Chapter 19 Leadership

A nurse-manager is orienting a new graduate nurse to the unit and has found this individual's charting regarding assessment to be inadequate. What is the most appropriate statement to initiate a discussion with the new RN? a. "I'm concerned that your assessment charting seems to be unclear. Can I help you with this?" b. "Unfortunately, your charting is inadequate in every way." c. "Do you think a refresher course in charting would help you?" d. "Are you having difficulty assessing your client?"

ANS: A Feedback: Assertive communication is not rude or insensitive, nor is it passive- aggressive. Backing up the communication to focus on the RN's intention is respectful and solution-oriented. The manager should not presume that the nurse is having difficulty with assessment unless there is evidence of this. The manager should avoid accusatory descriptors such as "inadequate in every way." Suggesting remediation would likely be premature before trying to work collaboratively with the nurse.

A nurse-manager has recently established a "best practice committee" at the clinic. Which behavior by the committee members suggests that it is in the "storming" stage? a. Members attempt to impress each other with their credentials. b. The short- and long-term goals for the group are agreed upon. c. Group members achieve their stated goals. d. The members receive their instructions and mandate from the manager.

ANS: A Feedback: Competition and posturing characterize the storming stage. Agreeing on goals occurs during norming, and these are accomplished during the performing stage. Initial instructions are given during the forming stage.

A new nurse-manager has been warned by colleagues about the prevalence of "the grapevine" in the organization's communication. What is the manager's best initial response to this phenomenon? a. Seek to understand the patterns and contributors of this pattern of communication. b. Inform subordinates about the harmful effects of grapevine communication and that it will not be tolerated. c. Instruct subordinates to use formal patterns of communication rather than informal patterns. d. Use grapevine communication to disseminate messages that are accurate and respectful.

ANS: A Feedback: Given the frequency of grapevine communication in all organizations, all managers must attempt to better understand how the grapevine works in their own organization as well as who is contributing to it. It cannot normally be dictated into nonexistence, and the manager should avoid using this form of informal communication because messages can be easily distorted.

Feedback from a nurse-manager's peers suggests that the manager's face-to-face communication is often ineffective. The manager should consider what potential cause of this problem? a. Incongruence between the manager's verbal and nonverbal messages b. Ineffective listening skills on the part of subordinates and colleagues c. Inadequate formal training on communication skills d. Career stagnation by the nurse-manager

ANS: A Feedback: The incongruence between verbal and nonverbal messages is the most significant barrier to effective interpersonal communication. Ineffective listening skills on the part of the receivers may contribute to a perception of poor communication by the manager, but this would unlikely be the case among many different individuals. Many people never receive formal training on communication, but this does not necessarily inhibit them from becoming reasonably skilled communicators. Career stagnation would be a problem, but it would be less likely to affect overall communication skills.

What strategy best increases the likelihood that a nurse-manager's communication will be accurately interpreted? a. Using more than one mode of communication b. Using primarily face-to-face communication c. Using primarily clear, simple, and written communication d. Repeating the message as often as possible

ANS: A Feedback: Using various communication methods in combination increases the likelihood that everyone in the organization who needs to hear the message actually will hear it. Repeating a message is often not as effective as communicating it in a different way using a different mode.

Which principle should guide the nurse-manager's use of nonverbal communication? A. It is generally consistent across cultures, unlike verbal communication. B. It supersedes verbal communication when the two are incongruent. C. Nonverbal communication should be minimized because it confuses the receiver regarding the true intent of the message. D. Nonverbal communication is a significant part of the communication exchange only when it is not congruent with the verbal exchange.

ANS: B Feedback: Because nonverbal communication indicates the emotional component of the message, it is generally considered more reliable than verbal communication. It varies widely between cultures, and the manager does not normally have to make a conscious effort to minimize it. It is always significant regardless of how it aligns with the verbal message.

A nurse-manager has consulted the hospital information system to address a clinical issue. What characteristic is the hospital information system most likely to have? a. It is likely based on a social media platform. b. It is probably not freely available from the Internet. c. There is a high likelihood that it is out of date. d. It is probably accessible only from desktop computers, not wireless devices.

ANS: B Feedback: For security and confidentiality purposes, hospital information systems are typically not available to all on the Internet. However, they have the advantage of being easy to update and are more likely to be up to date than paper-based equivalents. These systems would not be hosted on a social media platform due to security risks. They can often be accessed wirelessly, provided the user has access to the secure network.

