Leadership Exam 1

informed consent

authorization by the patient or the patient's legal representative to do something to the patient Legal capacity to give informed consent: -Age (> 18 years of age or emancipated minor) -Competent—can understand consequences of actions or ability to handle personal affairs -Voluntary action -- no coercion -Comprehension --Given sufficient information to make an informed decision --Informed refusal --Health literacy—key becomes an important concept for nurse managers in three very different instances. First, direct care nurses may approach the nurse manager with questions about informed consent; thus the nurse manager becomes a consultant for the direct care nurse. Second, and more often, the nurse manager is queried about patients' rights in research studies that are being conducted in the institution. Third, the issue of medical literacy has implications for the provision of valid informed consent by an ever-growing number of patients. emember: informed consent is the authorization by the patient or the patient's legal representative to do something to the patient; it is based on legal capacity, voluntary action, and comprehension. Legal capacity is usually the first requirement and is determined by age and competency. All states have a legal age for adult status defined by statute; generally, this age is 18 years. Competency involves the ability to understand the consequences of actions or the ability to handle personal affairs. State statutes mandate who can serve as the representative for a minor or incompetent adult. The following types of minors may be able to give valid informed consent: emancipated minors, minors seeking treatment for substance abuse or communicable diseases, and pregnant minors. Voluntary action, the second requirement, means that the patient was not coerced by fraud, duress, or deceit into allowing the procedure or treatment. Comprehension is the third requirement and the most difficult to ascertain. The law states that the patient must be given sufficient information, in terms he or she can reasonably be expected to comprehend, to make an informed choice. Inherent in the doctrine of informed consent is the right of the patient to informed refusal. Patients must clearly understand the possible consequences of their refusal. In recent years, most states have enacted statutes to ensure that the competent adult has the right to refuse care and that the healthcare provider is protected should the adult validly refuse care. This refusal of care is most frequently seen in end-of-life decisions. Box 5-1 lists the information needed for obtaining informed consent. Nurses often ask about issues concerning informed consent that concern the actual signing of the informed consent document, not the teaching and information that make up informed consent. Many nurses serve as witnesses to the signing of the informed consent document; in this capacity, they are attesting only to the voluntary nature of the patient's signature. There is no duty on the part of the nurse to insist that the patient repeat what has been said or what he or she remembers. If the patient asks questions that alert the nurse to the inadequacy of true comprehension on the patient's part or expresses uncertainty while signing the document, the nurse has an obligation to inform the primary healthcare provider and appropriate persons that informed consent has not been obtained. A separate issue with informed consent concerns the patient who is part of a research study. Federal laws regulate this area because patients are generally considered to come under the heading of vulnerable populations. Whenever research is involved, such as a drug study or a new procedure, the investigators must disclose the research to the subject or the subject's representative and obtain informed consent. Federal guidelines have been developed that specify the procedures used to review research and the disclosures that must be made to ensure that valid informed consent is obtained. Information Required for Informed Consent • An explanation of the treatment/procedure to be performed and the expected results of the treatment/procedure • Description of the risks involved • Benefits that are likely to result because of the treatment/procedure • Options to this course of action, including absence of treatment • Name of the person(s) performing the treatment/procedure • Statement that the patient may withdraw his or her consent at any time

Capitation

A reimbursement method in which healthcare providers are paid a per-person-per-year (or per-month) fee for providing specified services over a period of time.

Steady state

Career Style: Constancy in position with increasing professional skill -EX: Direct care nurses Motivation and Characteristics: -Increasing expertise -High professional identity -Obligation to serve -Maintenance of standards -Autonomy in performance of care -Preference for action -Personal accountability -The work itself -Stability Managerial Considerations: -Hold work in high esteem -Decentralize -Use and recognize abilities -Provide feedback about patient outcomes -Reward competence and tenure -Provide continuing education -Provide permanent assignment

secondary care

Disease restorative care Institutional or community: Prevent complications from disease; home health, hospitals Purpose: • Prevention of disease complications Organization or Unit Providing Services: • Home health care • Ambulatory care centers • Nursing centers

B

Nurses who engage in in-fighting, seek physician support against nursing colleagues, and avoid membership in nursing organizations: A. Refuse to believe that they are acting like members of groups that suffer socioeconomic oppression B. Do not understand how their failure to exercise power can limit the power of the whole profession. C. Purposefully choose to exercise their power in the workplace through indirect means. D. Suffer from learned helplessness as a result of abuse by powerful nurse executives.

Nurse practice act (NPA)

NPA = statutory law; defines nursing & nursing practice -NPA's are state specific -Define nursing and nursing functions: LVN/LPN, RN, & APRN -Define allowable action for each type of nursing above -Set education requirements -Set examination requirements (NCLEX; JP, Prescriptive Authority, etc.) Establish State Boards of Nursing, their duties, functions, and composition. Each state has its own NPA but all acts must be consistent with provisions or statutes established at the federal level. All nurses must know and practice within their own state NPA's. Nurse managers and leaders must know NPAs and monitor staff to ensure they are duly licensed and practicing within their RN, LPN/LVN, APRN scope of practice. Nurses and their managers/ leaders must keep current with NPAs in all states in which they practice and adhere to prescribed statutes, rules, and regulations. Otherwise they risk being liable (legally bound/ responsible) for their actions and those of whom they supervise. State Boards of Nursing -Ensure enforcement of NPAs -Protect the public -Regulate those who come under its provision -Prevent those not addressed within the act from practicing nursing -Ensure that those who present themselves as nurses are licensed to practice within the state Texas Nurse Practice Act: Texas Occupations Code And Statutes Regulating The Practice Of Nursing (As Amended September 2013) -Contain NPA and rules and regulations which explain and interpret the NPA; establishes the TBON -Written broadly to apply to all nurses in any practice act Most frequently referenced in NPA, Rules & Regulations: -NPA 301.002 Definition of Nursing -Rule 217.11 Standards of Nursing Practice -Rule 217.12 Unprofessional Conduct -Position Statement 15.14 Duty of a Nurse in Any Practice Setting -Six-Step Decision-Making Model for Determining Scope of Practice is the single most important piece of legislation for nursing because it affects all facets of nursing practice. Furthermore, the act is the law within the state or a U.S. territory, and state boards of nursing cannot grant exceptions, waive the act's provisions, or expand practice outside the act's specific provisions. Nurse practice acts define three categories of nurses: licensed practical or vocational nurses (LPNs and LVNs, respectively), licensed registered nurses (RNs), and advanced practice nurses. The nurse practice acts set educational and examination requirements, provide for licensing by individuals who have met these requirements, and define the functions of each category of nurse, both in general and in more specific terminology. The nurse practice act must be read to ascertain what actions are allowable for the three categories of nurses. In the few states where separate acts for RNs and LPNs/LVNs exist, the acts must be reviewed at the same time to ensure that all allowable actions are included in one of the two acts and that no overlap exists between the acts. In addition, nurse managers should understand that individual state nurse practice acts are not consistent in defining or delineating nursing practice, especially for advanced nursing roles. Each practice act also establishes a state board of nursing. The main purposes of state boards of nursing are to ensure enforcement of the act and to protect the public. The board enforces the act by regulating those practitioners who come under its provisions and preventing individuals not addressed within the act from practicing nursing. To protect the public, all those who present themselves as nurses must be licensed to practice within the state. The National Council of State Boards of Nursing (NCSBN) serves as a central clearinghouse, further ensuring that individual state actions against a nurse's license are recorded and enforced in all states in which the individual nurse holds licensure. These various boards of nursing develop and implement rules and regulations regarding the discipline of nursing and must be read in conjunction with the nurse practice act. Often any changes within the state's definition of nursing practice occur through modifications in the rules and regulations rather than in the act itself. This mandates that nurses and their nurse managers periodically review both the state act and the board of nursing rules and regulations. Because each state has its own nurse practice act and state courts have jurisdiction for the state, nurses are well advised to know and understand the provisions of the state's nurse practice act. This is especially true in the areas of diagnosis and treatment; states vary greatly on whether nurses can diagnose and treat or merely assess and evaluate. Thus an acceptable action in one state may be the practice of medicine in a bordering state. With the advent of the nurse license compact (NLC), informally known as multistate licensure, the need to know and understand provisions of state nurse practice acts has become even more critical. Multistate licensure permits an RN to be licensed in one state and to legally practice in states belonging to the NLC without obtaining additional state licenses. For the purposes of the law, the state nurse practice act that regulates the practice of the RN is the state in which the patient or client resides, not the state in which the nurse holds his or her license. Many of the nurses practicing under multistate licensure work with patients in a variety of states through telenursing, using telecommunications technology, such as telephone triage and advice. Others work for agencies or clinics that serve patients across state borders.

responsibility

The condition of being reliable and dependable and being obligated to accomplish work. refers to the reliability, dependability and obligation to accomplish work. It is a "two way process that is allocated and accepted"

Good Samaritan Immunity

The nurse is NOT liable for injury that occurs as a result of emergency treatment, provided that: Care is provided at the scene of the emergency Care is not grossly negligent

staff mix

The proportion of RNs to LPNs/LVNs to UAPs in a specific setting.

nursing case management

The process of a nurse coordinating health care by planning, facilitating, and evaluating interventions across levels of care to achieve measurable cost and quality outcomes. It was first seen in the early 1900s by social workers and public health nurses working in the public sector to identify and obtain resources for the needy. In the 1960s, insurers began to use nursing case management (NCM) as a strategy to manage the needs of complex patients who require coordination over the course of treatment. Acute care hospitals used nurses in this role under the term of utilization management, particularly when federal regulations required this service for all Medicare and Medicaid patients The case-management model of patient care delivery maintains quality care while streamlining costs for high-risk, high-volume, high-cost patient populations and seeks the active involvement of the patient, the family, and diverse healthcare professionals. Healthcare organizations have tailored the case-management system to meet their specific needs. The elements of the case-management model are the case manager and the critical pathway. The goal of case management is to provide cost-effective care through integration of clinical services in combination with financial services. In addition, the case manager serves as an advocate for the patient and the family. Nurses, social workers, and professionals in other disciplines may work as case managers, bringing with them their discipline-specific skills and knowledge. standards of practice for case managers. These include: 1. Addressing total individual concerns, including medical, psychosocial, behavioral, and spiritual needs 2. Collaborating to focus upon moving the individual to self-care whenever possible 3. Increasing the involvement of individual and caregivers in the decision-making processes 4. Minimizing fragmentation of care within the healthcare system 5. Using evidence-based guidelines, as available, in the daily practice of case management 6. Focusing on transitions of care, which includes a complete transfer to the next care setting or provider that is effective, safe, timely and complete 7. Improving outcomes by using adherence guidelines, standardized tools, and prevention processes to measure a client's understanding and acceptance of proposed plans, his/her willingness to change and his/her supports to maintain health behaviors 8. Expanding the interdisciplinary team to increase clients and/or their identified support system 9. Moving clients to optimal levels of health and well-being 10. Improving medication reconciliation for a client through collaborative efforts with medical staff 11. Improving adherence to the plan of care for the client, including medical differences The tool that case managers use to achieve patient outcomes is a clinical pathway. Also referred to as a multidisciplinary care pathway, integrated care pathway, critical path, or collaborative care pathway, these patient-focused documents describe the clinical standards, necessary interventions, and expected outcomes for the patient throughout the treatment process or hospital stay. These pathways facilitate coordinated and efficient plans to deliver patient care. However, they are not appropriate for all patients and cannot replace professional clinical judgment. Pathways are considered useful if the intervention (1) is a structured multidisciplinary plan of care; (2) is used to translate guidelines or evidence into a specific situation; (3) includes steps in a course of treatment or care in a plan, pathway, algorithm, guideline, protocol, or other "inventory of actions"; (4) includes time frames or criteria-based progression; and (5) aims to standardize care for a specific clinical problem, procedure, or episode of health care in a specific population If a patient's progress deviates from the normal path, a variance is indicated. A variance is anything that occurs to alter the patient's progress through the normal critical path. The reason(s) for the variance should be analyzed and the care revised to meet the needs of the patients. These reasons may be influenced by patient, provider, or care issues. For example, the symptoms experienced by a patient with a urinary tract infection may not resolve as rapidly as projected because a dose of the antibiotic prescribed was missed in error or because the patient couldn't tolerate the medication prescribed. Nursing case management (NCM) is a process for providing comprehensive care for those with complex health problems. Case management provides a well-coordinated care experience that can improve the care outcome, decrease the length of stay, and use multiple disciplines and services efficiently. Families and patients receive care across a continuum of settings, often from diverse institutions. NCMs can often break down invisible institutional barriers for the patient. Nurses receive a sense of satisfaction knowing that the patient and family received coordinated, quality care in a cost-effective manner across the spectrum of the illness or injury. In order to implement this approach effectively, interdisciplinary collaboration and coordination and consensus related to patient outcomes and the time frames proposed must be active. The nurse manager has increased demands when leading a case-management system. Quality improvement is constantly assessed to ensure that the clinical pathway is appropriate for the diagnosis-related group (DRG) and that case managers are adequately managing their caseloads. Reimbursement for the care delivered is tied to effective planning and care delivery within the case-management process. Patient satisfaction is also pertinent to evaluate for quality. If patients are not satisfied with the system, the census may decline. Communication among all systems must be coordinated. Because the NCM works with all departments within a healthcare organization, the nurse manager may need to facilitate interdepartmental communication. Educating the staff of other departments about the NCM's role and responsibilities will increase the effectiveness of the case-management process. The direct care nurse working with a patient who has a case manager as the coordinator of care provides patient care according to the case manager's specifications and must know the extent of the case manager's role. Effective communication to facilitate care is the responsibility of both the case manager and the staff RN. Plan, implement, evaluate care across all levels of care; built upon Social Work model; May require master's level RNs; use critical pathways; utilization management Today: insurance companies; some hospitals. Advantages: -care coordination for complex patients with catastrophic illnesses/ conditions -analyze variances and intervene to contain costs -revenue-protecting approach Disadvantages: -may create "turf wars" - need strong communication skills

Politics

can be defined in many ways. One simple definition of politics that this author uses when teaching health policy and politics in nursing is "a process of human interaction within organizations." Politics permeates all organizations, including workplaces, legislatures, professions, and even families. Young children often learn that one parent is more likely to readily give permission for special activities or more likely to buy toys and other desired items. They quickly learn to ask permission or ask for a desired item from that parent before asking the other. This is an unwritten political rule in many families. Political activism should be an unwritten rule in nursing. The American Association of Colleges of Nursing (AACN) identifies health policy as one of the essentials for baccalaureate, graduate, and doctoral education Some nurses are still uncomfortable with politics and the use of power, treating "politics" as if it was a dirty word. Historically, politics has been viewed with some disdain. Writer Robert Louis Stevenson noted, "Politics is perhaps the only profession for which no preparation is thought necessary." But contemporary nursing's need to thrive within a healthcare system demands that nursing education prepare nurses to engage in professional, workplace, and legislative politics. Developing Political Skills: • Build a working relationship with a legislator, such as one's state senator or representative or member of the U.S. Congress and the legislative staff members. • Join and be an active member of your state nurses' association affiliate of the ANA. • Join a specialty nursing organization related to your clinical specialty (e.g., critical care, pediatrics) or specialty role in nursing (nurse practitioner, manager). • Invite a legislator to a professional organization meeting. • Invite a legislator or staff person from the legislator's office to spend a day with you at work. • Register to vote, and vote in every election. • Join your state nurses' association's government relations or legislative committee and political action committee (PAC); join ANA's PAC. • Be in touch with your federal and state legislators on nursing and healthcare issues, especially related to specific bills, by writing letters, making telephone calls, or sending e-mails. • Participate in Nurse Lobby Day and meet with your state legislators. • Work on a federal or state legislative campaign. • Visit your U.S. senators and member of Congress if visiting in the Washington, D.C., area to discuss federal legislation related to nursing and health care, or visit their local offices. • Get involved in the local group of your political party. • Run for office at the local, county, state, or congressional level. • Enhance the image of nursing in all your policy efforts. • Communicate your message effectively and clearly. • Develop your expertise in shaping policy. • Seek appointive positions or elective office to shape policy more effectively. a process of human interaction within organizations Strategies to enhance your political activism: -Hold active membership in professional organizations that provide information and opportunities for networking -Attend workshops, conferences, and academic courses that support the development of political skills and expansion of political/ policy knowledge -Engage with legislators through lobbying and campaign work -Move into leadership roles in nursing organizations

supervision

defined as the active process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The nurse manager retains personal liability for the reasonable exercise of assignment, delegation, and supervision activities. The failure to assign, delegate, and supervise within acceptable standards of professional nursing practice may constitute malpractice. In addition, in a newer trend in the law, failure to delegate and supervise within acceptable standards may extend to direct corporate liability for the institution.

decision making

is a purposeful and goal-directed effort that uses a systematic process to choose among options. Some decisions are not prompted by a problem. The hallmark of any type of decision making is the identification and selection of options or alternatives.

C

One day, at coffee, your co-worker suggests that you and she sit with unit members of the hospital research committee. She suggests that this would be an excellent way to get to know people who share her interest in research. Her actions are an example of: A. Mentorship B. Politics C. Networking D. Empowerment

reward power

One is perceived as being able to provide rewards or favors. An instructor is perceived positively by a nursing student who received an A for a clinical course.

transforming care at the bedside (TCAB)

The variety of care delivery models and the complexity of patient needs, organizational structures, and technologic advances require individual action to improve practice patterns in specific units. In 2003, the Robert Wood Johnson Foundation and the Institute of Healthcare Improvement joined to create, test, and implement changes to dramatically improve care on medical/surgical units and improve staff satisfaction. An initiative called Transforming Care at the Bedside (TCAB) was implemented to redesign the work environment of nurses. A group of healthcare experts developed a guiding framework to redesign the work of nurses in medical/surgical units The TCAB initiative is based on a set of premises, which then serve as the underpinnings of four key design themes. These include reliability, vitality and teamwork, patient-centered care, and value-added care processes Premises: • Patient-centered work redesign can create value-added care processes and result in better clinical outcomes and reduced costs. • Effective care teams can have a positive impact on patient outcomes. • Management practices and organizational culture have a significant impact on the work environment. • Matching staff's knowledge and capabilities with work responsibilities enhances job satisfaction. • Eliminating inefficiencies through work redesign enhances staff satisfaction and morale. Objective/Design Themes • Reliability: The care for moderately sick patients who are hospitalized is safe, reliable, effective, and equitable. • Vitality: Effective care teams continually strive for excellence within a joyful and supportive environment that nurtures professional formation and career development. • Patient-centeredness: Patient-centered care on medical/surgical units honors the whole person and family, respects individual values and choices, and ensures continuity of care. • Increased value: All care processes are free of waste and promote continuous flow. The TCAB initiative was initially implemented at three pilot hospitals and subsequently moved to other hospitals across the country. Small groups in each hospital came together, first, to learn about the TCAB process and to ask themselves "what do we know" about the work environment related to a particular design theme. The group then was encouraged to tell stories about the work environment consistent with this theme. After the story-telling opportunity, the group participated in a brainstorming session to develop as many innovations as possible that would contribute to the themes they had chosen. Innovations requiring minimal time and resources were then prioritized and selected for a rapid cycle trial. Critical to practice changes, rapid cycle change is a process that encourages testing creative change on a small scale while determining potential impact. The process involves four stages—plan, do, study, and act (PDSA). During the plan phase, the team had to define the objectives and predict how the identified change would contribute to a design, how the change would occur, and what data collection methods were needed. During the do phase, the team had to focus on whether the changed occurred as expected and, if not, what interfered with the plan. In the study phase, the team had to determine if the innovation worked as predicted and what knowledge was gained. The act phase required the team to plan the next actions. Robert Wood Johnson (RWJ) Foundation --improve care on medical-surgical units Work redesign/ re-engineering! -Rapid cycle improvements; Plan, Do, Study, Act (PDSA) Premises Design themes -Reliability -Vitality -Patient-centeredness -Increased value

Fee-for-service

A system in which patients have the option of consulting any healthcare provider, subject to reasonable requirements that may include utilization review and prior approval for certain services but does not include a requirement to seek approval through a gatekeeper.

UAP

A term used to distinguish those for whom nurses are accountable as opposed to the numerous unlicensed assistive personnel providing aid in other clinical disciplines.

team nursing

A small group of licensed and unlicensed personnel, with a team leader, responsible for providing patient care to a group of patients. After World War II, the nursing shortage continued. Many female nurses who were in the military came home to marry and have children instead of returning to the workforce. Because the functional model received criticism, a new system of team nursing (a modification of functional nursing) was devised to improve patient satisfaction. "Care through others" became the hallmark of team nursing. This type of nursing care delivery remains in use, particularly when reduced reimbursement and nursing shortages have resulted in organizations changing the staff mix and increasing the ratio of unlicensed to licensed personnel. In team nursing, a team leader, who is a registered nurse, is responsible for coordinating a group of licensed and unlicensed personnel to provide patient care to a small group of patients. The team leader should be a highly skilled leader, manager, and practitioner, who assigns each member specific responsibilities according to role, licensure, education, ability, competency, and the complexity of the care required. The members of the team report patient progress according to the plan of care directly to the team leader, who then reports to the charge nurse or unit manager Some advantages of the team method, particularly when compared with the functional approach, are improved patient satisfaction, organizational decision making occurring at lower levels, and cost-effectiveness for the agency. Many institutions and community health agencies currently use the team nursing method. Inpatient facilities may view team nursing as a cost-effective system because it works with an expected ratio of unlicensed to licensed personnel. Thus the organization has greater numbers of personnel for a designated amount of money. The team method of patient care delivery has one major disadvantage, which arises if the team leader has poor leadership skills. The team leader must have excellent communication skills, delegation and conflict management abilities, strong clinical skills, and effective decision-making abilities to provide a working "team" environment for the members. The team leader must be sensitive to the needs of the patient and, at the same time, attentive to the needs of the staff providing the direct care. When the team leader is not prepared for this role, the team method becomes a miniature version of the functional method, and the potential for fragmentation of care is high. The nurse manager, charge nurse, and team leaders must have management skills to effectively implement the team nursing method of patient care delivery. In addition, the nurse manager must determine which RNs are competent and interested in becoming a charge nurse or team leader. Because the basic education of baccalaureate-prepared RNs emphasizes critical thinking, clinical reasoning, and leadership concepts, they are likely candidates for such roles. The nurse manager should also provide an adequate staff mix and orient team members to the team nursing system by providing continuing education about leadership, management techniques, delegation, and team interaction The charge nurse functions as a liaison between the team leaders and other healthcare providers, because nurse managers are often responsible for more than one unit and/or have other managerial responsibilities that take them away from the unit. The charge nurse provides support for the teams on a shift-by-shift basis. Appropriate support requires the charge nurse to encourage each team to solve its problems independently. The team leader plans the care, delegates the work, and follows up with members to evaluate the quality of care for the patients assigned to their team. In the ideal circumstance, the team leader updates the nursing care plans and facilitates patient care conferences. Time constraints during the shift may prevent scheduling daily patient care conferences or prevent some team members attending those that are held. The team leader must also face the challenge of changing team membership on a daily basis. Diverse work schedules and nursing staff shortages may result in daily changes in the staff mix of a team and a daily assignment change for team members. The team leader assigns the professional, technical, and ancillary personnel to the type of patient care they are prepared to deliver. Therefore the team leader must be knowledgeable about the legal and organizational limits of each role. Team nursing uses the strengths of each caregiver. The direct care nurses, as members of the team, develop expertise in care delivery. Some members become known for their expertise in the psychomotor aspects of care. If one nurse is skilled at starting IVs, she will start all IVs for her team of patients. If a nurse is especially skillful in motivating postoperative patients to ambulate, he should be assigned to the surgical patients. Under the guidance and supervision of the team leader, the collective efforts of the team become greater than the functions of the individual caregivers. Modification of functional nursing; team leader with team members who hold different credentials (staff mix); EX: RN Team Leader, 2 LVN, and 2 - 3 CNAs form a team & care for 20 - 30 patients. Today: area hospitals, long-term care facilities, home care, etc. Advantages: -efficient and cost effective -leadership at the staff nurse level Disadvantages: -not every RN makes a good team leader! -team members change daily, depending on work schedules

clinical nurse leader

An evolving role of the professional nurse being developed by the American Association of Colleges of Nursing (AACN).

