthink seriously impairs critical thinking and can result in erroneous and damaging decisions.

Succession Planning

the process of identifying and tracking high-potential employees who will be able to fill top management positions when they become vacant Succession planning is a strategic process that is a natural outgrowth of leadership development. It involves identifying core competencies required at each level of management, recognizing potential recruits, and providing opportunities for development and growth.

________________ today is commonly associated with access to care and how patients enter and leave the healthcare system. Hospitals measure the ______________ of patients, beginning with emergency department services and, if necessary, patients diverted away from the hospital based on resource availability; how long a patient has to wait for a bed; and the number of readmissions (Handel et al., 2010). Readmissions that occur within fewer than 120 days from discharge create financial penalties for hospitals as a measure of inadequate discharge planning. Using information technology, bed management systems are a tool to monitor patient throughput in real time (Gamble, 2009). The Joint Commission accreditation, a national accreditation program, requires hospitals to show data on throughput statistics

throughput throughput

Problem solving methods

trial-and-error experimentation past experience and intuition

_______________ integration, in contrast to horizontal integration, is an arrangement between or among dissimilar but related organizations to provide a continuum of services. An affiliation of a health maintenance organization with a hospital, pharmacy, and nursing facility represents vertical integration

vertical integration

A ___________ __________ is often written; it describes the future state of what the organization is to become through the aspirations of its leaders.

vision statement The vision statement is designed to keep stakeholders intent on why they have come together and what they aspire to achieve. "Our vision is to be a regional integrated healthcare delivery system providing premier healthcare services, professional and community education, and healthcare research" is an example of a vision statement for a healthcare system.

The warning signs of too much stress include the following....

· Undue, prolonged anxiety; phobias; or a persistent state of fear or free-floating anxiety that seems to have many alternating causes · Depression, which causes people to withdraw from family and friends; an inability to experience emotions; a feeling of helplessness to change the situation · Abrupt changes in mood and behavior, which may be exhibited as erratic behavior · Perfectionism, which is the setting of unreasonably high standards for oneself and leads to a feeling of constant stress · Physical illnesses, such as an ulcer, arthritis, colitis, hypertension, myocardial infarction, and migraine headaches