NUR 168: CONCEPTS 3: CHAPTER 10: LEADING, MANAGING, DELEGATING:

Leadership Styles: Quantum:

- A Textbook of New Leadership, argued that leaders must move beyond the traditional modes used by all levels of workers. - They, like others, focused on the impact of the information age, identified at the turn of the century, on work and workers. - The vertical command and control structures that generated the leadership styles previously mentioned are no longer useful for managers and workers, nor do they yield productivity for organizations. - The explosion of information and technology in health care, as in other industries, has spawned, by necessity, the "knowledge worker." - This social transformation is affecting aspects of all of our lives, including, perhaps most importantly, how we lead and manage our organizations. - We are in a difficult transition period between the old and the new. In the old, change was viewed as an entity to be planned, carefully managed, and accepted. In the new "quantum age," change is conceived as dynamic, ever present, and continually unfolding. - We are forced to experience change at the same time we perceive it, with little or no opportunity to definitively and laboriously plan and manage it. - Quantum leadership theory views an organization and its members as interconnected and collaborative—a helpful approach when unpredictable events and changing environments present themselves - Nursing leaders can model these new behaviors by combining these new attributes with the requisite technical skills.

Leadership Styles: Autocratic:

- Also called directive leadership or authoritarian leadership, involves the leader assuming control over the decisions and activities of the group. - It is often an efficient process, yet many people may resent this leadership approach when used regularly. - Staff and team members have limited opportunity to contribute suggestions and participate in organizational decisions. - High staff turnover and burnout are more common with this style of leadership. - Many experienced nurses are used to working under autocratic leaders because this approach was used in most hospitals in earlier years. - Although some health care workers still respond best to the directive approach, this style of leadership is gradually being replaced by the democratic style of leadership as nurses demand and receive more say in decision making. - Some situations may require an autocratic leadership style. For example, Nurse A discovers that one of her patients is bleeding excessively from his surgical incision. She knows that he needs immediate attention, so she gives specific orders to another team member to attend to the other patients. She tells the RN on her team to call the surgical resident to come as soon as possible. She implements a nursing care plan to prevent further blood loss or complications. Nurse A assumed the autocratic style of leadership in this situation so that all necessary tasks would be accomplished immediately. Although she rarely uses this style, she implemented it effectively in this emergency situation. This example illustrates that leadership is context dependent.

Leadership Styles: Laissez-Faire:

- Also called non-directive leadership, the leader relinquishes power to the group, such that an outsider could not identify the leader in the group. - This approach encourages independent activity by group members. - This style depends on the strengths of followers to direct the group activities. - It is most effective when all staff are clinical experts with a deep understanding of both clinical and administrative processes. - This style is rarely useful because task achievement is difficult when each nurse is working independently, and the staff on most units and departments have varying levels of clinical maturity. - However, it can be used effectively when the leader wants a problem to be solved completely by expert staff group members.

Leadership Styles: Democratic:

- Also called participative leadership, is characterized by a sense of equality among the leader and other participants. - Decisions and activities are shared. - Participants are encouraged to develop their skills and strengths within the group. - The group and leader work together to accomplish mutually set goals and outcomes. - As professionals, nurses generally respond well to this style of leadership when they are the followers and feel more comfortable when they are the leaders of democratic groups. - Group satisfaction and motivation are excellent benefits of this style. In situations in which a rapid response is essential, however, a democratic approach to leadership that requires gathering the input of team members may slow decision making. - An example: Nurse B, a head nurse, observes that staff members have not been documenting patient teaching and learning in their progress notes. Nurse B is not sure why this is occurring but believes that this problem must be solved. He calls a staff meeting and leads a discussion to seek information on possible causes and solutions. Nurse B decides that staff members need to be included in the problem-solving approach. He thinks the staff will be more motivated to document their teaching and the patients' learning if they have a say in what changes in practice are necessary and how they will be implemented. Nurse B has used the democratic style of leadership and decentralized decision-making process to resolve this issue.

Developing Leadership Responsibilities: Preceptorship:

- Alternative model for leadership training - The preceptor (experienced nurse) is selected (usually paid) to introduce an employee to new responsibilities through teaching/guidance. - This orientation ensured that the new RN gains appropriate knowledge, skills, support to care for patients safely and efficiently. - Preceptors also assist new RNs to learn policies/procedures of a new facility

Conflict Resolution Strategies: Smoothing:

- An effort to compliment the other party and focus on agreement rather than disagreement, this reduces the emotion in the conflict. - The original conflict is rarely resolved with this.

Leadership Styles:

- Autocratic - Democratic - Laissez-faire - Servant - Quantum - Transactional - Transformational

Conflict Resolution Strategies:

- Avoiding - Collaborating - Competing - Compromising - Cooperating/accommodating - Smoothing

Leadership Styles: Transformational:

- Can create revolutionary change. - Often described as charismatic, transformational leaders are unique in their ability to inspire and motivate others. - They create intellectually stimulating practice environments and challenge themselves and others to grow personally and professionally, and to learn. - Gifted in creating a common vision, they demonstrate passion for their vision and keep others similarly focused. - One of the unique qualities of transformational leaders is their vulnerability. - They communicate honestly and openly, and can express emotions as well as ideas as they share themselves with others. - They show concern and care for others and are willing to take risks. They pay attention to process as well as outcomes. - An example of transformational leadership is as follows. Nurse C is troubled by the plight of women and children in the inner city where she lives. She unites with other nurses and health care professionals to design and implement strategies to meet their needs. Within 18 months, a nursing center is funded and running, improving maternal-child outcomes in the area. The founding group of health care professionals continues to meet monthly to dream about future strategies and to support each other in their work. They are proudest of the improved self-esteem and independence in many of the women they serve. - Transformational leaders have a positive and compelling vision, fostering a new culture for nursing practice and patient care. - This style of leadership is a key component of organizations that achieve Magnet status.