A

A colleague asks you to give her your password access so that she can view her partner's healthcare record. This request violates the patient's right to: A. Privacy B. Fidelity C. Veracity D. Beneficence

total patient care

A model of care delivery in which one nurse provides total care for a patient during an entire work period. This method was used in the era of Florence Nightingale when patients received total care in the home. Today, total patient care is used in critical care settings where one nurse provides total care to one or two critically ill patients. Nurse educators often select this method of care when students are caring for patients. Variations of the case method exist, and it is possible to identify similarities after reviewing other methods of patient care delivery described later in this chapter. One advantage for this model of care delivery is that during an 8- or 12-hour shift, the patient receives consistent care from one nurse who is accountable for the continuity of communication with all healthcare providers and implementing the plan of care. The nurse, patient, and family usually trust one another and can work together toward specific goals. Because the nurse is with the patient during most of the shift, even subtle changes in the patient's status are easily noticed Usually, the plan of care is patient-centered, comprehensive, continuous, and holistic. However, if the nurse chooses to deliver this care with a task orientation, it would negate the holistic perspective In today's costly healthcare economy, total patient care provided by a registered nurse (RN) is very expensive. Is it realistic to use the highly skilled and extremely knowledgeable professional nurse to provide all the care required in a unit that may have 20 to 30 patients? In times of nursing shortages, there may not be enough resources or nurses to use this model. When using the case method of delivery, the manager must consider the expense of the system. He or she must weigh the expense of an RN versus the expense of licensed practical/vocational nurses (LPNs/LVNs) and unlicensed assistive (or nursing) personnel (UAPs) in the context of the outcomes required. UAPs are not licensed as healthcare providers. In various healthcare organizations, they may be called technicians, nurse aides, or certified nursing assistants. When the patient requires 24-hour care, the nurse manager must decide whether the patient should have RN care or RN-supervised care provided by LPNs/LVNs or UAPs. In the case method, the direct care RN provides holistic care to a group of patients during a defined work time. The physical, emotional, and technical aspects of care are the responsibility of the assigned RN. This model is especially useful in the care of complex patients who need active symptom management provided by an RN, such as the care of the patient in a hospice setting or an intensive care unit. This care delivery model requires the nurse who is assigned to total patient care to complete the complex functions of care, such as assessment and teaching the patient and family, as well as the less complex functional aspects of care, such as personal hygiene. Some nurses find satisfaction with this model of care because no aspect of nursing care is delegated to another, thus eliminating the need for supervision of others 1:1 Nurse : Patient ratio Today: in-home/ private duty or ICU Advantages: -Patient-Centered; Comprehensive; Continuous; Holistic -Useful if very critically ill, complex patient Disadvantages: -Very expensive!

chain of command

The hierarchy depicted in vertical dimensions of organizational charts.

Career

progressive achievement throughout a person's professional life Strategies for career development: -Be a lifelong learner—continue to prepare yourself by continuing education. -Work towards the criteria identified for the position above you -Say yes to being involved on unit projects and solving unit issues -Attend organizational functions -e.g., ball games, other social events -Network -Belong to and participate in professional organizations -Select a mentor, role model, etc. -Read professional journals -stay evidence-based! -Other Career Marketing Strategies: -Keep a record (Portfolio) of your achievements, publications, continuing education, experience, community and institutional service, honors, research, presentations, workshops, certification. -Prepare a curriculum vitae (usually for an academic job) -Prepare a resume (usually for a nursing clinical job) Curriculum vitae - many pages; details of your professional life Resume—1-2 pages; key highlights of professional life Professional cover letter, thank you letter, resignation letter defined as progress throughout an individual's professional life, is developed by selecting positions that contribute to professional goals. A relationship exists between an individual and a position, and that same relational fit is exhibited in a career path. A good fit is built on strong, similar goals and tolerable (or growth-producing) differences. The whole of any work situation is composed of the two elements—person and position—interacting in a complex environment. Analyzing positions and the required skills in light of individual talents can help applicants determine positions that fit with their strengths. When gaps occur between the requirements of a "dream" position and the person's skills, applicants can consider whether professional development activities might help improve the match between their current and desired future qualifications. Consideration of a career path, such as practitioner or administrator or educator, includes reflection on the most rewarding aspects of prior work. As an example, a nurse who determined that teaching patients, families, and students was the most personally rewarding aspect of practice might plan to develop a career as an educator. Whatever career is pursued, one key strategy is planning to obtain the right education and experience to meet future goals. Elements in Career Success: 1. Taking ownership: Own the process and take responsibility for your career. 2. Taking risks: Don't be afraid to try something new. Adjust course and challenge yourself. 3. Seeking to learn: Be inquisitive. Ask questions. Listen. Be open to feedback. 4. Choosing to engage: Take the initiative and inspire yourself. 5. Setting a goal and making a plan: Know what you want and create the path forward. 6. Striving to align: Connect with your current or future organization's priorities.

primary nursing

A model of patient care delivery whereby one registered nurse functions autonomously as the patient's main nurse throughout the entire hospital stay. A cultural revolution occurred in the United States during the 1960s. The revolution emphasized individual rights and independence from existing societal restrictions. This revolution also influenced the nursing profession, because nurses were becoming dissatisfied with their lack of autonomy. In addition, the hierarchical nature of communication in team nursing caused further frustration. Institutions were also aware of the declining quality of patient care. The search for autonomy and quality care led to the primary nursing system of patient care delivery as a method to increase RN accountability for patient outcomes. Primary nursing, an adaptation of the case method or total patient care, was developed by Marie Manthey as a method for organizing patient care delivery in which one RN functions autonomously as the patient's primary nurse throughout the hospital stay Primary nursing brought the nurse back to direct patient care. The primary nurse is accountable for the patients' care 24 hours a day from admission through discharge. Conceptually, primary nursing care provides the patient and the family with coordinated, comprehensive, continuous care When his primary nurse is not working, an associate nurse implements the plan. The associate nurse is an RN who has been delegated to provide care to the patient according to the primary nurse's specification. If the patient develops additional complications, the associate nurse notifies the primary nurse, who has 24-hour accountability and responsibility. The associate nurse provides input to the patient's plan of care, and the primary nurse makes the appropriate alterations. RNs practicing primary nursing must possess a broad knowledge base and have highly developed nursing skills. In this system of care delivery, professionalism is promoted. Nurses experience job satisfaction because they can use their education to provide holistic and autonomous care for the patient. This high level of accountability for patient outcomes encourages RNs to further their knowledge and refine skills to provide optimal patient care. If the primary nurse is not motivated or feels unqualified to provide holistic care, job satisfaction may decrease. In primary nursing, patients and families are typically satisfied with the care they receive, because they establish a relationship with the primary nurse and identify the caregiver as "their nurse." Because the patient's primary nurse communicates the plan of care, the patient can move away from the sick role and begin to participate in his or her own recovery. By considering the sociocultural, psychological, and physical needs of the patient and family, the primary nurse can plan the most appropriate care with and for the patient and family. A professional advantage to the primary nursing method is a decrease in the number of unlicensed personnel. The ideal primary nursing system requires an all-RN staff. The RN can provide total care to the patient, from bed baths to patient education, even both at the same time! Unlicensed personnel are not qualified to provide this level of inclusive care A disadvantage of the primary nursing method is that the RN may not have the experience or educational background to provide total care. The agency needs to educate staff for an adequate transition from the previous role to the primary role. One has to ask whether the RN is ready and willing and capable of handling the 24-hour responsibility for patient care. In addition, the nurse practice acts must be evaluated to determine whether primary nurses can be held accountable when they are not physically present. In times of nursing shortage, primary nursing may not be the model of choice. This model will not be effective if a unit has a large number of part-time RNs who are not available to assume the primary nurse role (24-hour responsibility). In addition, with the arrival of managed care in the 1990s, patients' hospital stays were shorter than in the 1970s, when primary nursing became popular. Expedited stays make it challenging for primary nurses to adequately provide the depth of care required by primary nursing. The primary nursing system can be modified to meet patient, nursing, and budgetary demands while maintaining the positive components that spawned its conception. The nurse manager who implements this care delivery model experiences some benefits. Primary nursing provides the nurse manager an opportunity to demonstrate leadership capabilities, clinical competencies, and teaching abilities to serve as a role model for professional practice. In addition, the roles of budget controller and unit quality manager remain. The traditional roles of delegation and decision making must be relinquished to the autonomous primary nurse. The nurse manager functions as a role model, advocate, coach, and consultant. The primary nurse uses many facets of the professional role—caregiver, advocate, decision maker, teacher, collaborator, care coordinator, and manager. Because primary nurses cannot be present 24 hours a day, they must depend on associate nurses to provide care when they are not available. The associate nurse provides care using the plan of care developed by the primary nurse. Changes to the plan of care can be made by the associate nurse in collaboration with the primary nurse. This model provides consistency among nurses and shifts. To function effectively in this setting, direct care nurses will need experience and opportunities to be mentored in this role. Modification of case method; Staff RN becomes "primary nurse" similar to patient's "primary physician" and provides/ directs all nursing care throughout patient's stay; Associate Nurse in charge when Primary Nurse not on duty; all RN staff; many hybrids! Today: some hospitals may use a hybrid.... Advantages: -coordinated, comprehensive, continuous care -professional approach to delivering nursing care -enhanced RN job satisfaction! Disadvantages: -costly! -some nurses are not capable or nor do they desire 24 hour responsibility and accountability for a patient's care

critical pathway

A component of a care MAP that is specific to diagnosis-related group reimbursement. The purpose is to ensure patients are discharged before insurance reimbursement is eliminated.

B

Budgeting and protection of revenues is a function of: A. Leadership B. Management C. Team Leadership D. Followers

advanced generalist

Clinical nurse leader, which is a protected title for those who successfully complete the CNL certification examination.

outcome criteria

The result of patient goals that are expected to be achieved through a combination of nursing and medical interventions.

functional model of nursing

A method of providing patient care by which each licensed and unlicensed staff member performs specific tasks for a large group of patients. became popular during World War II when there was a severe shortage of nurses in the United States. Many nurses joined the armed forces to care for the soldiers. To provide care to patients at home, hospitals began to increase the number of LPNs/LVNs and UAPs. These tasks are in part determined by the scope of practice defined for each type of caregiver. For example, the RN must be responsible for all assessments, although the LPN/LVN and UAPs may collect data that can be used in the assessment. Regarding treatments, an RN may administer all intravenous (IV) medications and do admissions, one LPN/LVN may provide treatments, another LPN/LVN may give all oral medications, one UAP may do all hygiene tasks, and another assistant may take all vital signs This division of aspects of care is similar to the assembly line system used by manufacturing industries. Just as an auto worker becomes an expert in attaching fenders to a new vehicle, the direct care nurse becomes expert in the tasks expected in functional nursing. A charge nurse coordinates care and assignments and may ultimately be the only person familiar with all the needs of any individual patient. Several advantages exist for this model of patient care delivery. First, each person becomes efficient at specific tasks, and much work can be done in a short time. Another advantage is that unskilled workers can be trained to perform one or two specific tasks very well. The organization benefits financially from this model because care can be delivered to a large number of patients by mixing staff with a fixed number of RNs and a larger number of UAPs. Although financial savings may be the impetus for organizations to choose the functional system of delivering care, the disadvantages may outweigh the savings. A major disadvantage is the fragmentation of care. The physical and technical aspects of care may be met, but the psychological and spiritual needs may be overlooked. Patients become confused with so many different care providers per shift. These different staff members may be so busy with their assigned tasks that they may not have time to communicate with each other about the patient's progress. Because no one care provider sees patient care from beginning to end, the patient's response to care is difficult to assess. Critical changes in patient status may go unnoticed. Fragmented care and ineffective communication can lead to patient and family dissatisfaction and frustration. In the functional model of nursing, the nurse manager must be sensitive to the quality of patient care delivered and the institution's budgetary constraints. Because staff members are responsible only for their specific task, the role of achieving patient outcomes becomes the nurse manager's responsibility. Staff members can view this system as autocratic and may become discontented with the lack of opportunity for input. By using effective management and leadership skills, the nurse manager can improve the staff's perception of their lack of independence. The manager can rotate assignments among staff within legal and organizational contexts to alleviate boredom with repetition. Staff meetings should be conducted frequently. This encourages staff to express concerns and empowers them with the ability to communicate about patient care and unit functions. The direct care RN becomes skilled at the tasks that are usually assigned by the charge nurse. Clearly defined policies and procedures are used to complete the physical aspects of care in an efficient and economical manner. However, the functional model of nursing may leave the professional nurse feeling frustrated because of the task-oriented role. Nurses are educated to care for the patient holistically, and providing only a fragment of care to a patient may result in unmet personal and professional expectations of nurses. As a result, this approach often leads to staff dissatisfaction and, ultimately, unacceptable staff turnover. works well in emergency and disaster situations. Each care provider knows the expectations of the assigned role and completes the tasks quickly and efficiently. Subacute care agencies, extended care facilities, and ambulatory clinics often use the functional model to deliver care. Team members perform tasks, i.e., medication nurse, treatment nurse; task-oriented vs. professional model; assembly line Today: used in some long-term care facilities Advantages: -proficiency at task; quick; -cost effective to mix staff Disadvantages: -fragmentation of care -ineffective communication -professional nurse dissatisfaction -less control of quality

Deeming authority

A power granted by one with power so that the recipient acts in his or her place

D

Before beginning her own nursing agency, a nurse worked with other temporary nursing agencies in nine states. This career style is known as: A. Linear B. Spiral C. Steady state D. Entrepreneurial/ transient

Problem Solving

Using a systematic process to solve a problem. which includes a decision-making step, is focused on trying to resolve an issue that can be viewed as the gap between "what currently is" and "the best available option." Often the "what currently is" can be seen as a problem.

Leader

an individual who works with others to develop a clear vision of the preferred future and to make that vision happen May or may not have delegated authority -referent power Frequently are not part of a formal organization—informal and formal leaders Experts May have a wider variety of roles than managers Focus on visioning, group process, information gathering, feedback, and empowering others Interpersonal skills and relationships are key

nonmaleficence

states that one should do no harm. For a nurse manager following this principle, performance evaluation should emphasize an employee's good qualities and give positive direction for growth. Destroying the employee's self-esteem and self-worth would be considered doing harm under this principle.

respondeat superior

the doctrine of respondeat superior (let the master answer) makes employers accountable for the negligence of their employees.

scope of practice

those actions and duties that are allowable by the profession, is defined and guided individually by each state in the nurse practice act.

redesign

Technique to analyze tasks to improve efficiency (e.g., identifying the most efficient flow of supplies to a nursing unit)

line function

A function that involves direct responsibility for accomplishing the objectives of a nursing department, service, or unit. Are those that involve direct responsibility for accomplishing the objectives of a nursing department, service, or unit. Line positions may include registered nurses, licensed practical/vocational nurses, and unlicensed assistive (or nursing) personnel who have the responsibility for carrying out all aspects of direct care.

associate nurse

A licensed nurse in the primary care model who provides care to the patient according to the primary nurse's specification when the primary nurse is not working.

patient-focused care

A model in which staff functions become centralized on a unit to reduce the number of staff required; emphasizes quality, cost, and value.

autocratic

An authoritarian style that places control within one person's position. decision-making method results in more rapid decision making and is appropriate in crisis situations. However, followers are generally more satisfied with a shared decision-making approach. Although this approach takes more time, it is more appropriate when conflict is likely to occur or when the problem is unstructured.

C

An organization in which a RN is assigned to provide care for patients but is not given any opportunity to determine policies, procedures or standards of care, can best be described as a: A. Bureaucratic organization. B. Decentralized organization. C. Centralized organization. D. Regulatory organization.

Entrepreneurial and Transient

Career Style: Desire to create new service; meeting own priorities -EX: Nurses in private practice; temporary assignments Motivation and Characteristics: -Limited organizational commitment -Opportunists -Novelty/creativity -Other people -Achievement Managerial Considerations: -Use flexibility to organization's benefit -Avoid burdening them with organizational and practice decisions -Provide immediate feedback

passive delegation

Delegation that does not require a decision-making process. The decisions derive from job descriptions or policies and thus the tasks are not actively delegated, they are assumed by virtue of the policy or job description. When a position description contains functions that are normally performed or are an essential part of the practice of a licensed individual (e.g., physician, nurse, pharmacist), the individual functioning in this role performs these functions through passive delegation. Therefore no active delegation decision is made by the registered nurse.

connection power

Gained by association with people who are powerful or who have links to powerful people. At a National Nurses' Week celebration, nurses take advantage of the opportunity to have extended, informal conversations with those who report to the chief nursing officer.

Achieving workable unity

Gardener's Goals Assisting patients/families to achieve optimal functioning to benefit the transition to enhanced health functions Assisting staff to achieve optimal functioning to benefit transition to enhanced organizational functions Assisting multidisciplinary leaders to achieve optimal functioning to benefit patient care delivery and collaborative care Another leadership challenge is to achieve workable unity between and among the parties being affected by change and to avoid, diminish, or resolve conflict so that vision can be achieved. Conflict resolution skills are essential for leaders. When a dispute occurs as a result of conflicting values or interests, following a defined set of principles to guide conflict resolution is an excellent aid.

motivating

Gardener's Goals Relating to and inspiring patients/families to achieve their vision Relating to and inspiring staff to achieve the mission of the organization and the vision associated with organizational enhancement Relating to and inspiring management, staff, and community leaders to achieve desired levels of health and well-being and appropriate use of clinical services When values drive our actions, they become a source of motivation. Motivation energizes what we value, personally and professionally, and stimulates growth and movement toward the vision. Motivators are the reinforcers that keep positive actions alive and sustained, fueling the desire to engage in change. Theories of motivation identify and describe the forces that motivate people.

Representing the group

Gardener's Goals Representing nursing and the unit in task forces, total quality initiatives, shared governance councils, and other groups Representing nursing and the organization on assigned boards, councils, committees, and task forces, both internal and external to the organization Representing the organization and patient care services on assigned boards, councils, committees, and task forces, both internal and external to the organization

powerlessness

Lacking strength or power Feeling helpless and totally ineffectual Lacking legal or other authority

Consolidated systems

Large national hospital companies Large voluntary affiliated systems Regional Hospital systems Metropolitan-based systems Special Interest groups -religious affiliations, other

C

On your nursing unit, you employ LPNs/LVNs, RNs, and APRNs. You will need to be familiar with at least: A. Two nurse practice acts. B. Two nurse practice acts in most states. C. One nurse practice act in your state. D. One nurse practice act and a medical practice act.

Private non-profit or not-for-profit organization

Organization that has funds redirected to maintenance and growth rather than as dividends to stockholders. often referred to as voluntary agencies—are controlled by voluntary boards or trustees and provide care to a mix of paying and charity patients. In these organizations, excess revenue over expenses is redirected into the organization for maintenance and growth rather than returned as dividends to stockholders. These organizations are required to serve people regardless of their ability to pay. Non-profit organizations located in impoverished urban and rural areas are often economically disadvantaged by the amount of uncompensated care that they provide. Historically, non-profit organizations have been exempt from paying taxes because they commit to providing an important community service. The owners of such organizations include churches, communities, industries, and special interest groups such as the Shriners. The ownership influences how organizations are structured, what services they provide, and which patients they serve. Voluntary Board of Directors Tax exempt Revenue returned to hospital to enhance facilities, add services, etc. Provide services regardless of person's ability to pay/ Charity care + community service EX: community hospitals

position power

Possessed by virtue of one's position within an organization or status within a group. The dean of a college of nursing is viewed on campus as powerful because this dean leads the fastest growing academic unit on campus.

tertiary care

Rehabilitative or long-term care Community or Institutional: Rehabilitation or long-term: home health; assisted living, rehabilitation centers, sub-acute facilities, skilled nursing facilities, hospice Purpose: • Rehabilitation • Long-term care Organization or Unit Providing Services: • Home health care • Long-term care facilities • Rehabilitation centers • Skilled nursing facilities • Assisted living programs/retirement centers

satisficing decision

Selecting an option that is acceptable but not necessarily the best option. (Satisfy+suffice=satisfice.)

optimizing decision

Selecting the ideal solution or option to achieve goals

restructuring

Technique to enhance organizational productivity (e.g., identifying the most appropriate type and number of staff members for a particular nursing unit)

Horizontal integration

The condition that results when two (or more) organizations with similar services come together. When organizations that provide similar services come together, the arrangement is referred to as horizontal integration. An example of horizontal integration is a group of acute care facilities that come together to provide coverage for an expanded region.

span of control

The number of individuals a supervisor manages. For budgetary reasons, span of control is often a major focus for organizational restructuring. refers to the number of subordinates a supervisor manages. For budgetary reasons, span of control is often a major focus for organizational restructuring. Although cost implications are present when a span of control is too narrow, when a span of control becomes too large, supervision can become less effective.

patient outcomes

The result of patient goals that are achieved through a combination of medical and nursing interventions with patient participation.

leadership theory

Trait Theory Style Theory Situational-Contingency Theory Transformational Theories Hierarchy of Needs Two-Factor Theory Expectancy Theory OB Modification

Renewing

Gardener's Goals Providing self-care to enhance the ability to care for staff, patients, families, and the organization served Providing self-care to enhance the ability to care for staff, patients, families, and the organization served Providing self-care to enhance the ability to care for patients, families, staff, and the organization served

health literacy

The degree to which individuals have the capacity to obtain, process, and understand basic health information, including services needed to make appropriate health decisions. issue with informed consent about which nurses and nurse managers should be cognizant Functional health literacy relates to the person's ability to act upon the basic health information received. Comprehending medical jargon is difficult for well-educated Americans; about 12% or American adults are considered proficient in health literacy Comprehending medical instructions and terms may be impossible for individuals whose first language is not English, who cannot read at greater than a second-grade level, or who have vision or cognitive problems caused by aging or disabilities. These individuals have difficulty following instructions that are printed on medication labels (both prescription and over-the-counter), interpreting hospital consent forms, and even understanding diagnoses, treatment options, and discharge instructions.