A hospital is downsizing, but the RNs have been assured that everyone on the unit will keep their jobs and that downsizing will occur through normal attrition. Today, the evening charge nurse reported to the manager that the staff was discussing rumors about mass layoffs. What is the best approach to take? a. Tell an informal leader the truth and let the leader spread the news informally. b. Hold a meeting for all staff members and tell them that the rumor is not true. c. Ignore the rumor because it will soon pass. d. Find out who started the rumor and correct the information.

ANS: B Feedback: Nurse-leaders should intervene appropriately when communication problems (in this case, rumors) arise. It is not particularly important who started the rumor if all staff members are now privy to it. Direct action is preferred to indirect action, such as introducing a competing message. Inaction would likely fuel the rumors.

A nurse is caring for a postoperative client whose pain is not being relieved by the current analgesia regimen. When using the SBAR model for communicating with the client's health care provider, how should the nurse best address the "A" component of the model? a. "The client is postoperative day 2 following total hip arthroplasty." b. "The client's pain control might be inadequate because it has been rated at 9 out of 10 for the past hour." c. "The client also has type 2 diabetes and atrial fibrillation." d. "An increase in her hydromorphone dose is probably a good idea."

ANS: B Feedback: The "A" in the SBAR or ISBAR model denotes "assessment," in which the nurse summarizes the client's condition and states what the problem likely is.

A nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease and who is experiencing a new onset of dyspnea. When contacting the client's care provider, the nurse should state the client's admitting diagnosis in what stage of the SBAR tool? a. S b. B c. A d. R

ANS: B Feedback: The "B" in the SBAR tool denotes "background." This is the stage of the tool where the nurse communicates the clinical context, including the client's diagnosis.

Which nursing action demonstrates compliance with the American Nurses Association (ANA) principles for social networking by nurses? a. Strictly avoiding the use of social networking in a professional setting b. Participating in the development of institutional policies governing online conduct c. Ignoring any information that appears to have the potential to harm a client's welfare d. Realizing that social networking is not related to a nurse's professional boundaries

ANS: B Feedback: The ANA has developed principles for social networking that include participation in policy development, nurse-client boundaries, separating personal and professional online information, and reporting to authorities when client welfare has been potentially harmed. There is not an absolute prohibition against the use of social media in a professional setting, but it must adhere to strict guidelines.

A member of a work group led by a nurse-manager is aloof and dismissive of the group's role. The member has occasionally made jokes during serious discussions and seems skeptical that the group will meet its goals. What role is this member playing? a. Blocker b. Playboy c. Dominator d. Recognition seeker

ANS: B Feedback: The playboy remains uninvolved and demonstrates cynicism, nonchalance, or horseplay. The blocker persists in expressing negative points of view and resurrecting dead issues. The dominator attempts to control and manipulate the group, whereas the recognition seeker works to focus positive attention on themselves.

A large health care organization has struggled to meet mandated electronic health record (EHR) standards. What actions address the likely challenge that this organization is facing? Select all that apply. a. Improving communication between managers at the organization's various sites b. Increasing the organization's budget for technology c. Investing more in employee training d. Engaging clients and families with the process e. Increasing the use of evidence-based practice

ANS: B, C Feedback: Many of the challenges faced during the adoption of EHRs involve inadequate technology and training. Communication between managers has not been identified as a major hurdle. Evidence-based practice enhances client care but does not directly address challenges around EHRs. Similarly, engaging clients and families greatly benefits the care that nurses provide but not the adoption of EHRs.

A nurse-manager has been approached by an angry employee whose vacation request was denied. What should the manager do when communicating with this employee? Select all that apply. a. Tell the employee that anger will not be tolerated and then leave the situation. b. State, "I understand that you are angry that your vacation request wasn't approved." c. Allow the employee sufficient opportunity to express what she wants from the manager. d. Tell the employee how the mode of communication is hindering the message. e. Ask the employee, "Are you accusing me of bullying you by turning down your request?"

ANS: B, C Feedback: When dealing with an emotional employee, the manager should allow the employee time to express what they want and then make statements that reflect back the employee's message. The manager should not terminate the interaction unless there is a plausible safety risk. Telling the employee how the tone is hindering communication and asking whether the employee is accusing the manager are likely to escalate the situation, further harming communication.