Transformational Theories

arose late in the past millennium when globalization and other factors caused organizations to fundamentally re-establish themselves. Many of these attempts were failures, but great attention was given to those leaders who effectively transformed structures, human resources, and profitability balanced with quality Transformational leadership refers to a process whereby the leader attends to the needs and motives of followers so that the interaction raises each to high levels of motivation and morality. The leader is a role model who inspires followers through displayed optimism, provides intellectual stimulation, and encourages follower creativity. Transformed organizations are responsive to customer needs, are morally and ethically intact, promote employee development, and encourage self-management. Nurse leaders with transformational characteristics experiment with systems redesign, empower staff, create enthusiasm for practice, and promote scholarship of practice at the patient-side.

Power

comes from the Latin word potere, meaning "to be able" is the ability to influence others in an effort to achieve goals. was once considered almost a taboo in nursing. In nursing's formative years, the exercise of _________ was considered inappropriate, unladylike, and unprofessional. In nursing's earliest decades in the United States, many decisions about nursing education and practice were made by persons outside of nursing Many social, technologic, scientific, and economic trends have shaped nursing and nurses and nursing's ability to exercise power during the twentieth and early twenty-first centuries. The American Medical Association (AMA), in 1988, proposed a new category of healthcare worker (the registered care technologist or RCT) to replace nurses during a nursing shortage. Nurses and nursing organizations responded powerfully. Nursing leaders came together in "summit meetings" to formulate powerful responses to the AMA and implemented a range of actions, including public education and the education of legislators. A new healthcare worker did not materialize from this proposal. Today, in an era of expanding nursing roles (e.g., advanced practice nurses and new roles for graduates of doctor of nursing practice [DNP] programs), nurses must continue to exercise their power to shape the continuing development of the profession of nursing and the future of the healthcare system and manage the efforts of medicine and others to control nursing practice. Some nurses, including both new graduates and seasoned veterans, have too often viewed power as if it were something immoral, corrupting, and totally contradictory to the caring nature of nursing. However, the definition in this chapter (the ability to influence others in an effort to achieve goals) demonstrates the essential nature of power to nursing. Nurses routinely influence patients to improve their health status. When nurses provide health teaching to patients and their families, the goal is to change patient/family behavior to promote optimal health. That is an exercise of power in nursing practice. Coaching other nurses to improve their performances is an exercise of power. Serving as the chief nursing officer of a hospital or health-related corporation, managing a multimillion dollar budget, demonstrates another exercise of power. Why be concerned with power, politics and influence? Nurses are one of the largest groups of healthcare professionals in the United States—1 of 4 people in the U.S. either knows a nurse or is a nurse. Nurses know the strengths and limitations of the current healthcare system and have ideas to strengthen and enhance health care reform. Working in coalitions and across professional boundaries can create new and synergistic approaches to deliver high quality, cost-effective and efficient healthcare. "Nurses must use their collective power and flex their political muscles to create a preferred future for the healthcare system, healthcare consumers, and the profession of nursing" Power and powerlessness in nursing: -History of less (if no) power in healthcare -Much change since 1960's and 1970's -Today, many nurses serve as legislators and policy makers -Today, many nurses serve on important governmental bodies that write health care policy and agendas. -Nurses are NOT powerless and must claim more of their power through influence, political activism and politics. the ability to influence others in an effort to achieve goals Types: -Personal power -Expert power -Position power -Perceived power -Information power -Connection power Power strategies for leaders, managers and followers: Develop a powerful image -self-image, grooming and dress -self-confidence -good manners -body language -speech Career commitment Value continuing education - life long learning Communication skills: verbal, non-verbal -Smile more often! -Be courteous and honest! -Listen! Network Mentor—give away your information and knowledge! Goal-setting Develop expertise Learn from your mistakes—grow! Be visible Be collegial Empower others—give credit where credit is due Develop coalitions Negotiate - win and lose gracefully Be a risk taker Be comfortable with conflict and ambiguity Promise keeping

jurisprudence

the science or philosophy of law; a division of law TBON Exam: -50 questions; 2 hours; 75% passing -Attestation required -Can have NPA, Rules and Regulations open during exam

A

A new graduate is seeking an RN position and wants to "sell" herself effectively. The best strategy is to: A. Create a resume and professional cover letter B. Practice interviewing C. Call the personnel office of the local hospital D. Create a curriculum vitae and cover letter

D

A nurse manager's responsibility for financial management involves making budgetary decisions. Budgets that allow the nurse manager to allocate resources at the unit level allow: A. Minimal nurse manager input. B. Limited rationale for budgetary requests. C. Budgetary allocations at the executive nurse level. D. Budgetary decision making at the point of service (POS).

A

A nurse on your inpatient psychiatric unit is found to have made sexually explicit remarks toward a patient with a previous history of sexual abuse. The patient sues, claiming malpractice. Which of the following conditions would likely not apply in this situation? A. Injury B. Causation C. Breach of duty D. Breach of duty of care owed

C

A nurse takes a leadership position in an ambulatory care center. This type of healthcare organization provides: A. Rehabilitation care. B. Disease-restorative care. C. Primary care. D. Long-term care.

Nurse navigator

A nurse who helps patients, often in a specific patient population, work through the healthcare system to secure quality, efficient care. similar in many ways to a case manager Although a number of navigator programs target care of the cancer patient, this role could be implemented when caring for patients with other chronic diseases in a variety of care delivery settings. For example, recent publications reveal that healthcare facilities carry out navigator programs for conditions other than cancer, such as high risk obstetrical care, osteoarthritis, HIV, and asthma. However published articles on cancer-related navigator programs far outnumber those pertaining to other disease states There is no single definition of a navigator. A review of the literature suggests two approaches: (1) the provision of specified services to provide care, and (2) removal of barriers to care

charge nurse

A registered nurse responsible for delegating and coordinating patient care and staff on a specific unit. A resource person for all staff; there is usually one charge nurse each shift per unit

licensure

A right granted that gives the licensee permission to do something that he or she could not legally do absent such permission; the minimum form of credentialing, providing baseline expectations for those in a particular field without identifying or obligating the practitioner to function in a professional manner as defined by the profession itself The National Council of State Boards of Nursing (NCSBN) serves as a central clearinghouse, further ensuring that individual state actions against a nurse's license are recorded and enforced in all states in which the individual nurse holds licensure.

optimizing

A specific decision process that is designed to produce the best (optimal) results. is a decision style in which the decision maker selects the option that is best, based on an analysis of the pros and cons associated with each option. A better decision is more likely using this approach, although it takes longer to arrive at a decision.

reengineering

A total reorganization of how an organization will function, with the goal of increased efficiency. It is a radical reorganization of the totality of an organization's structure and work processes. In reengineering, fundamentally new organizational expectations and relationships are created. An example of where reengineering is required is technologic change, particularly in information services, that provides a means of customizing care. Its potential for making all information concerning a patient immediately accessible to direct care givers has the potential for a profound positive impact on healthcare decision-making.

Manager Traits

Emphasizes organizing, coordinating, and controlling resources (e.g., space, supplies, equipment, people) Attends to short-term objectives/goals Maximizes results from existing resources Interprets established policy, procedures, and mandates Moves cautiously; dislikes uncertainty Enforces policy mandates, contracts, etc. (acts as a gatekeeper)

standard of care

Level of quality considered adequate by a profession; skills and learning commonly possessed by members of a profession; also written at a minimum level. The more difficult part is the nature of the duty, which involves the standard of care that represents the minimum requirements for acceptable practice or the minimum requirements for how one conducts oneself. Standards of care are established by reviewing the institution's policy and procedure manual, the individual's job description, and the practitioner's education and skills, as well as pertinent standards established by professional organizations, journal articles, and standing orders and protocols.

respect for others

Many consider the principle of respect for others as the highest principle. Respect for others acknowledges the right of individuals to make decisions and to live by these decisions. Respect for others also transcends cultural differences, gender issues, and racial concerns and is the first principle enumerated in the American Nurses Association's Code of Ethics for Nurses (2001). Nurse managers positively reinforce this principle daily in their actions with employees, patients, and peers because they serve as leaders and models for staff members and others in the institution.

personal liability

Serves to make each person responsible by law for his or her own actions defines each person's responsibility and accountability for individual actions or omissions. Even if others can be shown to be liable for a patient injury, each individual retains personal accountability for his or her actions.

individual accountability

The individuals' ability to explain their actions and results. is a component of delegation. The term refers to the individuals' ability to explain their actions and results. The Code of Ethics for Nurses, Provision 4, identifies the expectation of accountability and responsibility and specifically references delegation. Legally, the registered nurse has accountability for nursing care. For example, even when some portion of patient care is delegated to someone else, each individual nurse is accountable and responsible for his or her nursing practice, including the decision to delegate and the outcome of the delegated task.

high visibility

The strategy of high visibility within an organization can begin with volunteering to serve as a member or the chairperson of committees and task forces. High visibility can be nurtured by attending open meetings in the workplace, professional associations, or the community. Even if you are not a member, if meetings deal with local health issues, you must be visible. Review the agendas of these meetings if they are circulated or posted online ahead of time. Use opportunities both before and after meetings to share your expertise and provide valuable information and ideas to members and leaders of such groups. Share your expertise at open meetings when appropriate. Speak up confidently, but have something relevant to say. Be concise and precise; members of the committee will ask for more information if they need it. Create your own business cards using a computer and sheets of business card stock (purchased in any office supply store). Give members of these committees your personal card so that they can contact you later for information.

Person-Position fit

What factors do you think contribute to a "good-fit" for a person and an organization and factors that contribute to a "bad-fit"? Knowing yourself and your values as well as those of the organization (mission, vision, values) will help you find your "fit"!

D

While explaining the importance of developing leadership skills among nurses to a group of senior nursing students, a nursing unit manager emphasizes that: A. Most nurses will not assume leadership roles. B. The role of a nurse leader is primarily at the bedside, ensuring that patient care is performed according to established standards. C. Only individuals in formal leadership roles are expected to be leaders. D. Patients and families expect nurses to lead and manage healthcare environments that provide safe and effective nursing care.

emergence

addresses how individuals in positions of responsibility engage with and discover, through active organizational involvement, those networks that are best suited to respond to problems in creative, surprising, and artful ways—those who think "outside the box." Emergence is tied to unleashing constructive energy rather than constraining energy.

veracity

concerns telling the truth and demands that the truth be told completely. Nurse managers employ this principle when they give all the facts of a situation truthfully and then assist employees to make appropriate decisions. For example, when encouraging a staff member to accept a promotion to a position of greater responsibility, both the challenges and the benefits of the position must be discussed.

negligence

conduct that is lacking in care -Carelessness -Deviation from standard of care that a reasonable person would deliver typically concerns nonprofessionals

focus groups

explore issues and generate information. Focus groups can be used to identify problems or to evaluate the effects of an intervention. The groups meet face-to-face to discuss issues. Under the direction of a moderator or facilitator, participants are able to validate or disagree with ideas expressed. Depending on the purpose of a focus group, it may be helpful for an objective individual to facilitate the discussion (e.g., someone other than the manager). Because the interaction is face-to-face, potential disadvantages include the logistics of getting people together, time, and issues related to group dynamics. Nevertheless, if managed effectively, the experience can yield valuable information.

policy

is just a plan for action related to an issue that affects a group's well-being or ability to function

Empowerment

is a term that has come into common usage in nursing. That term has been used extensively in the nursing literature related to administration and management; it is also highly relevant to the domain of clinical practice. _______________ is the process of exercising one's own power to facilitate the participation of others in decision making and taking action so they are free to exercise power is consistent with the contemporary view of leadership, a paradigm that is exemplified by behaviors characteristic of all nurse leaders: facilitator, coach, teacher, and collaborator. Nursing leaders, in employment settings or in professional organizations, exercise power in making professional judgments in their daily work. These leadership skills are also essential to effective followers. Powerful nurse managers enable nurses to exercise power, influencing them to grow professionally. Powerful nurses support their patients and families so they can participate actively in their own care. Hence these leadership skills can be viewed as an essential component of professional nursing practice whether one is a clinician, an educator, a researcher, or an executive/manager. Nurses, including some leaders, sometimes view power as a finite quantity: "If I give you some of my power, I will have less." Empowerment emphasizes the notion that power grows when shared. Envision the exercise of shared power along a spectrum from low to high levels of sharing. The opposing ends of the spectrum can be characterized by two very different groups of nurses: •Nurses who view power as finite will avoid cooperation with their colleagues and refuse to share their expertise. •Nurses who view power as infinite are strong collaborators who gain satisfaction by helping their colleagues expand their expertise and their power base. Empowered nurses make professional practice possible, creating a culture that satisfies all nurses. Empowered clinicians are essential for effective nursing management, just as empowered managers set the stage for excellence in clinical practice. Encouraging a reticent colleague to be an active participant in committee meetings serves to empower that nurse and to shape practice policy with the institution. Guiding a novice nurse in exercising professional judgment empowers both the senior nurse and the novice clinician. Coaching a patient on how to be more assertive with a physician who is reluctant to answer the patient's questions is another form of empowerment Developing a collection of power strategies or tools is a critical aspect of personal empowerment. These strategies are used in situations that demand the exercise of leadership. Such strategies support one's professional power base and developing political skills within an organization Developing a Powerful Image • Self-confidence • Body language • Self-image, including grooming, dress, and speech • Career commitment and continuing professional education • Attitudes, beliefs, and values Additional Personal Power Strategies • Be honest. • Be courteous; it makes other people feel good! • Smile when appropriate; it puts people at ease. • Accept responsibility for your own mistakes, and then learn from them. • Be a risk taker. • Win and lose gracefully. • Learn to be comfortable with conflict and ambiguity; they are both normal states of the human condition. • Give credit to others where credit is due. • Develop the ability to take constructive criticism gracefully; learn to let destructive criticism "roll off your back." • Use business cards when introducing yourself to new contacts, and collect the business cards of those you meet when networking. • Follow through on promises. Strategies for Developing a Powerful Image: The most basic power strategy is the development of a powerful image. If nurses think they are powerful, others will view them as powerful; if they view themselves as powerless, so will others. A sense of self-confidence is a strong foundation in developing one's "power image," and is essential for successful political efforts in the workplace, within the profession, and within the public policy arena. Several key factors contribute to one's power image: •Self-image: thinking of oneself as powerful and effective •Grooming and dress: ensuring that clothing, hair, and general appearance are neat, clean, and appropriate to the situation •Good manners: treating people with courtesy and respect •Body language: maintaining good posture, using gestures that avoid too much drama, maintaining good eye contact, and being confident in movement •Speech: using a firm, confident voice; good grammar and diction; an appropriate vocabulary; and strong communication skills Concern about a powerful image may seem superficial. However, the impressions we make on people influence the way they view us now and in the future, as well as how they value what we do and say. We get only one chance to make a first impression. Given similar educational and experiential backgrounds, who is more likely to be hired for a nursing position: the candidate who comes dressed in a suit or the candidate who arrives in jeans and sandals Who will be seen as the more competent professional by a patient: the nurse in wrinkled scrubs or the nurse in neat street clothes and a freshly laundered lab coat? Who will have a greater positive impact on a member of the state legislature: the nurse who visits in a sweatshirt and shorts or the nurse in business attire? A powerful image signals to others that one is professionally competent, influential, powerful, and capable of exercising appropriate judgments.

beneficence

states that the actions one takes should promote good; beneficence is the basic obligation to assist others. Nurse managers employ this principle when encouraging employees to seek more challenging clinical experiences or to take on additional responsibilities, such as the position of assistant manager of a specific unit. Progressive discipline incorporates this principle when the employee's positive attributes and qualities are included when developing goals and expected outcomes.

shared governance

A flat type of organizational structure with decision making decentralized. goes beyond participatory management through the creation of organizational structures that facilitate nursing staff having more autonomy to govern their practice. Accountability forms the foundation for designing professional governance models. To be accountable, authority to make decisions concerning all aspects of responsibilities is essential. This need for authority and accountability is particularly important for nurses who treat the wide range of human responses to wellness states and illnesses. Organizations in which professional autonomy is encouraged have demonstrated higher levels of staff satisfaction, enhanced productivity, and improved retention Shared or self-governance structures, sometimes referred to as professional practice models, go beyond decentralizing and diminishing hierarchies. In an organization that embraces shared governance, the structure's foundation is the professional workplace rather than the organizational hierarchy. Shared governance vests the necessary levels of authority and accountability for all aspects of the nursing practice in the nurses responsible for the delivery of care. The management and administrative level serves to coordinate and facilitate the work of the practicing nurses. Mechanisms are designed outside of the traditional hierarchy to provide for the functional areas needed to support professional practice. These functions include areas such as quality management, competency definition and evaluation, and continuing education. Changing nurses' positions from dependent employees to accountable professionals is a prerequisite for the radical redesign of healthcare organizations that is required to create value for patients. This change requires administrators, managers, and staff to abandon traditional notions regarding the division of labor in healthcare organizations. Shared governance structures require new behaviors of all staff, not just new assignments of accountability. The areas of interpersonal relationship development, conflict resolution, and personal acceptance of responsibility for action are of particular importance. Education, experience in group work, and conflict management are essential for successful transitions.

vertical integration

Alignment of organizations to provide a full array or continuum of services. When organizations align to provide a full array or continuum of services, the arrangement is referred to as vertical integration. Organizations brought together in a vertical integration might include an acute care facility, a rehabilitation facility, a home care agency, an ambulatory clinic, and a hospice. Benefits attributed to vertical integration include enhanced coordination of services, efficiency, and customer services.

Certification

Designation of special knowledge beyond basic licensure. signifies completion of requirements in a particular field beyond basic nursing educational preparation for licensure. Nurses can be certified as recognition of competence in a number of different specialty areas. Certification is an expectation in some employment settings for career advancement; in the field of advanced practice nursing, it is a requirement for practice and reimbursement. In many states, certification in advanced practice is the mechanism to achieve recognition as an advanced practice registered nurse from the board of nursing. Consumers, nurses, managers, and administrators value certification.

disease management

For patients with complex chronic illness—help them to live well; Today: mostly used by insurance companies Advantages: -provide patient/family with strategies and support to manage complex, chronic illnesses; may enhance adherence to treatment regimes Disadvantages: -May be perceived by patients/families as intrusive -May involve "turf wars" with other professionals, e.g., pharmacy who also do disease management

B

In matrix organizational structures, a nurse manager understands that this type of structure: A. Is a simplified organizational structure. B. Has both a functional manager and a service or product-line manager. C. Arranges departments strictly according to function. D. Promotes harmony in organizational decision-making.

D

In the orientation of newly hired nurses within a multisystem healthcare organization, a nurse manager discusses the concept of healthcare networks and how these are important to this organization's viability. Healthcare networks are: A. Units that provide only primary care services. B. Owned by government institutions. C. A feature of most public and private healthcare organizations. D. Interconnected units that provide a full spectrum of services.

Theory X

Mcgregor's Theory Assumptions: People basically do not like their work and must be coerced to perform. Implications: Lower level basic needs are important, e.g., safety, security.

change agent

Or a change coach. Nurse managers have the responsibility of day-to-day decisions for their units, and they must manage change and also lead change initiatives that have positive impact on patient outcomes in the interest of patient quality and safety. In order to lead change the nurse manager must identify and develop skill sets that enable them to facilitate others, provide guidance, and inspire those around them. These tools allow the nurse managers to not only coach their staff and colleagues but also encourage their leaders in leading by example. These collaborative efforts to bring about change require active listening to understand the viewpoints of others and demonstrating integrity by communicating directly and fairly with their teams. The complexity of management is this and much more.

statute

Rule/regulation created by elected legislative bodies; also known as statutory law. All states have a legal age for adult status defined by statute; generally, this age is 18 years. Competency involves the ability to understand the consequences of actions or the ability to handle personal affairs. State statutes mandate who can serve as the representative for a minor or incompetent adult. most states have enacted statutes to ensure that the competent adult has the right to refuse care and that the healthcare provider is protected should the adult validly refuse care.

Organizational accountability

The accountability for the system of operations; the prime accountability of organizations is patient safety. Organizations are accountable for adequate resources to deliver safe care. Is another component of delegation. The NCSBN concurs with ANA that the driving principle in decision making is patient (public) safety. Making appropriate decisions depends on how well the organization provides adequate resources, including an appropriate ratio of registered nurses to LPNs/LVNs and UNPs. Successful organizations that have achieved Magnet™ status, through an extensive evaluation process, usually have supportive work environments and assist teams to function effectively. Chief nursing officers (CNOs) are accountable for establishing systems to assess, monitor, verify, and communicate competency requirements related to delegation

authority

The power to make decisions which often derives from policies, laws, and job descriptions. is the ability to perform duties in a specific role. Each individual is obligated to perform to the best of his or her ability and at a quality level. These individuals are also responsible for informing the delegator about any limitations that may prevent the accomplishment of the task or fulfillment of the expected outcome. legal authority, by virtue of the professional nursing license, is the ability to transfer selected nursing activities in a given situation to a competent individual When a nurse gives the delegatee the responsibility and authority for completing a task, the nurse retains accountability for ensuring that the task is completed by the right person and that person is supervised appropriately.

tag

The term tag references the philosophic, patient-centered, and values-driven characteristics that give an organization its personality, the "energy" that it has; a tag is sometimes called an attractor or a hallmark of culture, similar to values. Although clinical organizations often perform similar procedures and functions, an intangible sense that this particular organization has a "caring" or "good energy" attractor differs from one where the sense is the focus on efficiency and cost only. The term tag refers to these distinctions.

vision

Vision statements are: -Short -Focused -Project a desired future state -Easy to remember -Inspiring -Shares purpose & values of an organization LHSON: "Learn. Lead. Serve." Midwestern School of Nursing: "Visionary Learning for a Lifetime of Influence" Baylor Health Care System: "To be trusted as the best place to give and receive safe, quality, compassionate health care." Children's Health: "Children's will strive to be the best by gaining widespread recognition as one of the nation's preeminent children's hospitals "visioning" requires the leader to engage with others to assess the current reality, determine and specify a desired end-point state, and then strategize to reduce the difference. When this is done well, the nurse and the patient or nurses within an organization experience creative tension. Creative tension inspires the patient and others to work in concert to achieve a desired goal. Shared visioning gives direction to accelerate change.

C

You are the nurse manager of a nursing organization that provides 24-hour care to patients in their homes. To achieve maximum reimbursement for a patient who is recovering from a hip replacement, the nursing staff most likely will follow the nursing care guidelines presented in the: A. Nursing plan of care. B. Physician's orders. C. Critical pathway. D. Clinical practice guidelines.

malpractice

failure of a person with professional education and skills to act in a reasonable and prudent manner -Professional negligence -Dereliction (neglect/failure) of professional skill "What would the reasonably prudent nurse do?" Are actions the result of omission—not doing something the reasonably prudent nurse would do -Intentional (unintended consequences?) -Unintentional Are actions the result of commission—acting in a way to cause the patient harm -Intentional (unintended consequences?) -Unintentional Six elements required for a malpractice suit to succeed & have the court find liability. 1. Duty to the patient: use standards of care, policies and procedures, journal articles/ evidence, standard order sets/ protocols to establish nurse's duty (Failure to monitor a patient's response to treatment) 2. Breach of duty owed to patient: judgment that standards not met. (Failure to communicate change in patient status to the primary healthcare provider) 3. Forsee-ability of harm: nurse had prior knowledge that if minimum standards not met, patient may be harmed. (Failure to ensure minimum standards are met) 4. Causation - direct relationship between nurse's failure to act or actions and resultant harm to patient (Failure to provide adequate patient education) 5. Injury or harm - physical harm must result (Fractured hip and head concussion after a patient fall) 6. Damages - financial harm to patient (Additional hospitalization time; future medical and nursing care needs and costs) Six elements must be presented in a successful malpractice suit. All of these factors must be shown before the court will find liability against the nurse and/or institution. Nurses have an independent responsibility to take appropriate steps to safeguard patients. sometimes referred to as professional negligence Issues of malpractice have become increasingly important to the nurse as the authority, accountability, and autonomy of nurses have increased. The same types of actions may be the basis for either negligence or malpractice, though some actions almost always are seen as malpractice because only the professional person would be performing the action. Specific examples include drawing blood for arterial blood gas analysis via a direct arterial puncture or initiating blood transfusions. Common causes of malpractice or negligence among nurses include the failure to follow standards of care, communicate appropriately, access and monitor patients, and act as a patient advocate Negligence and malpractice have two commonalities. Negligence and malpractice both concern actions that are a result of omission (the failure to do something that the reasonable, prudent person or nurse would have done) or commission (acting in a way that causes injury to the patient). They also concern nonintentional actions; though there is some injury to a patient, the individual who caused the harm never intended to hurt the patient.

Primary Care

first-access care Community: Prevent disease: first-access care; ambulatory care centers, MD/NP offices, Walgreen's/Walmart, etc. clinics; school health clinics, Health Maintenance Organization (HMO); Managed care systems Public Health Departments, environmental services, nurse-owned clinics, support groups Purpose: • Entry into system • Health maintenance • Long-term care • Chronic care • Treatment of temporary non incapacitating malfunction Organization or Unit Providing Services: • Ambulatory care centers • Physicians' offices • Preferred provider organizations • Nursing centers • Independent provider organizations • Health maintenance organizations • School health clinics

Organizational Theory

The systematic analysis of how organizations and their component parts act and interact. (sometimes called organizational studies) is the systematic analysis of how organizations and their component parts act and interact. Organizational theory is based largely on the systematic investigation of the effectiveness of specific organizational designs in achieving their purpose. Organizational theory development is a process of creating knowledge to understand the effect of identified factors, such as (1) organizational culture; (2) organizational technology, which is defined as all the work being carried out; and (3) organizational structure or organizational development. A purpose of such work is to determine how organizational effectiveness might be predicted or controlled through the design of the organizational structure. An organization's mission, vision, and philosophy form the foundation for its structure and performance as well as the development of the professional practice models it uses. An organization's mission, or reason for the organization's existence, influences the design of the structure (e.g., to meet the healthcare needs of a designated population, to provide supportive and stabilizing care to an acute care population, or to prepare patients for a peaceful death). The vision is the articulated goal to which the organization aspires. A vision statement conveys an inspirational view of how the organization wishes to be described at some future time. It suggests how far to strive in all endeavors. Another key factor influencing structure is the organization's philosophy. A philosophy expresses the values and beliefs that members of the organization hold about the nature of their work, about the people to whom they provide service, and about themselves and others providing the services. systematic analysis of how organizations and their component parts act and interact -Organizational culture—norms, traditions, rituals, ceremonies -Organizational technology -Organizational structure/ development Organizational Structures Centralized organizational structures: -Decision maker is usually higher up in the chain of command -More bureaucratic -Delegate responsibility without authority Decentralized organizational structures: -Decision maker is usually lower down in the chain of command -More participatory (Shared Governance) -Delegate responsibility and authority Other considerations: -Geographic Dispersion -Networks, geography, spread... -Formalization -Policies, procedures, rules, regulations -14 principles of Management (Fayol, 1949) - Bureaucracy -Competition --redesign, restructuring, reengineering Functional -Major departments and/or specialties -EX: Nursing, Respiratory Therapy, Laboratory, Medicine Service-line -Product/ Service-line -EX: cardiology, rehabilitation, respiratory Matrix -Integrate functions and services -Complex interrelationships; may fit chaotic healthcare environments well Flat -Non- hierarchical; less bureaucratic; -Decision making with authority and autonomy closer to front line -Magnet -Shared governance Hybrid -Combination of many different organizational structures Organizational chart ("Org Chart"): Horizontal dimension of org chart: -Divisions and specializations (EX: Medicine; Surgery) -Span of Control Vertical dimension of org chart: -Chain of command/ hierarchy (EX: Who reports to whom?) Solid lines - indicate line functions -Direct line of reporting/ direct responsibility Broken/ dashed lines - indicate staff functions -Support those in line functions/ indirect responsibility

vicarious liability

Imputation of accountability upon one person or entity for the actions of another person; substituted liability or imputed liability. The law, though, sometimes allows other parties to be liable for certain causes of negligence. Known as vicarious liability, or substituted liability, the doctrine of respondeat superior (let the master answer) makes employers accountable for the negligence of their employees. The rationale underlying the doctrine is that the employee would not have been in a position to have caused the wrongdoing unless hired by the employer, and the injured party would be allowed to suffer a double wrong if the employee was unable to pay damages for the wrongdoings. Nurse managers can best prevent these issues by ensuring that the staff they supervise know and follow hospital policies and procedures and continually deliver safe, competent nursing care or raise issues about policies and procedures through formal channels.

Active delegation

Proactively making a decision about tasks and people to accomplish effective work. the registered nurse assesses the situation, determines what is appropriate for patient care, directs a UNP to perform certain tasks and holds the individual accountable. Even when protocols/policies within organizations indicate that an individual may perform a task on behalf of a registered nurse, the delegatee must be competent to perform the task. This expectation suggests that the delegator makes an initial and ongoing assessment of the delegatee performance as well as an assessment of patient care needs. Furthermore, state laws governing professional nursing practice define what the registered nurse must do when another individual assumes certain tasks.

information power

Stems from one's possession of selected information that is needed by others. A direct care nurse demonstrates great skill in teaching patients difficult self-care activities and is sought out by colleagues to help them teach their patients.

empowerment

The nurse is a source of shared power to build the exercise of power by others. The chief nurse executive develops a model of shared governance to enable nurses to have a stronger voice in patient care decisions. the process of exercising one's own power....process by which we facilitate the participation of others in decision making and taking action so they are free to exercise power

satisficing

A decision process where the solution is acceptable (rather than best). With this approach, the decision maker selects an acceptable solution, one that may minimally meet the objective or standard for a decision. This approach allows for quick decisions and may be the most appropriate when lack of time is an issue.

expert power

Based on one's reputation for expertise and ones' credibility. The knowledge and skills the nurse possesses that are needed by others. The leader of a state nurses' association (SNA) may have access to the leaders of the state legislature based on the leader's expert power, which has enabled years of work with members of the legislature. The SNA president has always delivered on promises of support and provided useful information to legislators on matters of health policy.

Linear

Career Style: Hierarchical orientation with steady climb -EX: Nursing service administrator Motivation and Characteristics: -Requisite authority and power -Had a challenging first job -Guided by internalized norms -Money -Recognition -Opportunities for self-development Managerial Considerations: -Provide management development -Reward and value both education and competence -Modify management selection and development systems -Provide decreasing supervision

flat organizational structure

Characterized by decentralization of decision making to the level of personnel carrying out the work. Providing staff with authority to make decisions at the place of interaction with patients is the hallmark of a flat organizational structure. Magnet hospitals have recognized the benefits of decentralized decision making and its impact on both nursing satisfaction and patient outcomes An example of a flat organizational structure is that at Buurtzorg Netherlands, a home care organization where nurses manage themselves, control their schedules, and operate with few policies or procedures are less formalized than hierarchical organizations. A decrease in strict adherence to rules and policies allows individualized decisions that fit specific situations and meet the needs created by the increasing demands associated with consumerism, change, and competition.

D

Complex care of acutely ill patients is required on a surgical unit, which utilizes differentiated nursing practice as its model of care delivery. The concept of differentiated nursing practice is based on: A. Licensure status. B. Experience in the agency. C. Leadership capabilities. D. Education and experience.

Conflict Resolution

1. Put the focus on interests: •Examine the real issues of all parties. •Be expedient in responding to the issues. •Use negotiation procedures and processes such as ethics committees and other neutral sources. 2. Build in "loop-backs" to negotiation: •Allow for a "cooling off" period before reconvening if resolution fails. •Review with all parties the likely consequences of not proceeding so that they understand the full consequences of failure to resolve the issue. 3. Build in consultation before and feedback after the negotiations: •Build consensus and use political skills to facilitate communication before confrontation, if anticipated, occurs. •Work with staff or patients after the conflict to learn from the situation and to prevent a similar conflict in the future. •Provide a forum for open discussion. 4. Provide necessary motivation, skills, and resources: •Make sure that the parties involved in conflict are motivated to use procedures and resources that have been developed; this requires ease of access and a nonthreatening mechanism. •Ensure that those working in the dispute have skills in problem solving and dispute resolution. •Provide the necessary resources to those involved to offer support, information, and other technical assistance.

failure to warn

A more recent area of potential liability for nurse managers is failure to warn potential employers of staff incompetence or impairment. Information about suspected addictions, violent behavior, and incompetency is of vital importance to subsequent employers. If the institution has sufficient information and suspicion to warrant the discharge of an employee or force a resignation, subsequent employers should be advised of those issues. In addition, the state board of nursing or agency that oversees disciplinary actions of professional and nonprofessional nursing staff should also be notified whenever there is cause to dismiss an employee for incompetency or impairment unless the employee voluntarily enters a peer-assistance program. One means of supplying this information is through the use of qualified privilege to certain communications. In general, qualified privilege concerns communications made in good faith between persons or entities with a need to know. Most states now recognize this privilege and allow previous employers to give factual, objective information to subsequent employers. Note, however, that the previous employee must have listed the nurse manager or institution as a reference before this privilege arises.

entrenched workforce

Baby Boomers, born after World War II, see work life very differently compared with the emerging workforce. Boomer workers are much more likely to believe in the power of collective action, based on their successes with social movements in their formative years in the 1960s. They tend to mistrust authority and are very comfortable with the process of getting to a goal. They find the journey of getting to the goal almost as important as reaching the goal. They are tolerant of, even depend on, meetings and ongoing discussions that the younger generation finds tedious and wasteful. The preferred leader of the entrenched workforce shares some of the characteristics of the younger generation's leader, such as being motivational, honest, approachable, competent, and knowledgeable. However, Baby Boomers also expect their leaders to be professional and supportive and have high integrity. Challenges for the entrenched workforce are sharing leadership with the younger generation, empowering them to lead in their own model rather than trying to make them into second-generation Baby Boomers, and retaining the younger leaders in leadership ranks. Many younger employees are opting out of traditional work roles to become entrepreneurs. They take their leadership potential with them where there are few older role models for them to follow. A risk for aging Boomers is that the best and the brightest potential leaders will lose interest in leading and will opt for personal satisfaction and wealth accumulation rather than leadership and service roles. The challenges of generational acceptance are some of many facing twenty-first century leaders. Attention to the needs of both the leader and the follower will create an environment in which everyone thrives.

Goal-setting

Every nurse knows about setting goals. Students learn to devise patient care goals or patient outcomes as part of the care-planning process. Nurses may be expected to write annual goals for performance reviews at work. Even a project at home (e.g., painting the bedrooms) may necessitate setting goals (e.g., painting a room each day of one's vacation). Goals help one know if what was planned was actually accomplished. Likewise, a successful nursing career needs goals to define what one wants to achieve as a nurse. Without such goals, one can wander endlessly through a series of jobs without a real sense of satisfaction. To paraphrase what the Cheshire Cat told Alice during her trip through Wonderland: Any road will take you there if you don't know where you are going. Well-defined, long-term goals may be hard to formulate early in a career. For example, few new graduates know specifically that they want to be chief nurse executives, deans, managers, or researchers; yet, eventually, some will choose those career paths. However, developing such a vision early in a career is an important personal power strategy. Once this career vision is developed, one must create opportunities to move toward that vision. Such planning is empowering—putting the nurse in charge rather than letting a career unfold by chance. Having this sense of vision is consistent with a commitment to a career in nursing, part of developing a power image. This vision is always subject to revision as new opportunities are encountered and new interests, knowledge, and skills are gained. Education and work experiences are tools for achieving the vision of one's career.

affirming values

Gardener's Goals Assisting the patient/family to sort out and articulate personal values in relation to health problems and the effect of these problems on lifestyle adjustments Assisting the staff in interpreting organizational values and strengthening staff members' personal values to more closely align with those of the organization; interpreting values during organizational change Assisting other organizational leaders in the expression of community and organizational values; interpreting values to the community and staff

Managing

Gardener's Goals Assisting the patient/family with planning, priority setting, and decision making; ensuring that organizational systems work in the patient's behalf Assisting the staff with planning, priority setting, and decision making; ensuring that systems work to enhance the staff's ability to meet patient care needs and the objectives of the organization Assisting other executives and corporate leaders with planning, priority setting, and decision making; ensuring that human and material resources are available to meet health needs The ability to manage is an important aspect of organizational functioning, because management requires determining routines and practices that offer structure and stability to others. This is especially true in certain positions of influence within a clinical setting, such as a nurse manager, clinical nurse specialist, or clinical nurse leader, all of whom share responsibility for creating effective structures that support clinical and organizational outcomes. Being effective as a manager requires behaviors different from those associated with effective leadership, and vice versa. Ideally, those charged with managing are good leaders and followers, because no organizational position is limited to one exclusive set of behaviors over another. Good leaders need management skills and abilities, and good managers need leading skills and abilities, and good followers need both skills too.

Serving as symbol

Gardener's Goals Representing the nursing profession and the values and beliefs of the organization to patients/families and other community groups Representing the nursing unit service and the values and beliefs of the organization to staff, other departments, professional disciplines, and the community at large Representing the values and beliefs of the organization and patient care services to internal and external constituents

Explaining

Gardener's Goals Teaching and interpreting information to promote patient/family functioning and well-being Teaching and interpreting information to promote organizational functioning and enhanced services Teaching and interpreting organizational and community-based health information to promote organizational functioning and service development Leading and managing require a willingness to communicate and explain—again and again. The art of communication requires the leader to do the following: 1.Determine what information needs to be shared. 2.Know the parties who will receive the information. Ask, "What will they 'hear' in the process of the communication?" Information that addresses the listener's self-interest must be presented. 3.Provide the opportunity for dialogue and feedback. Face-to-face communication is preferred when the situation requires immediate feedback because it offers the opportunity to clarify information. Written communication through the use of e-mail and text messages increasingly are used as primary communication mechanisms. Although expedient, these mechanisms have limitations that must be acknowledged. 4.Plan the message. Giving too much information can temporarily paralyze the listener and divert energy away from key responsibilities. 5.Be willing to repeat information in different ways, at different times. The more diverse the group being addressed, the more important it is to avoid complex terms, concepts, or ideas. Information should be kept simple. Remember, a message is heard when a person is ready to hear it, not before. 6.Always explain why something is being asked or is changing. The values behind the change should be reinforced. 7.Acknowledge loss and provide the opportunity for honest communication about what will be missed, especially if change is involved. 8.Be sensitive to nonverbal communication. It may be necessary in complex situations to have someone reinterpret key points and provide feedback about the clarity of the message after the meeting. Leaders must use every opportunity for explaining as a vehicle to fine-tune communication skills.

envisioning goals

Gardener's Goals Visioning patient outcomes for single patient/families; assisting patients in formulating their vision of future well-being Visioning patient outcomes for aggregates of patient populations and creating a vision of how systems support patient care objectives; assisting staff in formulating their vision of enhanced clinical and organizational performance Visioning community health and organizational outcomes for aggregates of patient populations to which the organization can respond Leading requires envisioning goals in partnership with others. At the point of care, leading helps patients envision their life journey when health outcomes are unknown. It might help a patient envision walking again, participating in family events, or changing a lifestyle pattern. In the case of leading peers (not dissimilar to working with patients and family members), leader competence, trustworthiness, self-assuredness, decision-making ability, and prioritization skills envision crafting solutions to care delivery problems. Imagine leading a change to an electronic health record from a traditional paper record: the leader uses the aforementioned abilities to engage with, convince, or persuade colleagues about the relevance of this change and proceeds with setting direction. Envisioning goals is contingent upon trustful relationships, shared information, and agreement on mutual expectations.

emerging workforce

Generational differences have always created challenges in the workplace. At the dawn of the twenty-first century, the workplace found an emerging workforce with goals, priorities, and work preferences that were vastly different from those of their Baby Boomer parents. Helping each generation understand and tolerate others is often a delicate orchestration of needs and wants, incentives and motives. Transgenerational leadership must focus on building an understanding and acceptance of each other. Nurse leaders need to understand generational differences in order to enhance performance. Multiple dimensions of diversity exist in the workplace, including religion, gender, culture, and race, but a nurse leader must also think about generation (not age) differences. A nurse leader must be able to become a generationally fluent translator, able to communicate among the different generations Part of this cohort, born between 1965 and 1976, represents the smallest workforce entry pool since 1930, with just 44 million, compared with the 77 million Baby Boomers preceding them and the 70 million Generation Ys following them. They have a mindset and work ethic that Baby Boomers do not understand. They are hard workers, but unlike the Baby Boomers, they do not have confidence in leaders and institutions. They tend to change jobs more frequently. Their focus is on work-life balance and they seek feedback about their performance Their younger siblings, the Generation Ys (also known as Generation Net, Nexter, or the Millennium Generation), who were born between 1977 and 1995, share many of the same approaches to work but bring their own challenges with no brand loyalty and a blatant disregard for status symbols. They are highly skilled in technology and seek to "figure out" how something works rather than read a manual. They tend to believe in themselves and are generally optimistic. Successfully leading the emerging workforce means the leader must shape a vision and win the 20-somethings to it. The vision must be one that excites them, because fun and balance are an important part of their lives. A vision that is powerful enough can transform the workplace. The successful leader must mobilize followers to act. The required actions must provide value to the followers (e.g., learning a new skill or attaining certification or recognition). The younger generations are happy to follow as long as they can retain balance in their lives, have information about and input into the decisions that affect them, and see some benefit in the activity. It is the leader's challenge to provide the type of environment in which younger-generation followers want to follow.

Two-Factor Theory

Herzberg (1991) is credited with developing a two-factor theory of motivation, first published in 1968. Hygiene factors, such as working conditions, salary, status, and security, motivate workers by meeting safety and security needs and avoiding job dissatisfaction. Motivator factors, such as achievement, recognition, and the satisfaction of the work itself, promote job enrichment by creating job satisfaction. Organizations need both hygiene and motivator factors to recruit and retain staff. Hygiene factors do not create job satisfaction; they simply must be in place for work to be accomplished. If not, these factors will only serve to dissatisfy staff. Transformational leaders use motivator factors liberally to inspire work performance.

Trait Theory

Leaders have a certain set of physical and emotional characteristics that are crucial for inspiring others toward a common goal. Some theorists believe that traits are innate and cannot be learned; others believe that leadership traits can be developed in each Self-awareness of traits is useful in self-development (e.g., developing assertiveness) and in seeking employment that matches traits (drive, motivation, integrity, confidence, cognitive ability, and task knowledge). first studied from 1900 to 1950. These theories are sometimes referred to as the Great Man theory, from Aristotle's philosophy extolling the virtue of being "born" with leadership traits. Stogdill (1948) is usually credited as the pioneer in this school of thought.

OB modification

Luthans (2011) is credited with establishing the foundation for Organizational Behavior Modification (OB Mod), based on Skinner's work on operant conditioning. OB Mod is an operant approach to organizational behavior. OB Mod Performance Analysis follows a three-step ABC Model: A, antecedent analysis of clear expectations and baseline data collection; B, behavioral analysis and determination; and C, consequence analysis, including reinforcement strategies. The leader uses positive reinforcement to motivate followers to repeat constructive behaviors in the workplace. Negative events that de-motivate staff are negatively reinforced, and the staff is motivated to avoid certain situations that cause discomfort. Extinction is the purposeful non-reinforcement (ignoring) of negative behaviors. Punishment is used sparingly because the results are unpredictable in supporting the desired behavioral outcome.

hierarchy of needs

Maslow is credited with developing a theory of motivation, first published in 1943. People are motivated by a hierarchy of human needs, beginning with physiologic needs and then progressing to safety, social, esteem, and self-actualizing needs. In this theory, when the need for food, water, air, and other life-sustaining elements is met, the human spirit reaches out to achieve affiliation with others, which promotes the development of self-esteem, competence, achievement, and creativity. Lower-level needs will always drive behavior before higher-level needs will be addressed. When this theory is applied to staff, leaders must be aware that the need for safety and security will override the opportunity to be creative and inventive, such as in promoting job change

Theory Y

Mcgregor's Theory Assumptions: People are more content when they have self-discipline and autonomy at work. Implications: People aim to satisfy through higher level accomplishments to achieve self-actualization.

C

Politics is usually: A. Confined to legislatures B. Seen in dysfunctional workplaces C. Found in all social organizations D. A representation of self-interest.

Style theories

Sometimes referred to as group and exchange theories of leadership, style theories were derived in the mid-1950s because of the limitations of trait theory. The key contributors to this renowned research were Shartle (1956), Stogdill (1963), and Likert (1987). focus on what leaders do in relational and contextual terms. The achievement of satisfactory performance measures requires supervisors to pursue effective relationships with their subordinates while comprehending the factors in the work environment that influence outcomes. To understand "style," leaders need to obtain feedback from followers, superiors, and peers, such as through the Managerial Grid Instrument developed by Blake and Mouton (1985). Employee-centered leaders tend to be the leaders most able to achieve effective work environments and productivity.

organizational culture

The attitudes, behaviors, and policies evident in an organization that create the ambiance and operation of the workplace is the reflection of the norms or traditions of the organization and is exemplified by behaviors that illustrate values and beliefs. Examples include rituals and customary forms of practice, such as celebrations of promotions, degree attainment, professional performance, weddings, and retirements. Other examples of norms that reflect organizational culture are the characteristics of the people who are recognized as heroes by the organization and the behaviors—either positive or negative—that are accepted or tolerated within the organization. can be effective and promote success and positive outcomes, or it can be ineffective and result in disharmony, dissatisfaction, and poor outcomes for patients, staff, and the organization. A number of workplace variables are influenced by organizational culture. When seeking employment or advancement, nurses need to assess the organization's culture and develop a clear understanding of existing expectations as well as the formal and informal communication patterns. Various techniques and tools are available to assist the nurse in performing a cultural assessment of an organization In the ever-changing environment of health care, nurse managers need to know the organizational culture at their workplace and how it is integrated with and supports their unit's mission and goals. Laschinger, Leiter, Day, Gilin-Oore, and Mackinnon (2012) report the results of a quasi-experimental study of 755 registered nurses in 5 hospitals (41 total units). The study's aim was to analyze a workplace intervention (Civility, Respect, and Engagement in the Workplace [CREW]) and its impact on structural empowerment of the nurse, discourteous co-workers and/or supervisors, and trust in nurse management. Units were surveyed 3 months before implementation of an intervention of CREW sessions and after the 6-month intervention. The CREW intervention involves routine work group sessions for employees, usually once or twice a week for 6 months. Employees work with an experienced facilitator to develop unit goals and improve collaboration and communication on the work unit. An example of CREW goals might be unit teambuilding or promoting interactions that are respectful among the unit staff. After the intervention period, the nursing supervisor's interactions with the nurses became significantly more courteous, and finally, trust in management improved.