A nurse-manager has a reputation as being an assertive communicator. How does this manager most likely communicate? a. Through confrontation and intimidation b. In a direct but sometimes disrespectful way c. Directly, honestly, and diplomatically d. In a clear, but occasionally offensive, manner

ANS: C Feedback: Assertive communication allows people to express themselves in direct, honest, and appropriate ways that do not infringe on another's rights. It is a myth that assertiveness is disrespectful, offensive, or confrontational.

An RN overhears a nurse's aide speaking in a harsh tone to a client with early Alzheimer's memory loss. Which statement should the RN make to begin addressing this issue? a. "You must remember to watch your tone of voice with clients. Someone might overhear." b. "Do you think it would be a good idea to have an inservice on dealing with Alzheimer's clients?" c. "I am concerned about your conversation with the client. It sounded short and impatient." d. "I have decided to reassign that client to another aide."

ANS: C Feedback: Assertive communication effectively identifies and addresses an issue without being rude, insensitive, or passive-aggressive. None of the other options actually identifies the specific communication problem.

Electronic health records (EHRs) have recently been introduced in a health care organization, and the steering committee is ensuring that the system meets the criteria for meaningful use. This characteristic of the EHR ensures that the system: a. is readily accessible in any care setting, nationwide. b. uses language that is accessible to and understandable by clients. c. contains data that has the potential to improve client outcomes. d. means the same thing to every user.

ANS: C Feedback: EHRs must meet meaningful use requirements, which involve capturing the right data that can improve client outcomes. This characteristic of EHRs does not specify their accessibility or require that they mean the same thing to all users.

What principle should guide the nurse-manager's understanding of gender differences in communication? a. Research has disproven any gender-based differences in communication that were thought to exist. b. Gender is the variable that has the greatest effect on an individual's communication style. c. People of different genders communicate and use language differently. d. In contrast with stereotypes, women have been shown to be more competitive communicators.

ANS: C Feedback: Gender is a significant factor in organizational communication, as men and women communicate and use language differently. Women are generally perceived as being more relationship-oriented than men, but this is not always the case. Gender is significant but is not seen as the most significant variable in communication.

A nurse-manager is having a difficult conversation with a subordinate whose performance has long been inadequate. The emotional component of the manager's message will be most clearly conveyed by: a. the formality or informality of the words the manager chooses. b. the pace and pitch of the manager's speech. c. facial expressions, body movements, and gestures. d. the amount of time that the manager lets the employee speak before interrupting.

ANS: C Feedback: Nonverbal communication is considered more reliable because it conveys the emotional part of the message. The other variables are not as significant communicators of emotion.

A nurse-manager is using the GRRRR model of listening when interacting with a colleague who exhibits challenging behaviors. What is the final action that the manager should implement when using this model? a. Confirm an action plan. b. Request any necessary information from the colleague. c. Thank the colleague for the collaborative conversation. d. Reflect privately on the quality of the interaction.

ANS: C Feedback: The final phase of the GRRRR model of listening involves reward, when both parties reward each other by recognizing and thanking each other for a collaborative exchange. The model does not explicitly prescribe a time of reflection. Confirming an action plan and requesting information take place in earlier phases of the model.

A nurse-manager is sitting on a practice committee and has adopted the role of gatekeeper. What action should the manager perform in this role? a. Acknowledge and praise each member's contributions. b. Mediate, harmonize, and resolve conflict when it arises. c. Facilitate and promote participation by all group members. d. Record the group's process and provide feedback to the group.

ANS: C Feedback: The gatekeeper makes sure all voices in the group are heard in order to facilitate and promote open communication. Acknowledging and praising each member's contributions is the role of the encourager. The recorder records the group's process and provides feedback to the group. The harmonizer mediates, harmonizes, and resolves conflict.

A nurse-manager is communicating with a subordinate. What component of this communication would be considered as part of the external climate? a. The clarity of the message b. The subordinate's personality c. The culture of the organization d. The manager's stress level

ANS: C Feedback: The organizational climate and culture would be considered part of the external climate of this communication. The sender's and receiver's personality and stress levels are components of the internal climate. The clarity of a message is not a component of the external climate.