Coalitions

The exercise of power is often directed at creating change. Although an individual can often be effective at exercising power and creating change, creating certain changes within most organizations requires collective action. Coalition building is an effective political strategy for collective action are groups of individuals or organizations that join together temporarily around a common goal. This goal often focuses on an effort to effect change. The networking among organizations that results in coalition building requires members of one group to reach out to members of other groups. This often occurs at the leadership level and may come through formal mechanisms such as letters that identify an issue or problem—a shared interest—around which a coalition could be built. For example, a state nurses association may invite the leaders of organizations interested in child health (e.g., organizations of pediatric nurses, public health nurses and physicians, elementary school teachers, daycare providers) and consumers (e.g., parents) to discuss collaborative support for a legislative initiative to improve access to immunization programs in urban and rural areas. Such coalitions of professionals and consumers are powerful in influencing public policy related to health care. Collaboration among groups and individuals with common interests and goals often results in greater success in effecting change and exercising power in the workplace and within other organizations, including legislative bodies. A group of diverse nursing organizations may come together as a coalition to support a modification of the state nursing practice act. Expanding networks in the workplace, as suggested earlier in this chapter, facilitates creating a coalition by developing a pool of candidates for coalition building before they are needed. Invite people with common goals to lunch or coffee to begin building a coalition around an issue. Discuss this shared interest, and gain the commitment of the individuals. Meet informally with members of the committee or task force that is working on this issue. Attend the open meetings of professional groups that share the same interests as the organization to which you belong. Share ideas on how to create the desired change most effectively while building coalitions. Coalition building is an important skill for involvement in legislative politics. Nursing organizations often use coalition building when dealing with state legislatures and Congress. Changes in nurse practice acts to expand opportunities for advanced nursing practice have been accomplished in many states through coalition building. State medical societies or the state agencies that license physicians often oppose such changes. Efforts by a single nursing organization (e.g., a state nurses' association or a nurse practitioners' organization), representing a limited nursing constituency, often lack the clout to overcome opposition by the unified voice of the state's physicians. However, the unified effort of a coalition of nursing organizations, other healthcare organizations, and consumer groups can be powerful in effecting change through legislation.

A

The manager of a surgical area has a vision for the future that requires the addition of RN assistants or unlicensed persons to feed, bathe, and walk patients. The RNs on the staff are resistant to this idea. The best initial strategy in this situation would include: A. Explore the values of the RN group in relationship to this change B. Leave the RNs alone for a time so they can think about the change before they are approached again. C. Drop the idea and try for the change in another year or so. D. Hire the assistants and allow the RNs to see what good additions they are to the nursing unit.

quality indicators

The nurse manager and the staff are consistently concerned with the quality of care that is being delivered on their unit. The quality indicators developed by the American Nurses Association (ANA), such as the National Database of Nursing Quality Indicators (NDNQI) (n.d.), are excellent resources for the nurse manager. The NDNQI measures are specifically concerned with patient safety and aspects of quality of care that may be affected by changes in the delivery of care or staffing resources. The quality indicators address staff mix and nursing hours for acute-care settings, as well as other care components. The NDNQI project is designed to assist healthcare organizations in identifying links between nursing care and patient outcomes. The Joint Commission expects organizations, as part of meeting accreditation, to adhere to and strive for improvement in certain core measures. Hospitals are compared across the nation in these measurements. Examples of core measures required by The Joint Commission are practices associated with acute myocardial infarctions, care for the patient with congestive heart failure, care associated with the treatment of pneumonia, and patient satisfaction. As with the NDNQI measures, the core measures are concerned with level of quality of care and outcomes of care. Organizations may also benchmark within their system or within groups of other organizations to compare outcomes and practices.

systems thinking theory

The principles of systems thinking theory have been characterized classically by Anderson and Johnson (1997) as: •Thinking of the "Big Picture" The nurse who looks past an individual assignment and comprehends the needs of all units of the hospital, or who can focus on the needs of all the residents in a long-term care facility, or who can think through the complications of emergency department overcrowding in an urban setting is seeing the big picture. These nurses have the ability to envision the context of their work beyond the immediate tasks. •Balancing Short-Term and Long-Term Objectives The nurse who recognizes the consequences of actions taken today on the long-term effect of the organization or patient care, such as the decision of a patient to terminate clinical treatment, can guide thinking about how to balance decision making for quality outcomes. •Recognizing the Dynamic, Complex, and Interdependent Nature of Systems All things are connected. Patients are connected to families and friends. Together, they are connected to communities and cultures. Communities and cultures make up the fabric of society. The cost of health care is linked to local economies, and local businesses are connected to global industries. Identifying and understanding these relationships helps solve problems with full recognition that small decisions can have a large impact. •Using Measurable versus Nonmeasurable Data Systems This thinking triggers a "tendency to 'see' only what we measure." If we focus our measuring on morale, working relationships, and teamwork, we might miss the important signals that only objective statistics can show us. On the other hand, if we consider only numbers, (e.g., number of patients seen), we might miss a big perspective, such as lack of engagement in the workplace.

ethics committee

With the increasing numbers of ethical dilemmas in patient situations and administrative decisions, healthcare providers are increasingly turning to hospital ethics committees for guidance. Such committees can provide both long-term and short-term assistance. Ethics committees provide structure and guidelines for potential problems, serve as open forums for discussion, and function as true patient advocates by placing the patient at the core of the committee discussions. To form such a committee, the involved individuals should begin as a bioethical study group so that all potential members can explore ethical principles and theories. The composition of the committee should include nurses, physicians, clergy, clinical social workers, nutritional experts, pharmacists, administrative personnel, and legal experts. Once the committee has become active, individual patients or patients' families and additional representatives of members of the healthcare delivery team may be invited to committee deliberations. Ethics committees traditionally follow one of three distinct structures, although some institutional committees blend the three structures. The autonomy model facilitates decision making for competent patients. The patient-benefit model uses substituted judgment (what the patient would want for himself or herself if capable of making these issues known) and facilitates decision making for the incompetent patient. The social justice model considers broad social issues and is accountable to the overall institution. In most settings, the ethics committee already exists because complex issues divide healthcare workers. In many centers, ethical rounds, conducted weekly or monthly, allow staff members, who may later become involved in ethical decision making, to begin reviewing all the issues and to become more comfortable with ethical issues and their resolution.

emotional intelligence

characterized by social skills, interpersonal competence, psychological maturity, and emotional awareness that help people harmonize to increase their value in the workplace Nurses have countless interactions throughout the workday in the face of emotionally-laden challenges that involve life and death. A professional nurse's portfolio contains five domains that are necessary for leading, managing, and following: •Deepening self-awareness and encouraging others to do the same (stepping outside oneself to envision the context of what is happening while recognizing and owning feelings associated with an event) •Managing emotions in self and others (owning feelings such as fear, anxiety, anger, and sadness and acting on those feelings in a healthy manner; avoiding passive-aggressive and victim responses) •Motivating self and others (focusing on a goal, often with delayed gratification, such that emotional self-control is achieved and impulses are stifled) •Being empathetic (valuing differences in perspective and showing sensitivity to the experiences of others in ways that demonstrate an ability to reveal another's perspective on a situation) •Fostering and handling relationships (exhibiting socially appropriate behavior, expanding social networks, and using social skills to help others manage emotions). Emotionally intelligent nurses are credible as leaders, managers, and followers because they possess awareness of the individual, family, or community that is the locus of caregiving, have enhanced organizational skills because they have invested in relationships, and are able to collaborate, show insight into others, and commit to self-growth. When coupled with performing clinical tasks tied to critical thinking and action, the emotionally intelligent nurse demonstrates the capacity to be a high-performing professional. The synergy associated with credibility and capability fuse to become makers of success. Without self-reflective skills, growth in emotional intelligence is stymied, work becomes routine, and asynchrony with others results.

followership

engaging with others who are leading or managing by contributing to problem identification, completing tasks, and providing feedback for evaluation complementary set of healthy and assertive actions Attributes: -Engaged -Collaborative -Assertive -Action oriented -Evaluative -Positive A healthy definition of followership is that each member contributes optimally, but acquiesces to a peer who is leading or managing in a setting where a team has gathered to ensure the best clinical decision-making and actions are taken to achieve clinical or organizational outcomes. When in the following role, teamwork is palpable, where each person acts together in purpose and in a rhythm that addresses the aim at hand. Traits that great followers possess include acting synergistically with others, relieving others and stepping into leading and managing situations to prevent fatigue, speaking and acting with principle and integrity, adding value to the work being accomplished, and questioning decisions and directions when they are unclear or fail to be patient-focused.

management

guiding others through a set of derived practices and procedures that are evidence-based and known to satisfy pre-established outcomes based on repeated clinical situations Theories: -scientific management -bureaucratic management -human relations management -management functions, skills, roles -management by objectives -total quality management -six sigma Attributes: -Positive energy and stamina -Critical thinker and effective decision maker -Use facts/ evidence to enhance intuition -Responsible for actions—take credit when actions don't produce desired outcomes -Give credit to others when actions result in desired outcomes -Humble -Coach and mentor -Trustworthy and respectful -Competent and confident Responsibilities/Tasks: -Establish and communicate goals and objectives -Plan, organize, staff, budget, direct, control, motivate -Organize, analyze and divide work into manageable tasks -Motivate and communicate -Analyze, appraise and interpret performance and measurements -Develop self and others Outcomes: -Goals and objectives achieved -Safe staffing levels maintained -Operating and capital budgets within parameters -Staff and patient satisfaction maintained -Performance evaluations completed on time and with honest and growth producing feedback is the ability to plan, direct, control, and evaluate others in situations where the outcomes are known or preestablished, where one of more ways of performing have been agreed upon based upon evidence, where feedback and communication is shared to improve clinical processes and outcomes, and where sustained relationships advance consistency of purpose. Traits needed for effective managers include (1) the ability to identify recurring problems that exist where the design of evidence-based routines create structure and improved work efficiency, (2) persistent and vigilant behavior in self and others, and (3) communication that maintains esprit de corps in the face of repetitive work tasks. is needed to provide organization in the workplace, a sense of purpose, and safety. The complexities of blood or chemotherapy administration are examples of highly complex management routines. Even basic care routines, such as oral care and skin hygiene, if neglected, have serious clinical outcomes for patients. Nursing and scientific knowledge supports what we know to be best practice, yet without persistence and vigilance, efforts shift to monitoring basics such as hand hygiene and lift practices

Mentoring

has become an important force in nursing. Mentors are competent, experienced professionals who develop a relationship with less experienced nurses for the purpose of providing advice, support, information, and feedback to encourage the development of that person. Mentoring has been an important element in the career development of men in business, academia, and selected professions. Mentoring has become a significant power strategy for women in general and for nurses in particular during the past 30 years. Mentoring provides expanded access to information, power, and career opportunities. Mentors have been a critical asset to novice nurses trying to negotiate workplace and professional politics. Effective mentoring in nursing benefits both the mentor and the mentee. Mentors benefit by expanding their own professional development and that of their colleagues, improving their own self-awareness, experiencing the intrinsic benefits of teaching another, nurturing their own interpersonal skills, and expanding their political savvy. Mentees receive one-on-one nurturing and coaching from the mentor, gain insight or savvy about the political rules of the organization and learn about organizational culture from an insider, can expand their self-confidence in a supportive relationship, receive career development advice, profit from the mentor's professional network, and have a unique opportunity for individualized professional development. Mentoring is an empowering experience for both mentors and protégés. The process of seeking out mentors is an exercise in growth for protégés. Mentors often come from one's professional networks. Mentors sometimes select their protégés; at other times, the reverse is true. Protégés learn new skills from influential mentors and gain self-confidence. Mentors share their influence through the influence of those they mentor and gain satisfaction by experiencing the evolution of those nurses into experienced nurses.

transformational leadership

is based on an inspiring vision that changes the framework of the organization for employees. Employees are encouraged to transcend their own self-interest. This style of leadership involves communication that connects with employees' ideals in a way that causes emotional engagement. The transformational leader can motivate employees by articulation of an inspirational vision; by encouragement of novel, innovative thinking; and by individualized consideration of each employee, thus accounting for individual needs and abilities. occurring when leaders and followers have a relationship in which the leader does not hold all of the power and authority, but the leader "created an environment that brought leaders and followers together to solve problems, create new ways of doing work, and manage change together" "The goal of transformational leadership is to transform people and organizations in a literal sense, to change them in mind and heart; enlarge vision, insight, and understanding; clarify purposes; make behavior congruent with beliefs, principles, or values; and bring about changes that are permanent, self-perpetuating, and momentum-building" identify five key practices in transformational leadership, as follows: 1. Challenging the process, which involves questioning the way things have been done in the past and thinking creatively about new solutions to old problems 2. Inspiring shared vision or bringing everyone together to move toward a goal that all accept as desirable and achievable 3. Enabling others to act, which includes empowering people to believe that their extra effort will have rewards and will make a difference 4. Modeling the way, meaning that the leader must take an active role in the work of change 5. Encouraging the heart by giving attention to those personal things that are important to people, such as saying "thank you" for a job well-done and offering praise after a long day Leader Behaviors • Charismatic • Inspirational and motivational • Intellectual stimulation • Individualized consideration Effect on Followers • A shared vision • Increased self-worth • Challenging and meaningful work • Coaching and mentoring happens • A sense of being valued Organizational Outcomes • Increased loyalty • Increased commitment • Increased job satisfaction • Increased morale • Increased performance particularly suited to the nursing environment. For example, the Magnet Recognition Program places great emphasis on this type of leadership to move an organization to high levels of quality. A transformative leader creates a vision of what quality could look like and then provides specific actions that create a sense of community, which supports satisfaction, retention, communication, and interprofessional work. This type of leader listens to the views of others, finds ways to remove barriers, and serves as an advocate for those who care for patients. is hard work; investment of time and energy is required to bring out the best in people. And a leader does not have to be good at everything. A good leader seeks to create a whole from the various members of a team. Transformational leadership is not unique to nursing as the following Research Perspective illustrates.

justice

is the principle of treating all persons equally and fairly. This principle most often arises in times of short supplies or when competition for resources or benefits is occurring. This principle is used by nurse managers when they decide which staff members to promote or to recommend for professional development opportunities. The staff member's overall performance and skills should be considered rather than who may have seniority or the popular vote of his/her peer group. Justice is also encountered when deciding who should be floated to another unit/service within the institution or which staff member should be moved to a straight day position rather than remaining on a rotating schedule.

Influence

is the process of using power. _____________ can range from the punitive power of coercion to the interactive power of collaboration. Coaching a new graduate to complete a complicated nursing procedure successfully demonstrates the ability of the experienced nurse to influence that orientee. The coach uses expert, positional, and informational power to influence the orientee not only at that moment but also perhaps over the span of a career. Nurses can use personal, expert, and perceived power while working on the campaigns of legislators who support nursing and healthcare issues. the process of using power...may range form the punitive power of coercion to the interactive power of collaboration

transactional leadership

is the traditional "boss" image employees understand that a superior makes the decisions with little or no input from subordinates. Transactional leadership relies on the power of organizational position and formal authority to reward and punish performance. Followers are fairly secure about what will happen next and how to "play the game" to get where they want to be. A transactional leader uses a quid pro quo style to accomplish work (e.g., I'll do x in exchange for you doing y). Transactional leaders reward employees for high performance and penalize them for poor performance. The leader motivates the self-interest of the employee by offering external rewards that generate conformity with expectations Leader Behaviors: • Contingent reward (quid pro quo) • Punitive • Management by exception (active)—monitors performance and takes action to correct • Management by exception (passive)—intervenes only when problems exist Effect on follower: • Fulfills the contract or gets punished • Does the work and gets paid • Errors are corrected in a reactive manner Organizational Outcomes: • Work is supervised and completed according to the rules • Deadlines are met • Limited job satisfaction • Low to stable levels of commitment

Negotiation

or bargaining, is a critically important skill for organizational and political power. It is a process of making trade-offs. Children are natural negotiators. Often, they will initially ask their parents for more than what they are willing to accept in the way of privileges, toys, or activities. The logic is simple to children: Ask for more than is reasonable and negotiate down to what you really want! often works the same way within organizations. People will sometimes ask for more than they want and be willing to accept less. In other situations, both sides will enter negotiations asking for radically different things but each may be willing to settle for a position that differs markedly from the respective original position. In the simplest forms of bargaining, each participant has something that the other party values: goods, services, or information. At the "bargaining table," each party presents an opening position. The process moves on until they reach a mutually agreeable result or until one or both parties walk away from a failed negotiation. Bargaining may take many forms. Individuals may negotiate with a supervisor for a more desirable work schedule or with a peer to effect a schedule change so that one can attend an out-of-town conference. A nurse manager may sit at the bargaining table with the department director during budget planning to expand education hours for the nursing unit in the next year's budget. Representatives of a coalition of nursing organizations meeting with a legislator may negotiate with the legislator over sections of a proposed healthcare-related bill in an effort to eliminate or modify those sections not viewed by the nursing coalition as in the best interests of nurses, patients, or the healthcare system. Nurses may bargain with nursing and hospital administration over wages, staffing levels, other working conditions, and the conditions and policies that govern clinical practice. This is called collective bargaining, a specific type of negotiating that is regulated by both state and federal labor laws and that usually involves representation by a state nurses association or a nursing or non-nursing labor union Successful negotiators are well informed about not only their own positions but also those of the opposing side. Negotiators must be able to discuss the pros and cons of both positions. They can assist the other party in recognizing the costs versus the benefits of each position. These skills are also essential to exercising power effectively with the arenas of professional and legislative politics. When lobbying a member of the legislature to support a bill that is desired by nurses, one must understand the position of those opposed to the bill to respond effectively to questions that the legislator may ask.

manager

person with accountability for a group of people Always an assigned position Legitimate source of power (delegated authority) that accompanies position Carry out specific functions Emphasize planning (strategic and other), control, decision making, decision analysis and results The roles of manager and leader are often considered interchangeable, but they are actually quite different. The manager may also be a leader, but the manager is not required to have leadership skills within the context of moving a group of people toward a vision. The term manager is a designated leadership position. Leadership is an abilities role, and it is most effective if the manager is also a leader. Management can be taught and learned using traditional teaching techniques. Leadership can also be taught, but it is usually a reflection of rich personal experiences. The manager is concerned with doing things correctly in the present. The role of manager is very important in work organizations because managers ensure that operations run smoothly and that well-developed formulas are applied to staffing situations, economic decisions, and other daily operations. The manager is not as concerned with developing creative solutions to problems as with using known strategies to address today's issues. A well-managed entity may be proceeding correctly but, without leadership, may be proceeding in the wrong direction states, "the difference between management and leadership is that management is working on your business, and leadership is working on your people."

confidentiality

right to privacy of the medical record Institutions can reduce potential liability in this area by allowing access to patient data, either written or oral, only to those with a "need to know." Persons with a need to know include physicians and nurses caring for the patient, technicians, unit clerks, therapists, social service workers, and patient advocates. Usually, this need to know extends to the house staff and consultants. Others wishing to access patient data must first ask the patient for permission to review a record. Administrative staff of the institution can access the patient record for statistical analysis, staffing, and quality-of-care review. The nurse manager is cautioned to ensure that staff members both understand and abide by rules regarding patient privacy and confidentiality. "Interesting" patients should not be discussed with others, and all information concerning patients should be given only in private and secluded areas. All nurses may need to review the current means of giving reports to oncoming shifts and policies about telephone information. Many institutions have now added to the nursing care plan a place to list persons to whom the patient has allowed information to be given. If the caller identifies himself or herself as one of those listed persons, the nurse can give patient information without violating the patient's privacy rights. Patients are becoming more knowledgeable about their rights in these areas, and some have been willing to take offending staff members to court over such issues. The patient's right of access to his or her health record is another confidentiality issue. Although the patient has a right of access, individual states mandate when this right applies. Most states give the right of access only after the health record is completed; thus the patient has the right to review the record after discharge. Some states do give the right of access while the patient is hospitalized, and therefore individual state law governs individual nurses' actions. When supervising a patient's review of his or her record, the nurse manager or representative should explain only the entries that the patient questions or about which the patient requests further clarification. The nurse makes a note in the record after the session, indicating that the patient has viewed the record and what questions were answered. Patients also have a right to copies of the record, at their expense. The health record belongs to the institution as a business record, and patients never have the right to retain the original record. This is also true in instances in which a subpoena is obtained to secure an individual's health record for court purposes. A hospital representative will verify that the copy is a "true and valid" copy of the original record.

mentor

someone who models behavior, offers advice and criticism, and coaches the novice to develop a personal leadership style. A mentor is a confidante and coach, as well as a cheerleader and teacher. In other words, a mentor is knowledgeable and skilled. Where do you find a mentor? Usually, a mentor is someone who has experience and some success in the leadership realm of interest, such as in a clinical setting or in an organization. A respected faculty member; a nurse manager, director, or clinician; or an organizational officer or active member may be a mentor. Mentorship is a two-way street. The mentor must agree to work with the novice leader and must have some interest in the novice's future development. A mentor can be close enough geographically to allow both observation and practice of leadership behaviors, as well as timely feedback. A mentor may also be geographically remote and yet well-connected to the mentee. A mentor should provide advice, feedback, and role-modeling. In addition, the mentor has a right to expect assistance with projects, respect, loyalty, and confidentiality. In a mentoring relationship, aspiring leaders soak up knowledge and experience and should expect to return it by serving as a mentor to a young, aspiring leader in the future. Most managers were mentored, formally or informally, at one time in their career by someone of influence. In turn, a manager should be concerned about preparing successors. is viewed as an interactive, multifaceted role that assists the staff, especially novice staff, with setting realistic, attainable goals. Through mentoring their staff, nurse managers can help boost staff self-confidence, thereby helping them gain professional satisfaction as they reach their goals. Nurse managers give clinical guidance to their staff, and they can be instrumental in assisting them with their present work and their own career development.

process of care

specifies the desired sequence of steps to achieve clinical standardization, safety, and outcomes. Effective management depends on knowing, adhering to, and improving processes for efficiency and effectiveness. Each person must respect and act on his or her prescribed role in a process of care. Data-driven outcome measurements add to good management and support feedback, coaching, and mentoring opportunities. Rewards for individual and team effectiveness reinforce desired behaviors. Followers complement leaders and managers with their skills. Followers and leaders fill gaps that exist to build on each other's cognitive, technical, interpersonal, and emotional strengths. Followers, showing sensitivity to leaders, offer respite in times of stress. Followers need and respond to feedback from leaders to stay on course. The follower must acquiesce to the skills and abilities of the leader or manager to promote teamwork. This does not mean that the follower does not have the skills and abilities of the leader or manager, because the follower may be thrust into one of those roles when circumstances demand. Tasks of management: 1. Identify systems and processes that require responsibility and accountability, and specify who owns the process. 2. Verify minimum and optimum standards/specifications, and identify roles and individuals responsible to adhere to them. 3. Validate the knowledge, skills, and abilities of available staff engaged in the process; capitalize on strengths; and strengthen areas in need of development. 4. Devise and communicate a comprehensive big picture plan for the division of work, honoring the complexity and variety of assignments made at an individual level. 5. Eliminate barriers/obstacles to work effectiveness. 6. Measure the equity of workload, and use data to support judgments about efficiency and effectiveness. 7. Offer rewards and recognition to individuals and teams. 8. Recommend ways to improve systems and processes. 9. Use a social network to engage others in decision making and for feedback, when appropriate or relevant.