An RN is a team leader for a small module of clients. While listening to a recorded report on a client, one of the team members remarks, "My mother lives near him, and she says his home life is in chaos." How should the RN best respond? a. Politely ask the team member to be quiet. b. Include the information in report for the next shift. c. Ask the team member how this information relates to the client's care. d. Ignore the team member's comment.

ANS: C Feedback: The role of the leader is to encourage communication that is appropriate and discourage communication that is inappropriate among staff. The RN's question about the purpose of this communication helps to determine whether it was appropriate or not. This should be clarified before deciding how to proceed.

A nurse sits at the foot of a client's bed during an admission interview. This positioning supports the proxemics concept of which psychological comfort zone? a. Intimate relationships b. Personal interactions c. Social exchange d. Public distance

ANS: C Feedback: The study of how space and territory affect communication is called proxemics. In the United States, between 6 and 18 inches of space is typically considered appropriate only for intimate relationships, between 18 inches and 4 feet is appropriate for personal interactions, between 4 and 12 feet is common for social exchanges, and more than 12 feet is a public distance. Most Americans claim a territorial personal space of about 4 feet.

Which vocal delivery suggests to a listener that a person is asking a question rather than making a statement? a. Loudness b. Frequent pauses c. Tentativeness d. Rapid delivery

ANS: C Feedback: Vocal clues such as tone, volume, and inflection add to the message being transmitted. Tentative statements sound more like questions than statements, leading listeners to think that you are unsure of yourself. Speaking quickly may be interpreted as being nervous. Loud and frequent pauses can be barriers to communication but do not suggest questioning.

A manager is careful to address nonverbal aspects of communication when communicating with employees. What practices should the manager adopt? Select all that apply. a. Have communications in public places as much as possible to reduce intimidation. b. Stand between 12 and 18 inches from an employee when having an important conversation. c. Be thoughtful about aspects of appearance that can be controlled by the manager. d. Avoid crossing arms across the chest. e. Limit eye contact with employees to avoid being perceived as aggressive.

ANS: C, D Feedback: The manager should take care on aspects of appearance and should avoid crossed arms, which communicate defensiveness or aggression. There are many communications that are inappropriate to have in a public place. Space of 12 to 18 inches is considered unusually close. Even though some individuals and cultures perceive eye contract as provocative or aggressive, it is still valued in most circumstances.

What statement about the maintenance of confidentiality is true? a. It is the right of every client and must never be breached. b. It is made easier with electronic technology. c. It is primarily the duty of the medical records staff. d. It can be violated when there is a legitimate professional need.

ANS: D Feedback: Confidentiality is a right that must be upheld, unless there is a legitimate professional need to know, such as when a provider must share information about a client with another provider so that the other provider can assume care. New technologies pose new threats to confidentiality, and every health care provider shares responsibility for it.

What is the best example of downward communication by a nurse-manager? a. The manager reports a nurse's serious error to the chief nursing officer. b. The manager seeks advice from a colleague about how to deal with an employee who is chronically late. c. The manager contacts a client's physician to confirm the client's scheduled transfer. d. The manager reviews the results of a nurse's performance appraisal with the nurse.

ANS: D Feedback: In downward communication, the manager relays information to subordinates. Reporting to the chief nursing officer would be upward communication; communication with a fellow manager would be horizontal. Communication with a physician would be diagonal.

A nurse-manager is drafting a memo that will be distributed within the organization. When using this form of communication, the manager should: a. send it to everyone in the organization to ensure equal access to information. b. begin with at least one page of background information to ensure clarity. c. avoid using headings so the reader is not confused. d. include only essential information.

ANS: D Feedback: Only essential information is included in a memo because extraneous information will detract from the message. Headers should be used to make the memo easier to read, and it should only be sent to a small to moderate number of people. Brevity is valued, so one page of background information would be excessive.

How can the Internet be best used as a means of improving one's personal nursing practice? a. Accessing the latest research and best practice information b. Communicating with other health care team members c. Minimizing the need for paper documentation d. Securing client information for confidentially

ANS: A Feedback: As an information source, the Internet allows nurses to access the latest research and best practice information so that their care can be evidence-based. It is not a secure form of communication in many cases. Electronic health records (not the Internet) replace paper records. Since it is not secure, the Internet is not used as a confidential repository of client information.