managed care

was introduced in the 1980s. The goal of managed care is to provide needed services efficiently and at an appropriate cost. In essence, this goal requires nurse managers to know and incorporate business principles into patient-care practices. Nurse managers who know business principles become conduits for ensuring safe, effective, affordable care. The same can be said for the Never Events identified by the Centers for Medicare & Medicaid Services (CMS) over the years. The term Never Events refers to conditions for which healthcare organizations will not be paid. They are conditions that are acquired while the patient is institutionalized. Examples of some of the Never Events include a stage 3 or 4 pressure ulcer acquired during a hospital stay, a bloodstream infection acquired while hospitalized, a fall occurring during a hospital stay that results in an injury requiring a longer stay, or surgery on the wrong body part or side of the body requiring a return trip to surgery.

law

All nurses must know applicable state law and use the nurse practice act for guidance and appropriate action. Nurse managers have this same basic responsibility to apply legal principles in their practice. However, they are also responsible for monitoring the practice of employees under their supervision and for ensuring that personnel maintain current and valid licensure. Unless nurses and nurse managers remain current with the nurse practice act in their state or with nurse practice acts in all states in which nurse managers supervise employees, a constant potential for liability exists.

accountability

The expectation of explaining actions and results. determines if the actions were appropriate and provides a detailed explanation of what occurred The delegator discusses with the delegatee what tasks must be completed and transfers the responsibility and authority for those tasks to the delegatee. Even though the delegatee performs a task related to patient care, the registered nurse does not abandon the patient or the accountability for patient care. It is essential that the registered nurse complete a critical analysis, using the nursing process, to determine if the actions taken in a situation were appropriate, and if not, what occurred and why.

autonomy

addresses personal freedom and self-determination; the right to choose what will happen to oneself as well as the accountability for making individual choices. The legal doctrine of informed consent is a direct reflection of this principle. Autonomy involves respect for other's decisions, even if the nurse manager does not agree with the decision chosen. An example could be in the instance of progressive discipline. The employee has the option to meet delineated expectations or accept the consequences of not complying with these delineated expectations.

case management

is a method used for many years to provide care for patients in outpatient service areas. Increasingly, more traditional acute inpatient care is moving to outpatient service areas. The key to effective case management is proactive coordination of care from the point of admission, with identified time frames for accomplishing appropriate care outcomes. The nurse manager often provides oversight of or collaboration with the case managers, and in some settings, the nurse manager is the immediate supervisor of the case managers. Case management involves components of case selection, multidisciplinary assessment, collective planning, coordination of events, negotiation, and evaluation and documentation of the outcomes of patient status in measures of cost and quality. Case managers are employed in acute care settings, rehabilitation facilities, subacute care facilities, community-based programs, home care, and insurance companies. These managers must possess a broad range of personal, interpersonal, and management skills.

role theory

represents a collection of concepts and a variety of hypothetical formulations that predict how actors will perform in a given role, or under what circumstances certain types of behaviors can be expected explains that there are socially desired behavioral norms, and there are three central components that are modeled after certain social behaviors. These include role expectations, the assumption of social roles, and the subsequent enactment of those roles

indemnification

the institution has the right under indemnification to countersue the nurse for damages paid to an injured patient. The principle of indemnification is applicable when the employer is held liable based solely on the actions of the staff member's negligence and the employer pays monetary damages because of the employee's negligent actions.

A

As a charge nurse on the night shift, you counsel a staff RN that he has satisfied his duty of care by notifying a child's physician of his concerns about deterioration in the child's status at 0330 hours. The physician does not come in. The child dies at 0630 hours. As a charge nurse, you could be held liable for: A. Professional negligence B. Assault C. Avoidance D. Murder

hybrid

Possessing characteristics from several types of organizational structures. As organizational structures change, some managers are hesitant to relinquish their traditional role in a centralized decision-making process. This reluctance, when combined with recognition of the need to move to a more facilitative role, is partially responsible for the development of hybrid structures. Managers are unsure of what needs to be controlled, how much control is needed, and which mechanisms can replace control. They fear that chaos will ensue without tight managerial control. These fears stem from loss of centralized control because authority, with its concomitant responsibilities, moves to the place of interaction. Registered nurses prepared at the higher educational level develop and use leadership techniques that empower themselves and others to take responsibility for their work and develop skills associated with effective leadership and followership. The evolutionary development of shared-governance structures in nursing departments demonstrates a type of flat structure being used to replace hierarchical control.

public institution

Providing health services under the support and direction of local, state, or federal government. These organizations must answer directly to the sponsoring government agency or boards and are indirectly responsible to elected officials and taxpayers who support them. Examples of these service recipients at the federal level are veterans, members of the military, Native Americans, and inmates of correctional facilities. State-supported organizations may be health service teaching facilities, chronic care facilities, and prisoner facilities. Locally supported facilities include county-supported and city-supported facilities County, state or federal facilities EX: County hospitals, State mental health facilities, Veteran's Health Administration, Prison Health

hierarchy

Chain of command that connotes authority and responsibility. vests authority in positions on an ascending line away from where work is performed and allows control of work. Staff members are often placed on a bottom level of the organization, and those in authority, who provide control, are placed in higher levels.

magnet recognition

In 1983, the American Academy of Nursing's (AAN) task force on nursing practice in hospitals conducted a study of 163 hospitals to identify and describe variables that created an environment that attracted and retained well-qualified nurses who promoted quality care. Forty-one of these institutions were described as Magnet™ hospitals because of their ability to attract and retain professional nurses. In 1990, the American Nurses Credentialing Center (ANCC), building on the concepts of the 1983 Magnet™ hospital study, developed a program that recognized excellence in the nurses' work environment. Prominent in the designation process is the hospital's documentation of the presence of the Forces of Magnetism. The Magnet Recognition Program® is designed for hospitals to achieve recognition of excellent nursing care through a self-nominating, self-appraisal process to achieve. The rigorous self-appraisal process is lengthy, often requiring 2 or more years of preparation. The hospital makes application for Magnet status, submits documentation to demonstrate its compliance with the Magnet™ standards, and hosts a site visit by Magnet™ appraisers. When the application process is successful, Magnet status is awarded for 4 years. attract and retain nurses "like a magnet" Conditions in Magnet hospitals favorable to professional nursing practice and professional work environments

Expectancy theory

Vroom (1994) is credited with developing the expectancy theory of motivation. Individuals' perceived needs influence their behavior. In the work setting, this motivated behavior is increased if a person perceives a positive relationship between effort and performance. Motivated behavior is further increased if a positive relationship exists between good performance and outcomes or rewards, particularly when these are valued. Expectancy is the perceived probability of satisfying a particular need based on experience. Therefore nurses in leadership roles need to provide specific feedback about positive performance.

paternalism

allows one person to make partial decisions for another and is most frequently deemed to be a negative or undesirable principle. Paternalism, however, may be used to assist persons to make decisions when they do not have sufficient data or expertise. Paternalism becomes undesirable when the entire decision is taken from the employee. Nurse managers employ this principle in a positive manner by assisting employees in deciding major career moves and plans, helping the staff member more fully understand all aspects of a possible career change, or conversely, assisting staff members comprehend why such a potential change could impact their future growth opportunities within the organization.

A

A charge nurse on a busy 40-bed medical/surgical unit is approached by a family member who begins to complain loudly about the quality of care his mother is receiving. His behavior is so disruptive that it is overheard by staff, physicians, and other visitors. The family member rejects any attempt to intervene therapeutically to resolve the issue. He leaves the unit abruptly and the nurse is left feeling frustrated. Which behavior by the charge nurse best illustrates refined leadership skills in an emotionally intelligent practitioner? A. Reflect to gain insight into how the situation could be handled differently in the future. B. Try to catch up with the angry family member to resolve the concern. C. Discuss the concern with the patient after the family member has left. D. Notify nursing administration of the situation.

For-profit organization

An organization, such as a hospital, that is operated to create excess income (profit) for the benefit of owners or stockholders are also referred to as proprietary or investor-owned organizations. These organizations operate with the specific intent of earning a profit by providing healthcare services to individuals who can afford to pay for these services. Organizations such as private or public insurers who provide healthcare insurance coverage are known as third-party payers. Many for-profit organizations, like the not-for-profit ones, receive supplementary funds through private and public sources to provide special services and research. This funding allows them to provide financial assistance to patients who can afford ordinary care but are not in a position to finance catastrophic occurrences such as vital organ failure, birth of premature or sick infants, or transplant operations. Must pay taxes Revenue returned to investors Generally have higher hospital charges, lower wage and salary costs Avoid charity care if can

critical thinking

A composite of knowledge, attitudes, and skills; an intellectually disciplined process. Also, the ability to assess a situation by asking open-ended questions about the facts and assumptions that underlie it and to use personal judgment and problem-solving ability in deciding how to deal with it -decision making -problem solving -creativity -professional judgment Although critical thinking has been defined in numerous ways, The Critical Thinking Community (2011) defines critical thinking as " a mode of thinking, about any subject, content, or problem, in which the thinker improves the quality of his or her thinking by skillfully analyzing, assessing, and reconstructing it. Critical thinking is self-directed, self-disciplined, self-monitored, and self-corrective thinking." Effective critical thinkers are self-aware individuals who strive to improve their reasoning abilities by asking "why," "what," or "how." A nurse who questions why a patient is restless is thinking critically. Compare the analytical abilities of a nurse who assumes a patient is restless because of anxiety related to an upcoming procedure with those of a nurse who asks if there could be another explanation and proceeds to investigate possible causes. It is important for nurse leaders and managers to assess staff members' ability to think critically and enhance their knowledge and skills through staff-development programs, coaching, and role modeling. Establishing a healthy work environment can promote staff members' ability to think critically.

partnership model

A form of primary nursing where an RN is paired with a technical assistant. (or co-primary nursing model) of providing patient care, an RN is paired with a technical assistant. The partner works with the RN consistently. When the partner is unlicensed, the RN allows the assistant to perform basic nursing functions consistent with the state delegation rules. This frees the RN to provide "semi-primary care" to assigned patients. A partnership between an RN and an LPN/LVN allows the LPN/LVN to take more responsibility, because the scope of practice for an LPN/LVN is greater than that of a UAP. In some settings, the partnership is legitimized with an official contract to formalize the relationship. Rehabilitative care settings often use the partnership model to deliver care. Another view of primary care is the care delivered in a patient-focused care unit. Developed in the late 1980s, the patient-focused care model integrates principles from business and industry. The goals for this model of care included (1) improving patient satisfaction and other patient outcomes, (2) improving worker job satisfaction, and (3) increasing efficiencies and decreasing costs The multidisciplinary team formulates the plan of care after the primary nurse and the physician have assessed the patient. Patient-focused care units require a change in the physical environment where care is delivered. Services required by patients are decentralized. Satellite laboratories, radiology facilities, pharmacies, and supply rooms are geographically proximate to the patient rooms Original models of a patient-focused care unit included an RN paired with a cross-trained technician who provided patient-side care, including respiratory therapy, phlebotomy, and electrocardiographs. Modifications in this nurse-managed model include team members who provide direct care activities such as recording vital signs, drawing blood, and bathing patients. In a patient-focused care unit, the role and scope of the nurse manager expand. No longer is the individual just a manager of nurses. Now the nurse manager assumes the accountability and responsibility to manage nurses and staff from other, traditionally centralized departments. Because the care is focused on the needs of the patient and not the needs of the department, the role of the manager becomes more sophisticated. The nurse manager orchestrates all the care activities required by the patient and family during the hospitalization.

synergy model

A model of care delivery adopted by the American Association of Critical-Care Nurses that matches the needs and characteristics of the patient with the competencies of the nurse. Seven characteristics are unique to every patient, and each nurse has varying levels of ability, which are categorized into eight competencies. When the knowledge, skills, and competencies of the nurse are used to meet the complex needs of the patient and family, the care is optimal. identifies patient characteristics as "drivers" of the necessary competencies for nurses. When a match between the competencies of the nurse and the characteristics of the patient occurs, the best patient outcomes and safe passage through a hospital stay will be achieved The Synergy Model describes the following eight patient characteristics: resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision making, and predictability. The eight nurse competencies are clinical judgment, advocacy and moral agency, caring practices, facilitation of learning, collaboration, systems thinking, response to diversity, and clinical requirement more theoretical than a practical approach to divide labor and get work done; AACN; Basically, no matter which delivery care model is used, there needs to be synergy among all care providers and the patient/ family

differentiated nursing practice

A model of care that recognizes the difference in the level of education and competency of each registered nurse. The differentiation is based on education, position, and clinical expertise. The BSN role was conceptualized as operating across time from preadmission to post-discharge. The guiding principles of this role are found in the unusual and often unpredictable response of the patient that goes beyond needs addressed in the standards or pathways. Collaborating with other disciplines and agencies, the BSN intervenes to design and facilitate a comprehensive, well-prepared discharge based on the unique needs of the patient and family Advanced by professional nursing associations to refine definitions and practices for the various levels of RNs RN with BSN = Professional Nurse RN with ADN = Associate Nurse RN with MSN/ DNP = Advanced Practice Registered Nurse (APRN) RN with MSN = Clinical Nurse Leader (CNL)/ Advanced Generalist All approaches an attempt to clarify knowledge, skills and abilities (KSAs) of all levels of RNs, refine job descriptions, differentiate pay scales, and identify appropriate levels of decision - making associated with various roles; Overall, some progress...but still a ways to go!

Portfolio

A professional assemblage of materials that represent the work of the professional. These materials include such elements as evaluations, letters of recommendation or appreciation, certificates of accomplishment, copies of articles, documentation of projects (e.g., research, clinical changes, management projects), and additional educational achievements (continuing education and degree achievement). Creating a professional portfolio, the basics of which are found in the citations made in your CV, can help organize one element of your professional life. Keeping notes of recognition, copies of evaluations, and pictures of your successes are examples that help round out the resource documents behind the CV data. Although a portfolio takes time to develop and to maintain, that work pays off at evaluation, promotion, and position-seeking times. Consider organizing your data in an electronic portfolio format. Some employers prefer receiving portfolio application materials in electronic form rather than large collections of paper. The electronic format allows for easy customization based on a specific position. In other words, this system of maintaining professional information provides a resource to respond promptly to new or emerging opportunities.

service-line structures

A type of structure in which the functions necessary to produce a specific service or product are brought together into an integrated organizational unit under the control of a single manager or executive (sometimes called product lines) For example, a cardiology service line at an acute care hospital might include all professional, technical, and support personnel providing services to the cardiac patient population. The manager or executive in this service line would be responsible for the chest pain evaluation center situated within the emergency department, the coronary care unit, the cardiovascular surgery intensive care unit, the telemetry unit, the cardiac catheterization lab, and the outpatient cardiac rehabilitation center. In addition to managing the budget and the facilities for these areas, the manager typically would be responsible for coordinating services for physicians and other providers who care for these patients.

apparent agency

Today, courts have begun to hold the institution liable under the principle of apparent agency. Apparent authority or apparent agency refers to the doctrine whereby a principal becomes accountable for the actions of his or her agent. Apparent agency is created when a person (agent) holds himself or herself out as acting in behalf of the principal; in the instance of the agency nurse, the patient cannot ascertain whether the nurse works directly for the hospital (has a valid employment contract) or is working for a different employer. At law, lack of actual authority is no defense. This principle applies when it can be shown that a reasonable patient believed that the healthcare worker was an employee of the institution. If it appears to the reasonable patient that this worker is an employee of the institution, the law will consider the worker an employee for the purposes of corporate and vicarious liability. The use of temporary or "agency" personnel has created increased liability concerns among nurses and nurse managers. Until recently, most jurisdictions held that such personnel were considered independent contractors and thus the institution was not liable for their actions, although their primary employment agency did retain potential liability.

collective bargaining

also called labor relations, is the joining together of employees for the purpose of increasing their ability to influence the employer and improve working conditions. Collective bargaining is defined and protected by the National Labor Relations Act of 1935 and its amendments; the National Labor Relations Board (NLRB) oversees the act and those who come under its auspices. The NLRB ensures that employees can choose freely whether they want to be represented by a particular bargaining unit, and it serves to prevent or remedy any violation of the labor laws.

delegation

Achieving performance of care outcomes for which an individual is accountable and responsible by sharing activities with other individuals who have the appropriate authority to accomplish the work. defined as the "transfer of responsibility for the performance of a task from one individual to another while retaining the accountability for the outcome" The terms delegator and delegatee represent the two key roles enacted in the process of delegation. Delegators are registered nurses who allocate a portion of work related to patient care to another individual. Delegatees are often comprised of UNPs, often called assistants, technicians, patient care associates, or aides. Although registered nurses do not supervise all unlicensed assistive personnel (e.g., physical therapy technicians), they have exchanges regarding patient care with UNPs and LPNs/LVNs. Some states have different delegation standards depending on the type of healthcare facility. For example, a long-term care facility may have an LPN/LVN responsible for a nursing unit with a registered nurse supervising the patient care. Nurses need to understand the nurse practice acts of their states, understand the delegation standard related to individual job descriptions, and function within their states' regulatory guidelines. Delegation rights: 1. Task • Is the task appropriate to delegate based on institutional policies and procedures? • Is the task legally appropriate to delegate? Yes responses: The risk task 2. Circumstance • Is the delegation process appropriate to the situation? • Is the environment conducive to completing the task safely? • Are the equipment and resources available to complete the task? • Do staffing ratios demand the use of high-level delegation strategies? • Does the delegatee have appropriate supervision to complete the task? Yes Response: the right circumstance 3. Person • Is the prospective delegatee a willing and able employee? • Does the delegatee have the knowledge and experience to perform the specific task safely? • Does the delegatee have the expertise to complete the task safely and effectively in relation to the acuity of the patient? Yes responses: the right person 4. Direction/communication • Do the delegator and delegatee understand a common work-related language? (Do terms such as time frame, patient needs, and critical mean the same to each of them?) • Does the delegator provide clear and concise directions for the task? • Does the delegatee understand the assignment, directions, limitations, and expected results as they relate to the task? • Do the delegator and delegatee know how to maintain open lines of communication for the purpose of questions and feedback? • Does the delegatee understand how, what, and when to report to the delegator? Yes responses: the right direction/communication 5. Supervision • Is it clear that the delegatee will provide feedback related to the task, when appropriate? • Is the delegator able to monitor and evaluate the patient appropriately? Yes responses: the right supervision

Interviewing

After your letters and résumé are effective in career marketing, the next step is participating in an interview. Interviewing is a two-way proposition; the interviewee should be gathering as much information as the interviewer is. Both should be making judgments throughout the process so that if a position is offered, the interviewee will be prepared to accept, decline, or explore further. Interviews may take place with one or more individuals and may include a range of activities. To be at ease, the interviewee should wear professional and comfortable clothing. Rehearse specific questions to ask and points to make so that you can feel more at ease during the interview. During interviews, employers should ask all applicants for a given position the same questions. In addition to providing comparable information as the basis for a decision, the applicant's expectation for equal treatment is upheld. Only questions related to the position and its description are legitimate. Employers should not ask other questions, and applicants should decline to answer if asked such inappropriate questions. If the interviewer asks an inappropriate question, the applicant can choose not to answer the direct question by addressing the content area. For example, if asked about your spouse's employment, you might say, "I believe what you are asking is how long I will be able to be in this position. Let me assure you that I intend to be here for at least 2 years." Prepare for interview by reading any and all information you can find about a prospective employer. During the interview, you may have an opportunity to share information that lets the employer know you have read their publications/web site and that you are highly interested. Wear comfortable, business, & professional dress. Very high heels for women may not be the image you wish to convey. No gum chewing, etc Behavioral event interviewing is the norm today. Rehearse responses to questions you may think they will ask. For example, "Describe a time when you encountered a difficult patient situation about....how did you handle it...what was the result...would you do anything different....etc." Practice facial expressions in front of mirror. Always have one or two questions for prospective employer.

nominal group technique

Allows group members the opportunity to provide input into the decision-making process. Participants are asked to not talk to each other as they write down their ideas to solve a predefined problem or issue. After a period of silent generation of ideas, generally no more than 10 minutes, each member is asked to share an idea, which is displayed on a flip chart. Comments and elaboration are not allowed during this phase. Each member takes a turn sharing one idea each until all ideas are presented, after which, discussion is allowed. Members may "pass" if they have exhausted their list of ideas. During the next step, ideas are clarified and the merits of each idea are discussed. In the third and final step, each member privately assigns a priority rank to each option. Group members can then place colored stickers on the flip chart next to their first, second, and third choices or they may use pieces of paper to record their choices. The solution chosen is the option that receives the highest ranking by the majority of participants. The advantage of this technique is that it allows equal participation among members and minimizes the influence of dominant personalities. The disadvantages of this method are that it is time-consuming and requires advance preparation. A similar process can be facilitated via the use of web conferencing technologies.

teaching institution

An academic health center and affiliated hospital. is applied to academic health centers (those directly affiliated with a school of medicine and at least one other health profession school) and affiliated teaching hospitals (those that provide only the clinical portion of a medical school teaching program). Although care is usually more costly at teaching hospitals than at nonteaching hospitals (estimates range from 12% higher in Canada to 27% higher in the United States), teaching hospitals generally offer better care because of their access to state-of-the-art technology and researchers. The higher costs of teaching hospitals have been attributed to the unique missions these institutions tend to pursue, including graduate medical education, biomedical research, and the maintenance of stand-by capacity for highly specialized patient care Traditionally, teaching hospitals have received government reimbursement to cover these additional costs. However, intrinsic costs of providing a medical training program are not fully reimbursed by the government. Maintaining a teaching program places a financial burden on hospitals relative to the direct cost of the program and the indirect cost of the inefficiencies surrounding the training process. These inefficiencies include (1) salaries of physicians who supervise students' care delivery and participate in educational programs such as teaching rounds and seminars, (2) duplicated tests or procedures, and (3) delays in processing patients related to the teaching process. Currently, these expenses are reimbursed based on a formula that considers the cost of caring for the low-income and uninsured patients who populate most academic teaching programs. This reimbursement is being revised as states reduce subsidies for the education of physicians. Hospitals make strategic decisions about their level of participation in physician training. Because of the additional costs, few for-profit hospitals sponsor teaching programs. Teaching hospitals are usually located close to their affiliated medical school. They tend to be larger and located in more urban and economically depressed inner- city areas than their nonteaching counterparts. Teaching hospitals, therefore, tend to exhibit weaker economic performance compared with nonteaching hospitals. Academic Medical Centers Generally more costly Have access to latest in research and technology Located close to a Medical School Generally affiliated with not-for-profit institutions due to costs associated with medical training programs EX: Cleveland Clinic, UCLA Medical Center, NYU Medical Center, Parkland Memorial Hospital

matrix structure

An organizational structure influenced by dual authority, such as product line and discipline are complex and designed to reflect both function and service in an integrated organizational structure. In a matrix organization, the manager of a unit responsible for a service reports to both a functional manager and a service or product line manager. For example, a director of pediatric nursing could report to both a vice president for pediatric services (the service-line manager) and a vice president of nursing (the functional manager) can be effective in the current healthcare environment. The matrix design enables timely response to the forces in the external environment that demand continual programming, and it facilitates internal efficiency and effectiveness through the promotion of cooperation among disciplines. A matrix structure combines both a bureaucratic structure and a flat structure; teams are used to carry out specific programs or projects. A matrix structure superimposes a horizontal program management over the traditional vertical hierarchy. Personnel from various functional departments are assigned to a specific program or project and become responsible to two supervisors—their functional department head and a program manager. This approach creates an interdisciplinary team.

variance

Anything that alters a patient's progress through a normal care path. The difference between the projected budget and the actual performance for a particular account. For expenses, a favorable, or positive, variance means that the budgeted amount was greater than the actual amount spent. An unfavorable, or negative, variance means that the budgeted amount was less than the actual amount spent. Positive and negative variances cannot be interpreted as good or bad without further investigation. For example, if fewer supplies were used than were budgeted, this would appear as a positive variance and the unit would save money. This would be good news if it means that supplies were used more efficiently and patient outcomes remained the same or improved. A problem might be suggested, however, if using fewer or less-expensive supplies led to poorer patient outcomes. Or it might mean that exactly the right amount of supplies was used but that the patient census was less than budgeted. To help managers interpret and use variance information better, some institutions use flexible budgets that automatically account for census variances.

Professional organization (association)

Belonging to a professional association not only demonstrates leadership but also provides numerous opportunities to meet other leaders, participate in policy formation, continue specialized education, and shape the future of the profession. Professional associations (organizations) are groups of people who share a set of professional values and who decide to join their colleagues to effect change. Many nursing associations set standards and objectives to guide the profession and specialty practice. Standards can also serve as critical measurements for the profession and its practitioners. In today's changing healthcare environment, increasing numbers of associations are serving unique healthcare interests in society. Although associations have very different agendas and goals, many nursing organizations share the same motivation and long-term goal of uniting and advancing the profession. More than 75 specialty nursing organizations represent nurses in particular areas of the profession. Some are clinically focused, such as the American Association of Critical-Care Nurses, the Oncology Nurses Association, and the American Association of Neuroscience Nurses. Others are role focused, such as the American Organization of Nurse Executives and the National League for Nursing. Still others represent specific groups in nursing, such as the American Assembly for Men in Nursing and the National Black Nurses Association. To attract future members, many specialty organizations offer reduced membership rates to students and new graduates, which include discounted meeting and convention rates, discounts on insurance, networking opportunities, and informative publications and mailings about the association.

Managed Care

Care purchased through a public or private healthcare organization whose goal is to promote quality healthcare outcomes for patients at the lowest cost possible through planning, directing, and coordinating care delivered by healthcare organizations that it may own, have contractual agreements with, or have authority over by virtue of the fact that it reimburses the organization for services provided its patients. This model rewards providers for low utilization of care that is relatively low in cost; also, a system of care in which a designated person determines the services the patient uses. The economic forces of capitated payments and managed care have caused healthcare organizations to reorganize, restructure, and reengineer to decrease waste and economic inefficiency. Many organizations are forming multi-institutional alliances that integrate healthcare systems under a common organizational infrastructure. These alliances are accomplished through acquisitions or mergers. Acquisitions involve one organization directly buying another. Mergers involve combining two or more organizations and their assets to form a new entity. Mergers can also happen within organizations as departments or patient care units come together. People, structure, culture, and political issues or organizational change can be very traumatic and lead to dysfunctional outcomes if it is not managed well.

Spiral

Career Style: Rational, independent responsibility for shaping career -EX: Nurse who returns after raising a family Motivation and Characteristics: -Novelty -Prestige -Intense period of employment followed by non-employment or a different employment -Care for others -Opportunities for self-development -Typically well paid, service-oriented -Recognition Managerial Considerations: -Configure specific job that needs doing -Be flexible about terms and length of commitment -Find challenging initial assignment -Negotiate -Encourage creativity

bureaucracy

Characterized by formality, low autonomy, a hierarchy of authority, an environment of rules, division of labor, specialization, centralization, and control. referred to the centralization of authority in administrative bureaus or government departments. The term has come to refer to an inflexible approach to decision making or an agency encumbered by red tape that adds little value to organizational processes. an administrative concept imbedded in how organizations are structured. The concept arose at a time of societal development when services were in short supply, workers' and clients' knowledge bases were limited, and technologies for sharing information were undeveloped. Characteristics of bureaucracy arose out of a need to control workers and were centered on the division of processes into discrete tasks. organizations could achieve high levels of productivity and efficiency only by adherence to what he called "bureaucracy." Weber believed that bureaucracy, based on the sociological concept of rationalization of collective activities, provided the idealized organizational structure. Bureaucratic structures are formal and have a centralized and hierarchical command structure (chain of command). Bureaucratic structures have a clear division of labor and well-articulated and commonly accepted expectations for performance. Rules, standards, and protocols ensure uniform actions and limit individualization of services and variance in workers' performance. Although bureaucracy enhances consistency, by nature, it limits employee autonomy and thus the potential for innovations and client-centric service.

Creativity

Conceptualizing new and innovative approaches to solving problems or making decisions. essential for the generation of options or solutions. Creative individuals can conceptualize new and innovative approaches to a problem or issue by employing flexible and independent thinking. It takes just one person to plant a seed for new ideas to generate.

delphi technique

Involves systematically collecting and summarizing opinions and judgments on a particular issue from respondents, such as members of expert panels, through interviews, surveys, or questionnaires. Opinions of the respondents are repeatedly reported back to them with a request to provide more refined opinions and rationales on the issue or matter under consideration. Between each round, the results are tabulated and analyzed so that the findings can be reported to the participants. This allows the participants to reconsider their responses. The goal is to achieve a consensus. Different variations on the Delphi technique exist. The procedure includes anonymous feedback, multiple rounds, and statistical analyses. One advantage of this technique is the ability to involve a large number of respondents, because the participants do not need to physically convene. Indeed, participants may be located throughout the country or world. Also, the questionnaire or survey requires little time commitment on the part of the participants. This technique may actually save time because it eliminates the off-the-subject digressions typically encountered in face-to-face meetings. In addition, the Delphi technique prevents the negative or unproductive verbal and nonverbal interactions that can occur when groups work together. Although the Delphi technique has its advantages, using it may result in a lower sense of accomplishment and involvement because the participants are detached from the overall process and do not communicate with each other.

Continuing education

Learning that builds on prior knowledge and experience with the goal of being a more competent professional defined as "systematic professional learning experiences designed to augment the knowledge, skill, and attitudes of nurses, thereby enriching the nurses' contributions to quality health care and their pursuit of professional career goals" In addition to increasing your knowledge base, continuing education provides professional networking opportunities, contributes to meeting certification and licensure requirements, and documents additional pursuits in maintaining or developing clinical expertise. Sponsors of continuing education include employers, professional associations, schools, and private entrepreneurial groups. Both types of formal professional development (i.e., graduate education and continuing education) are valuable, and both can contribute to a specific area of career development—certification.

Texas Board of Nursing

Mission statement: The mission of the Texas Board of Nursing (BON or Board) is to protect and promote the welfare of the people of Texas by ensuring that each person holding a license as a nurse in this state is competent to practice safely. The Board fulfills its mission through the regulation of the practice of nursing and the approval of nursing educational programs. This mission, derived from the Nursing Practice Act, supersedes the interest of any individual, the nursing profession, or any special interest group. Part of the Executive branch of Texas state government Oversee largest number of licensees in the State of Texas ->300,000 nurses TBON members: appointed by the Governor, confirmed by the State Senate; serve 6- year staggered term; TBON members represent nursing practice, education and consumers TBON meetings: held quarterly (Jan., April, July and Oct.); open to the public Receive input from a variety of stakeholders via committees, meetings and hearings.

third-party payers

Organizations that provide financing for health care comprise another subset of supportive and organizations. As noted earlier, the government, through CMS, finances a large portion of the population and represents the largest third-party organization involved in healthcare provision. Private health insurance carriers, who account for most of the remaining financing, are composed of not-for-profit and for-profit components. Commercial insurance companies represent the private sector. Third-party financing organizations have a major effect on the actual delivery of health care. They do so by identifying those procedures, tests, services, or drugs that will be covered under their healthcare insurance programs. In addition, they indirectly affect the configuration of the healthcare delivery system through the use of their significant political influence. As the cost of health care increases and the number of medically uninsured and underinsured grows, pressure increases for significant changes in healthcare reimbursement. Under the Affordable Care Act of 2010, reconfiguration of the current system is certain to bring with it restructuring of the organizations responsible for delivery of healthcare services. Private insurance; Health Maintenance Organizations (HMO); Preferred Provider Organizations (PPO); Independent Practice Associations (IPA) Federal Government: Medicare, Medicaid Federal government is the primary payer of healthcare costs in the US! Fee-for-Service Capitation Discounting/cost-shifting

Accreditation

Process by which an authoritative body determines that an organization meets certain standards to such a degree that the organization is able to meet the standards as a whole and without ongoing monitoring of each aspect of performance. refers to the approval, recognition, or certification by an official review board that an organization has met certain standards. CMS is responsible for the enforcement of its standards through its certification activities. For a healthcare organization to participate in and receive payment from either Medicare or Medicaid, the organization must be certified as complying with the CoP. One manner that an organization can be recognized as complying with the CoP is through a survey process conducted by a state agency on behalf of CMS. Alternatively, an organization can be surveyed and accredited by a national accrediting body holding "deeming authority" for CMS. To obtain deeming authority, an accreditation organization must undergo a comprehensive evaluation by CMS to ensure that the standards of the accrediting organization are at least as rigorous as CMS standards. Another characteristic that can be used to distinguish one organization from another is whether a healthcare organization has been accredited by an external body as having the structure and process necessary to provide high-quality care. Private organizations play significant roles in establishing standards and ensuring care delivery compliance with standards by accrediting healthcare organizations. Examples of these organizations are The Joint Commission and The National Committee for Quality Assurance (NCQA). The Joint Commission provides accreditation programs for ambulatory care, behavioral health care, acute care and critical access hospitals, laboratory services, long-term care, and hospital-based surgery. The NCQA is a non-profit organization that accredits, certifies, and recognizes a wide variety of healthcare organizations, services, and providers. Accrediting Bodies: -The Joint Commission (TJC) -American Osteopathic Association (AOA) -Det Norske Vetias (DNV) Centers for Medicare and Medicaid (CMS) -"deeming authority" - approved for payment from Medicare or Medicaid (TJC, AOA, DNV)

mission

The mission statement defines the organization's reason or purpose for being. The mission statement identifies the organization's customers (individuals, families, populations, or communities) and the types of services offered, such as outreach, comprehensive care management, acute care, rehabilitation, or home care. It enacts the vision statement. The mission statement sets the stage by defining the services to be offered, which, in turn, identify the kinds of technologies and human resources to be employed. The mission statement of accountable care organizations (a group of providers and healthcare organizations who are organized to give comprehensive, coordinated care focused on improving patient outcomes) are focused on providing comprehensive coordinated care in order to improve the health and well-being of a group of individuals. Hospitals' missions are primarily treatment-oriented; the missions of ambulatory care group practices combine treatment, prevention, and diagnosis-oriented services; long-term care facilities' missions are primarily maintenance and social support-oriented; and the missions of nursing centers are oriented toward promoting optimal health status for a defined group of people. The definition of services to be provided and the implications for technologies and human resources greatly influence the design of the organizational structure, that is, the arrangement of the work group. Nursing, as a profession providing a service within a healthcare agency, formulates its own mission statement that describes its contributions to achieve the agency's mission. One of the purposes of the nursing profession is to provide nursing care to patients. The statement should define nursing based on theories that form the basis for the model of nursing to be used in guiding the process of nursing care delivery. Nursing's mission statement tells why nursing exists within the context of the organization. This statement is written so that others within the organization can know and understand nursing's role in achieving the agency's mission. The mission should be the guiding framework for decision making. It should be known and understood by other healthcare professionals, by patients and their families, and by the community. It indicates the relationships among nurses and patients, other personnel in the organization, the community, as well as health and illness. The mission provides direction for the evolving statement of philosophy and the organizational structure. It should be reviewed for accuracy and updated routinely. Various work units that provide specific services such as intensive care, women's health services, or hospice care may also formulate mission statements that detail their specific contributions to the overall organization.

nursing care delivery models

The process of a nurse coordinating health care by planning, facilitating, and evaluating interventions across levels of care to achieve measurable cost and quality outcomes. is the method used to provide care to patients. Because nursing care is viewed primarily as a cost rather than a source of revenue, institutions evaluate their method of providing patient care for the purpose of saving money, while still providing quality care. In this chapter, various models of nursing care delivery are discussed, including the case method (total patient care), functional nursing, team nursing, primary nursing including hybrid forms, and nursing case management. In addition, the influence of differentiated nursing practice, Transforming Care at the Bedside, and transitional care models are introduced. Each nursing care delivery model has advantages and disadvantages, and no single method is ideal. Managers in any organization must examine the organizational goals, the unit objectives, patient population, staff availability, and the budget when selecting a care delivery model. Historical overviews of the common care models are designed to convey the complexity of how care is delivered. This perspective is important because each of these approaches is still used within the broad range of healthcare organizations. In addition, these models often serve as the foundation for new innovative care delivery models.

staffing

Three issues arise under the general term staffing. These include (1) maintaining adequate numbers of staff members in a time of advancing patient acuity and limited resources; (2) floating staff from one unit to another; and (3) using temporary or "agency" staff to augment the healthcare facility's current staffing. Though each area is addressed separately, common to all three of these staffing issues is the requisite of collaboration among nurse managers in addressing the needs for the entire institution or healthcare agency. Accreditation standards, specifically those of TJC and the Community Health Accreditation Program (CHAP), as well as other state and federal standards, mandate that healthcare institutions provide adequate staffing with qualified personnel. This applies not only to the number of staff but also to the legal status of the staff. For instance, some areas of an institution, such as critical care areas, postanesthesia care areas, and emergency care centers, must have greater percentages of RNs than LPNs/LVNs. Other areas, such as the general nursing areas and some long-term care areas, may have equal or lower percentages of RNs to LPNs/LVNs or nursing assistants. Whether understaffing exists in a given situation depends on the number of patients, care acuity scores, and number and classification of staff. Courts determine whether understaffing existed on an individual case basis. Federal legislation regarding safe staffing was first introduced during the 2007-2008 legislative session by Senator Daniel Inouye and Representative Lois Capps. Defeated in that session, the legislation was reintroduced in subsequent legislative sessions. In 2011, it was again introduced as the Registered Nurse Safe Staffing Act of 2011 and included such provisions as a required public reporting of staffing information, a procedure for receiving and investigating complaints, and allowing the imposition of civil monetary penalties for each known violation. Because staffing has major implications for quality, legislation likely will be introduced and refined over several sessions.

philosophy

a written statement that articulates the values and beliefs held about the nature of the work required to accomplish the mission and the nature and rights of both the people being served and those providing the service. A nursing philosophy states the vision of what nursing practice should be within the organization and how it contributes to the health of individuals and communities. For example, the organization's mission statement may incorporate the provision of individualized care as an organizational purpose. The philosophy statement would then support this purpose through an expression of a belief in the responsibility of nursing staff to act as patient advocates and to provide quality care according to the wishes of the patient, family, and significant others. Philosophies are evolutionary in that they are shaped both by the social environment and by the stage of development of professionals delivering the service. Nursing staff reflect the values of their time. The values acquired through education are reflected in the nursing philosophy. Philosophies require updating to reflect the extension of rights brought about by such changes.

Resume

are customized documents that relate to the qualifications of a specific organizational position and help create an image of you serving in that position. Unlike the CV, a résumé provides details. It is presented in sentences or phrases (not both) to share the value of the information. For example, rather than listing years of service in a position by title and organization, a résumé might include information that you served as the only nurse to provide some distinctive service. For the experienced nurse, a résumé could be used to reflect increasing skills and abilities; for the new nurse, it could focus on specific "extra" abilities (e.g., competencies) that are not normally expected of a new graduate. The résumé is a better choice than a CV for advertising your skills and talents to a prospective employer. Because a résumé is brief (typically no more than two pages) and tailored to the position being sought, the information is pointed toward specific position requirements. Details and action words help the reader view you as accomplishing important work. Verbs that relate to outcomes (produced, created) are the most powerful in conveying your achievements. Basically, résumés can be produced in two ways. One is conventional, and it provides chronological information about positions and activities. The other approach, called functional, may combine multiple positions into role areas you are trying to highlight. So, rather than using experience as a heading (as in a conventional résumé), the functional résumé heading may relate to writing or client education and describe how you achieved results across several positions. A functional approach is best if you are planning a sharp departure from your present position or if you have considerable experience before entering nursing. The focus is on experience in diverse roles/positions rather than the specific positions held. As with the CV, your résumé should be error-free, grammatically correct, accurate, and logical. Both of these documents should be printed on high-quality paper. Electronic résumés are best sent as a pdf or image file so that no distortion in the design or layout can occur. This is also a universally accepted electronic format, so recipients should have no difficulty opening the attachment. Bringing a résumé to an interview is especially useful if you were asked previously to provide a CV. This additional work of applying your talents to the specific position in the résumé helps the interviewer see you as fitting in the organization.

values

are the connecting thoughts and inner driving forces that give purpose, direction, and precedence to life priorities. An organization, through its members, shares collective values that are expressed through its mission, philosophy, and practices. Leaders influence decision making and priority setting as an expression of their values. People (either patients or peers being influenced by the leader) also use their values to achieve their goals, which are then manifested through behavior. The word value connotes something of worth; intentional actions reflect our values. A leader continuously clarifies and acknowledges the values that draw attention to a problem and the resources in human and material terms to solve it. Values are powerful forces that promote acceptance of change and drive achievement toward a goal.

systems theory

attempts to explain productivity in terms of a unifying whole as opposed to a series of unrelated parts Systems can be either closed (self-contained) or open (interacting with both internal and external forces). In systems theory, a system is described as comprising four elements: structure, technology, people, and their environment. Systems theorists focus on the interplay among these elements in a framework of (1) inputs—resources such as people, money, or materials; (2) throughputs—the processes that produce a product from the inputs; and (3) outputs—the product of inputs and throughputs. The theoretical concepts of systems theory have been applied to nursing and to organizations. Systems theory presents an explanation of organizational evolution that is similar to biological evolution. Systems theory produces a model that explains the process of healthcare organization evolution The survival of the organization, as portrayed throughout this chapter, depends on its evolutionary response to changing environmental forces; it is seen as an open system. The response to environmental changes brings about internal changes, which produce changes that alter environmental conditions. The changes in the environment, in turn, act to bring about changes in the internal operating conditions of the organization. A very simplified example of this can be seen in the implementation of the prospective payment system that was caused by the economic driving force of escalating healthcare costs in the 1990s. Ambulatory surgery, same-day admissions, and hospital- and community-based home care organizations are some of the internal healthcare organization changes that resulted from an environmentally driven policy change—the cap that was placed on reimbursing expenses incurred by hospitalized patients. These internal organizational developments placed pressure on the external environment to create mechanisms to respond to increasing percentages of the population with self-care deficits who were returning to the community. This open systems approach to organizational development and effectiveness emphasizes a continual process of adaptation of healthcare organizations to external driving forces and a response to the adaptations by the external environment, which generates continuing inputs for further healthcare organization development. This open system is in contrast to a closed system approach that views a system as being sufficient unto itself and thus untouched by what happens around it. Structure, technology, people, environment Inputs, throughputs, outputs Open and closed systems • Definition: A system comprises four elements (structure, technology, people, and environment) forming a unified whole • Viewed as inputs, throughputs, and outputs • Closed systems—self-contained • Open systems—interacting with internal and external forces

brainstorming

can be an effective method for generating a large volume of creative options. Often, the premature critiquing of ideas stifles creativity, idea generation, and innovation. When members use inflammatory statements, euphemistically referred to as killer phrases, the usual response is for members to stop contributing. Some killer phrases are "It will never work," "Administration won't go for it," "What a dumb idea," "It's not in the budget," "If it ain't broke, don't fix it," and "We tried that before." The hallmark of effective brainstorming is to list all ideas as stated without critique or discussion. The group leader or facilitator should encourage people to build upon or spin off ideas from those already suggested. One idea may be piggybacked on others. Ideas should not be judged, nor should the relative merits or disadvantages of the ideas be discussed while brainstorming. The goal is to generate ideas, no matter how seemingly unrealistic or absurd. It is important for the group leader or facilitator to cut off criticism and be alert for nonverbal behaviors signaling disapproval. Because the emphasis is on the volume of ideas generated, not necessarily the quality, solutions may be superficial and fail to solve the problem. Group brainstorming also takes longer, and the logistics of getting people together may pose a problem. If the facilitator allows the group to establish the rules for discussion, the aspects that impede open discussion often are eliminated by the group's norms or agreements of participation.

Curriculum vitae

is the documentation of one's professional life. It is designed to be all-inclusive but not detailed. A curriculum vitae follows some designated flow of information reflective of the ten categories 1. Education Name of school, address, phone numbers, Website address, years of attendance, date of graduation, name of degree(s) received, minor earned, honors received (e.g., Dean's List) 2. Continuing education Dates attended, places, topics and any special outcomes, type and amount of credit earned 3. Experience Dates of employment, title of position, name of employing agency, location and phone numbers, Website address, name of chief executive officer, chief nursing officer, immediate supervisor, salary range, typical duties (role description) 4. Community/institutional service Dates of service, name of committee/task force and the parent organization (e.g., name of hospital or professional organization), your role on the committee (e.g., chairperson, secretary, member), general description of committee's functions, any distinctive accomplishments 5. Publications Articles: author(s) name(s), year of publication, title, journal, volume, issue, pages; books: author(s), year of publication, title, location and name of publisher 6. Honors Date, description of award, special factors related to award (e.g., competitive, community-wide, national) 7. Research Date, title of research, role in research (e.g., principal investigator, co-investigator, team member), funded/unfunded 8. Speeches/presentations given Date, title of speech presented, place, name of sponsoring organization, nature of the presentation (e.g., keynote, concurrent session) 9. Workshops/conferences presented Date, title of workshop/conference presented, place, name of sponsoring group and nature of the presentation, brief description of the activity 10. Certification Initial date of certification, expiration date, certifying body, area/type of certification

moral distress

most often occurs when faced with situations in which two ethical principles compete, such as when the nurse is balancing the patient's autonomy issues with attempting to do what the nurse knows is in the patient's best interest. Moral distress may occur also when the nurse manager is balancing a direct care nurse's autonomy with what the nurse manager perceives to be a better solution to an ethical dilemma. Though the dilemmas are stressful, nurses must make decisions and implement those decisions. Seen as a major issue in nursing today, moral distress is experienced when nurses cannot provide what they perceive to be best for a given patient. Examples of moral distress include constraints caused by financial pressures, limited patient care resources, disagreements among family members regarding patient interventions, and/or limitations imposed by primary healthcare providers. Moral distress may also be experienced when actions nurses perform violate their personal beliefs. The impact of moral distress can be quite serious. Moral distress compromises patient care and that moral distress may be manifested in such behaviors as avoiding or withdrawing from patient care situations. Additional behaviors include failure to act as a patient advocate, which often further contributes to patient discomfort and suffering. The Literature Perspective gives additional information about the seriousness of moral distress and risk factors for ethical issues in clinical practice.

privacy

patient's right to protection against unreasonable and unwarranted interference with his or her solitude This right extends to protection of the person's reputation as well as protection of one's right to be left alone. Within a medical context, the law recognizes the patient's right to protection against (1) appropriation of the patient's name or picture for the institution's sole advantage, (2) intrusion by the institution on the patient's seclusion or affairs, (3) publication of facts that place the patient in a false light, and (4) public disclosure of private facts about the patient by the hospital or staff.

whistle blowing

the disclosure of information regarding misconduct within a workplace that either is illegal or endangers the welfare of others an employer may not discharge an employee if it would violate the state's public policy doctrine or a state or federal statute Several recent court cases attest to the number of terminations in healthcare settings that serve as retaliation for the employer. More commonly known as whistle-blowing cases, the healthcare provider in these cases is terminated for one of three distinct reasons: (1) speaking out against unsafe practices, (2) reporting violations of federal laws, or (3) filing lawsuits against employers. Essentially, whistleblower laws state that no employer can discharge, threaten, or discriminate against an employee regarding compensation, terms, conditions, location, or privileges of employment because the employee in good faith reported or caused to be reported, verbally or in writing, what the employee had a reasonable cause to believe was a violation of a state or federal law, rule, or regulation. Most whistleblowers are internal, that is they report misconduct to a fellow employee or supervisor within the agency. External whistleblowers are those who report misconduct to outside persons or entities.

SWOT analysis

the individual or team lists the Strengths, Weaknesses, Opportunities, and Threats related to the situation under consideration. Strengths and weaknesses are internal to the individual, group, or organization, whereas the opportunities and threats are external factors Strengths • Familiar with the healthcare system • Clinically competent and has received favorable performance appraisals • Good communication skills; well liked by her peers • Recently completed 12-lead electrocardiogram (ECG) interpretation class Weaknesses • Has not attended the critical care class • Has had a prior unresolved conflict with one of the surgeons who frequently admits to the intensive care unit (ICU) • Is uncertain whether she wants to work full-time, 12-hour shifts Opportunities • Anticipated staff openings in the ICU in the next several months • Critical care course will be offered in 1 month • Advanced cardiac life support (ACLS) course is offered four time a year • A friend who already works in ICU has offered to mentor her Threats • Possible bed closures in another critical care unit may result in staff transfers, thus eliminating open positions • Another medical-surgical nurse is also interested in transferring

assignment

the transfer of both the accountability and the responsibility from one person to another. This is typically what happens between professional staff members. The nurse manager assigns patient care responsibilities to other professional nurses working in the same unit of the institution or community healthcare setting. The level of accountability for the nurse manager who assigns as opposed to delegates is fairly obvious, although some accountability can occur in both instances. The degree of knowledge concerning the skills and competencies of those one supervises is of paramount importance. The doctrine of respondeat superior has been extended to include "knew or should have known" as a legal standard in both assigning and delegating tasks to individuals whom one supervises. If it can be shown that the nurse manager assigned/delegated tasks appropriately and had no reason to believe that the nurse to whom tasks were assigned/delegated was not competent to perform the task, the nurse manager potentially has no or minimal personal liability. The converse is also true; if it can be shown that the nurse manager was aware of incompetence in a given employee or that the assigned/delegated task was outside the employee's capabilities, the nurse manager becomes substantially liable for the subsequent injury to a patient.

Delegation

used throughout all of nursing history, has evolved into a complex, work-enhancing strategy that has the potential for varying levels of legal liability. Before the early 1970s, nurses used delegation to direct the multiple tasks performed by the various levels of staff members in a team-nursing model. Subsequently, the concept of primary nursing and assignment became the desirable nursing model in acute care settings, with the focus on an all-professional staff, requiring little delegation but considerable assignment of duties. By the mid-1990s, a nursing shortage had again shifted the nursing model to a multilevel staff, with the return of the need for delegation. Nurse managers need to know certain definitions regarding this area of the law. Delegation involves at least two people, a delegator and a delegatee, with the transfer of authority to perform some type of task or work. A working definition could be that delegation is the transfer of responsibility for the performance of an activity from one individual to another, with the delegator retaining accountability for the outcome. In other words, delegation involves the transfer of responsibility for the performance of tasks and skills without the transfer of accountability for the ultimate outcome. Examples include an RN who delegates patients' personal care tasks to certified nursing aides who work in a long-term care setting. In delegating these tasks, the RN retains the ultimate accountability and responsibility for ensuring that the delegated tasks are completed in a safe and competent manner. Typically, delegation involves the tasks and procedures that are given to unlicensed assistive personnel, such as certified nursing aides, orderlies, assistants, attendants, and technicians. However, delegation can also occur with licensed to licensed staff members. For example, if one RN has the accountability for an outcome and asks another RN to perform a specific component of the overall function, that is delegation. This is typically the type of delegation that occurs between professional staff members when one member leaves the unit/work area for a meal break. Delegation is complex because it involves the delegation relationship and communication. It also involves trusting others, because both the delegator and the delegatee have shared accountability for certain tasks and duties. Interventions are needed to improve this relationship and communication effectiveness, which directly affects the quality of competent care delivery. Multiple players, usually with varying degrees of education and experience and different scopes of practice, are involved in the process. Understanding these variances and communicating effectively to the delegatee involve an understanding of competencies and the ability to communicate with all levels of staff personnel.

coercive power

Stems from fear of someone's real or perceived fear of another person. A nurse who lacks confidence in her performance in a new position is worried about an upcoming review with the nursing director.

Developing Trust

Gardener's Goals Keeping promises to patients and families; being honest in role performance Sharing organizational information openly; being honest in role performance Representing nursing and executive views openly and honestly; being honest in role performance A hallmark task of leadership is to behave with consistency so that others believe in and can count on the leader's intentions and direction. Trust develops when leaders are clear with others about this direction, and the way to achieve high performance is through building on strengths and mitigating poor performance. Inherent in this concept is the behavior of truth telling. Although leaders cannot always share all information, it is unwise to misdirect others in their thinking and actions. Trust, according to Lencioni's (2002) classic work, is the key component of a team. Without it, the team is dysfunctional. Trustworthiness is reflected in actions and communications.

chaos theory

Unpredictable and random environment Self-organizing and adapting if want to survive Constant change, little long-term stability Unfortunately, health care as an industry is not always as predictable and orderly as systems theorists would have us believe. In contrast to the somewhat orderly universe described in systems theory, in which an organization can be viewed in terms of a linear, cause-and-effect model, chaos theory sees the universe as filled with unpredictable and random events. According to the proponents of chaos theory, organizations must be self-organizing and adapt readily to change in order to survive. Organizations, therefore, must accept that change is inevitable and unrelenting. When one embraces the tenets of chaos theory, one gives up on any attempt to create a permanent organizational structure. Using creativity and flexibility, successful managers will be those who can tolerate ambiguity, take risks, and experiment with new ideas in response to each day's unique situation or environment. They will not rest upon a successful transition or organizational model because they know the environment that it flourished in is fleeting. The successful nurse leaders will be those individuals who are committed to lifelong learning and problem solving. Definition: The universe is chaotic and requires organizations to be self-organizing and adaptive to survive • Viewed as unpredictable and random events • Constant change resulting in little long-term stability

quantum theory

foundation was based on a rapidly changing dynamic environment; it does not represent one event and at its very foundation is connectedness. Porter-O'Grady and Malloch (2011) identified qualities for nurse leaders such as self-awareness, vision, and empathy that are grounded in the complexity of quantum theory leadership. These authors suggest that a team player knows that the greatest outcome is achieved from the sum of small acts or parts and uses an analytical approach to view problems as opportunities. Flexibility is key for the leader in striving for win-win solutions. Nurse leaders today must serve as quantum leaders embracing uncertainty and seeking to understand behaviors and relationships before attempting to change them. Now, when new nurses enter the workforce with enormous technologic demands for their knowledge and skills, it is up to the nurse leader to help foster their growth and their comfort with flexibility and the unknown. Quantum leaders are change catalysts and innovators. They are also transformational, and as such they must be courageous. Developing courage has never been more needed in health care than it is today. Having the courage and ability to own one's opinions and to stand up when it is more popular not to is a hallmark of great leadership and a trait of a quantum leader.

ethics

science relating to moral actions and moral values; rules and conduct recognized in respect to a particular class of human actions -Codes of Ethics -Ethical Decision Making -Moral Distress -Ethics committees Leaders and Managers: Some ethical dilemmas for nurse leaders and managers: -limited physical, human and financial resources -increasing technology -regulatory pressures -competition an area of professional practice in which nurse managers should have a solid foundation, because it is becoming increasingly more prominent in clinical practice settings. However, it remains an area in which many nurses feel the most inadequate. This is partially because ethics is much more nebulous than are laws and regulations. In ethics, no right and wrong answers are possible, just better or worse answers, and nurses seek mentorship and counseling from nurse managers when they encounter difficult situations. Thus nurse managers must have a deep understanding of ethical principles and their application. Ethics may be distinguished from the law because ethics is internal to an individual, looks to the ultimate "good" of an individual rather than society as a whole, and concerns the "why" of one's actions. The law, comprising rules and regulations pertinent to society as a whole, is external to oneself and concerns one's actions and conduct. Ethics concerns the individual within society, whereas law concerns society as a whole. Law can be enforced through the courts, statutes, and boards of nursing, whereas ethics is enforced via ethics committees and professional codes. Today, ethics and legal issues often become entwined, and it may be difficult to separate ethics from legal concerns. Legal principles and doctrines assist the nurse manager in decision making; ethical theories and principles are often involved in those decisions. Thus the nurse manager must be cognizant of both laws and ethics in everyday management concerns, remembering that ethical principles form the essential base of knowledge from which to proceed, rather than giving easy, straightforward answers.

developing expertise

As noted earlier in this chapter, expertise is one of the bases of power. Developing expertise in nursing is an important power strategy. Nursing expertise must not be limited to clinical knowledge. Leadership and communication skills, for example, are essential to the effective exercise of power. Education and practice provide the means for developing such expertise in any domain of nursing—clinical practice, education, research, and management. Developing expertise expands one's power among nursing colleagues, other professional colleagues, and patients. A high level of expertise can make one nearly indispensable within an organization. This is a powerful position to have within any organization, whether it is the workplace or a professional association. A high level of expertise can also lead to a high level of visibility within an organization.

Collegiality and Collaboration

Developing a sense of unity requires each nurse to act collaboratively and collegially in the workplace and in other organizations (e.g., professional associations). Collegiality demands that nurses value the accomplishments of nursing colleagues and express a sincere interest in their efforts. Turning to one's colleagues for advice and support empowers them and expands one's own power base at the same time. Unity of purpose does not contradict diversity of thought. One does not have to be a friend to everyone who is a colleague. Collegiality demands mutual respect, not friendship. Collaboration and collegiality require that nurses work collectively to ensure that the voice of nursing is heard in the workplace and the legislature. Volunteer to serve on committees and task forces in the workplace, not only within the nursing department but also on organization-wide committees. Become an active member of nursing organizations, especially state nursing organizations and specialty organizations consistent with one's clinical specialty (e.g., AACN) or functional role (e.g., American Organization of Nurse Executives [AONE]). If eligible, become a member of a chapter of Sigma Theta Tau International, nursing's honor society. Get involved in the politics of organizations, in the workplace, and in professional associations. If the workplace uses shared governance or other participatory models, get involved in these councils, committees, task forces, and work groups to share your energy, ideas, and expertise. Many organizations have interdisciplinary committees that bring together nurses, physicians, and other healthcare professionals to improve the quality of professional collaboration and the quality of patient care. Become an active, productive member of such groups within the workplace and in the professional associations and community groups dealing with healthcare issues and problems.

Barriers to Leadership

False Assumptions: Some people have false assumptions about leaders and leadership. For example, some believe that position and title are equivalent to leadership. Having the title of Chief Executive Officer or Chief Nursing Officer does not guarantee that a person will be a good leader. Consequently, a good executive is not necessarily a good leader. Furthermore, assuming a management or administrative role does not automatically confer the title of leader on an individual. Inspired and forward-moving organizations often select these executives specifically because of their ability to forge a vision and lead others toward it. Leadership is an earned honor and an action-oriented responsibility. Others believe that workers who do not hold official management positions cannot be leaders. Some nursing units are managed by the nurse manager but led by the unit clerk. Leaders are those who do the best job of sharing their vision of where the followers want to be and how to get there. Many new nurse managers make the mistake of assuming that along with their new job comes the mantle of leadership. Leadership is an earned right and privilege. Time Constraints: Leadership requires a time commitment; it does not just happen. The leader must fully comprehend the situation at hand, investigate and research options for action, assume the responsibility to communicate the vision to others, and continually reevaluate the organization or the team to ensure that the vision remains relevant and attainable. All of these activities take time. The twenty-first century has been described as the period of doing more with less. Everyone is busy. Finding time to lead is, therefore, a barrier for many who have inspirational ideas but lack time to develop the skills needed to lead effectively. Leadership Development: Leadership effectiveness depends on mastering the art of persuasion and communication. Success depends on persuading followers to accept a vision by using convincing communication techniques and making it possible for the followers to achieve the shared goals. Several important leadership tasks, when used effectively, will help ensure success

referent power

Granted by association with a powerful person. A graduating senior nursing student asks a well-respected nurse manager to be her preceptor for the senior leadership course. The student wants to work in this agency upon graduation.

Leadership

Leadership is an ANA Standard of Practice Standard 12: The registered nurse demonstrates leadership in the professional practice setting and the profession not an optional activity the process of engaged decision making linked with actions taken in the face of complex, unchartered, or perilous circumstances in clinical situations for which no standardized solution exists the ability to influence others toward accomplishing common goals The problem facing healthcare organizations is that they are overmanaged and underfed Theories and approaches: -trait theories -style theories -situational-continugency theories -servant leadership -transactional and transformation theories -complexity theory Attributes: -Positive energy and stamina -Critical thinker and effective decision maker -Use facts/ evidence to enhance intuition -Responsible for actions—take credit when actions don't produce desired outcomes -Give credit to others when actions result in desired outcomes -Humble -Coach and mentor others -Trustworthy and respectful -Life-long learners; continually engage in self-renewal -Synergistic—see that whole is greater than the sum of the parts -Service-oriented -Competent and confident -Concerned with the common good -Believe in others -Lead balanced lives and view life as an adventure Responsibilities/Tasks: -Envision goals/ visioning -Affirm values -Motivate -Manage -Achieve workable unity/ healthy work environments -Develop trust -Explain/ communicate -Serve as symbol -Represent the group -Renew Leader/ Leadership Outcomes -Staff satisfaction -Reduced staff turnover -Increased feelings of staff empowerment -Enhanced communication & intraprofessional collaboration -Patient satisfaction -Patient safety - continuity of care Leader Development: -Find a mentor -Lead by example -Accept responsibility -Share rewards -Have a clear vision -Be willing to grow can be defined as the use of individual traits and abilities, in relationship with others, and the ability to (often rapidly) interpret the environment/context where a situation is emerging, and enter that situation in the absence of a script or defined plan that could have been projected. Leadership is required when the unknown presents itself, necessitates the use of principles to improvise solutions, and helps others to cope, thrive, and function at a high capacity based on the situation. Key traits that leaders possess include articulating a vision for the desired future state; seeing possibilities in this midst of challenging, often complex, uncharted, or even dire circumstances; communicating effectively, sometimes powerfully, with others; adapting to new situations and environments; and using experience and knowledge to judge reasonable risks.

Follower Traits

Perceives the needs of both the leader and other staff Demonstrates cooperative and collaborative behaviors Exerts the power to communicate through various channels Remains fully accountable for actions while relinquishing some autonomy and conceding certain authority to the leader Exhibits willingness to both lead and follow peers, as the situation warrants, allowing for competency-based leadership Assumes responsibility to understand what risks are acceptable for the organization and what risks are unacceptable

liability

Personal -accountability for one's own actions Vicarious (substituted) - employers accountable for the negligence of their employees Corporate - institution has responsibility and accountability for maintaining an environment that ensures quality care and competent staff All Nurses Nurses have increased liability because they: -have more authority and independent decision making than ever before -have increased legal accountability for decision making -do more interventions that used to be in realm of medicine -make more money -carry malpractice insurance—a good thing! Leaders/Managers -Delegation -Supervision -Duty to orient, educate and evaluate -Failure to warn (addictions, violent behavior, incompetency) -Staffing issues -Competency ensured/ documented

follower

Responsibilities/Tasks: Demonstrate accountability for work within system and team Implement standards and processes for safe patient care Offer knowledge, skills and abilities to complete work Collaborate with leaders and managers—avoid negativity and passive-aggressive behaviors Seek evidence for work activities Take reasonable risks Evaluate efficiency and effectiveness of systems and processes Give and receive constructive feedback to promote nurturing and generative culture Outcomes: -Effective team functioning -Safe patient care -Healthy work environments

D

The director of critical care nursing services has been observing staff interactions in a 20-bed intensive care unit. Based on her observations, which of the following staff members is an obvious leader? A. The unit secretary who knows everyone's business. B. The chief nursing officer who is in charge and is responsible for nursing services. C. The intensivist who manages the medical care for all critical patients in the unit. D. The staff nurse who persuades other staff members to practice by making evidence-based decisions.

Situational-Contingency Theories

Theorists emerged in the 1960s and early 1970s to mid-1970s. These theorists believed that leadership effectiveness depends on the relationship among (1) the leader's task at hand, (2) his or her interpersonal skills, and (3) the favorableness of the work situation. Three factors are critical: (1) the degree of trust and respect between leaders and followers, (2) the task structure denoting the clarity of goals and the complexity of problems faced, and (3) the position power in terms of where the leader was able to reward followers and exert influence. Consequently, leaders were viewed as able to adapt their style according to the presenting situation. The Vroom-Yetton model was a problem-solving approach to leadership. Path-Goal theory recognized two contingent variables: (1) the personal characteristics of followers and (2) environmental demands. On the basis of these factors, the leader sets forth clear expectations, eliminates obstacles to goal achievements, motivates and rewards staff, and increases opportunities for follower satisfaction based on effective job performance. The most important implications for leaders are that these theories consider the challenge of a situation and encourage an adaptive leadership style to complement the issue being faced. In other words, nurses must assess each situation and determine appropriate action based on the people involved.

Leader Traits

Values commitments, relationships with others, and esprit de corps in the organization Provides a vision that can be communicated and has a long-term effect on the organization that moves it in new directions Communicates the rationale for changing paths; charts new paths that lead to progress Endorses and thrives on taking risks that bring about change Demonstrates a positive feeling in the workplace and relates the importance of workers

Networking

an important power strategy and political skill A network is the result of identifying, valuing, and maintaining relationships with a system of individuals who are sources of information, advice, and support. Networking supports the empowerment of participants through interaction and the refinement of their interpersonal skills. Many nurses have relatively limited networks within the organizations where they are employed. They tend to have lunch or coffee with the people with whom they work most closely. One strategy to expand a workplace network is to have lunch or coffee with someone from another department, including managers from non-nursing departments, at least two or three times a month. Active participation in nursing organizations is the most effective method of establishing a professional network outside one's place of employment. Although only a minority of nurses actively participate in professional organizations, such participation can propel a nurse into the politics of nursing, including involvement in shaping health policy. State nurses' associations offer excellent opportunities to develop a network that includes nurses from various clinical and functional areas Membership in specialty organizations, including organizations for nurse managers and executives, provides the opportunity to network with nurses with similar expertise and interests. In addition, membership in civic, volunteer, and special interest groups and participation in educational programs (e.g., formal academic programs and conferences) also provide networking opportunities. Use of social media, like LinkedIn and Twitter, also can expand one's professional network around the globe. The nurse must be cautious to avoid mixing one's personal life and professional life in social media. The successful networker identifies a core of networking partners who are particularly skilled, insightful, and eager to support the development of colleagues. These colleagues need to be nurtured through such strategies as sharing information with them that relates to their interests; introducing them to persons who have comparable interests or who are connected with others of influence; staying connected through notes, e-mail, phone calls, social media, or text messages; and meeting them at important events. Successful networkers are not a burden to others in making requests for support, and they do not refuse the support that is provided.

complexity theory

is important because it is a nontraditional theory, emerging from the work of physical sciences and, more recently, social sciences. Classic physical and, now, organizational sciences developed theory based on assumptions that by reducing something into its component parts it could be better understood. Think of the learning that took place in biology through the process of dissection. Organizations are sometime referenced as silos; like dissection, each has been organized by functional clusters (radiology, laboratory, nutrition, nursing, and medical services, for instance). Complexity science promotes the idea that the world is full of patterns that interact and adapt through relationships. These interactive patterns can be missed when one focuses solely on the part, so complexity scientists pay keen attention to what naturally occurs as patterns in the universe and how these patterns create adaptive change rather than planned or forced change. Stated in nursing terms, professional nurses can care for individual patients repeatedly, whereas each patient is a unique challenge. But with time and perspective, patterns emerge and nurses learn that these patterns lead to ways to control pain, engage family members in care at the end-of-life, and address a host of other issues. As healthcare providers are very focused on problems and predictable solutions, it is possible that reframing care to build on an individual, family, or community strengths presents quite a different perspective that unleashes solutions to complex problems and shifts human energy toward a positive outcome. Therefore complexity science expands the repertoire of nursing actions to include strategies that are multidimensional and with a different patient or organizational view. In adaptive leadership, consistent with the definition of leadership provided earlier, the goal in responding to patient and organizational problems is to examine a problem through a different lens. This view might examine the "whole" that includes potential threats, exposes conflict, or challenges norms as part of the art of improvising change. An adaptive leader understands that systems are ecological—they restore themselves—and that change can happen equally from the bottom up or from the top down. One leads by entering the stream, not observing it and sitting off to the side to critique it. Questioning, observing patterns, and generating new patterns through being involved is how change unfolds. Imagine the power of social networking where no top-down leader exists. Rather, a series of powerful interactions and messages constantly shift to first re-create reality and then major social change. Adaptive leaders appreciate that they have influence and can help shape direction, with no sense that absolute control is either necessary or possible. In complexity theory, traditional organizational hierarchy plays a less significant role as the "keeper of high-level knowledge." It is replaced with decision making distributed among the human assets within an organization without regard to hierarchy. Less time is spent trying to control the future (which is not predictable anyway), and more time is spent moving toward and into energy while influencing, innovating, and responding to the many factors that are influencing health care. In complexity science, every voice counts and every encounter with patients and families emerge to co-create a desired outcome.

fidelity

means keeping one's promises or commitments. Nurse managers abide by this principle when they follow through on any promises they have previously made to employees, such as a promised leave, a certain shift to be worked, or a promotion to a preceptor position within the unit.