Lewin's Theory Of Change: Refreezing:

- Change becomes operational

Lewin's Theory Of Change: Moving:

- Change is initiated after a careful process of planning

Leadership Qualities:

- Charismatic - Dynamic - Enthusiastic - Poised - Confident - Self-directed - Flexible - Knowledgeable - Politically aware

Leadership Skills:

- Commitment to excellence - Problem-solving skills - Commitment to and passion for one's work - Trustworthiness and integrity - Respectfulness - Accessibility - Empathy and caring - Responsibility to enhance personal growth of all staff - Do not technical skills with nursing leadership

Steps For Using Time Effectively:

- Establish goals and priorities for each day. - Evaluate goals in terms of your ability to meet needs of patients. - Establish a time line. - Evaluate your success or failure in managing time. - Use these results to direct your next day's priorities and time line.

Overcoming Resistance To Change:

- Explain proposed change to all affected. - List the advantages of the change. - Relate the change to the person's existing beliefs and values. - Provide opportunities for open communication and feedback. - Indicate how change will be evaluated. - Introduce change gradually. - Provide incentives for commitment to change

Conflict Resolution Strategies: Compromising:

- For this to be effective, both parties must be willing to relinquish something of equal value. - If that doesn't occur, either or both parties may feel that they have lost the conflict and given up more than the other group

Achieving Self-Knowledge:

- Identify your strengths. - Evaluate how you accomplish work. - Clarify your values. - Determine where you belong and what you can contribute. - Assume responsibility for relationships. - Self-evaluation, how you make improvements

Factors Prompting Change in Health Care Industry:

- Increased number of chronically ill and older people - Increased role of government and industry in health care - Rising cost of health care - Changing patterns of health care delivery

Developing Leadership Responsibilities: Mentorship:

- Is a relationship in which an experienced person (the mentor) advises/assists a less experienced person (protege). - Effective way of easing a new nurse into leadership responsibilities. - Mentors link with proteges by common interest and provide support, information, network links. - Relationship does not include financial reward - Mentors should be excellent role models.

Leadership Styles: Transactional:

- Is based on a task-and-reward orientation. - Team members agree to a satisfactory salary and working conditions in exchange for commitment and compliance to their leader. - Health care organizations have often used transactional leadership strategies to provide direction and recognize employees' progress in meeting pre-established goals and work deadlines. - Transactional leaders maintain control by rewarding good behavior and punishing behavior they perceive as detrimental or negative. - Employees have minimal opportunities for creative thinking and involvement in organizational decisions, and employer and employee may not share a common vision. - Transactional leaders provide little inspiration for nurses to participate in reforming health care, problem solving, or engaging in practices and research that promote nursing excellence

Leadership Styles: Servant:

- It's a philosophy and set of practices that enriches the lives of individuals, builds better organizations, and ultimately creates a more just and caring world. - It begins with the natural feeling that one wants to serve. - Greenleaf recognized that, although some prize leadership because of their love for power and material possessions, others aspire to leadership because of wanting to serve. "The difference manifests itself in the care taken by the servant first to make sure that other people's highest priority needs are being served. The best test, and most difficult to administer, is: Do those served grow as people? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants? And what is the effect on the least privileged in society? Will they benefit or at least not be further deprived?" - Relationships are the key to successful servant leadership. - It is easy to see why many nurses find servant leadership a great fit with nursing values, roles, and responsibilities. Fahlberg and Toomey believe that many of the best nursing leaders practice servant leadership. "We lead, speak up, volunteer, and advocate because it is the right thing to do. We want to make something better. We see a wrong and we want to make it right, so we do something. - Soon, others join in, becoming leaders as they learn and grow through their service"

Conflict Resolution Strategies: Collaborating:

- Joint effort to resolve the conflict with a win-win solution. - All parties set aside previously determined goals, determine a priority common goal, and accept mutual responsibility for achieving this goal. - This focus on problem solving is based on mutual respect, honest communication, and shared decision making

Developing Leadership Responsibilities: Nursing Organizations:

- Leaders address special interests, goals, and purposes, as well as advocate for the nursing profession. - Ex: ANA, AACN, etc.

Conflict Resolution Strategies: Cooperating/Accommodating:

- One party makes a conscious decision to let the other group win and may collect an "IOU" for use in the future. - This party's original loss may result in a more positive outcome in the future.

Considerations When Delegating Nursing Care:

- Patient's condition - Complexity of the activity - Potential for harm - Degree of problem solving and innovation necessary - Level of interaction required with the patient - Capabilities of the UAP - Availability of professional staff to accomplish workload

Role Of Nurse Manager:

- Planning: Identifying problems/developing goals, objectives, related strategies to meet the demands of clinical arena. - Organizing: acquiring, managing, mobilizing resources to meet both clinical/financial objectives - Staffing: Hiring, orienting, scheduling to facilitate team building; also includes staff development - Directing: Leading others in achieving goals within the constraints of current fiscal/workforce shortage scenarios, a demanding task for managers/staff. - Controlling: Implementing mechanisms for ongoing evaluation, particularly in areas of clinical quality and financial accountability. - Can't maintain both clinical and manager roles to be effective

Clinical Nurse Leader Role:

- Position was created by the American Association of Colleges of Nursing (AACN) as a leadership role. - The CNL works collaboratively with the health care team to facilitate, coordinate, and oversee patient care. - The CNL should be able to clearly communicate with other health care professionals, integrate evidence-based practices into patient care, and evaluate patient risks and outcomes. - The person-centered focus of the CNL role includes functioning as a patient advocate, educator, and provider of patient care in complex situations.

Developing Leadership Responsibilities: Continuing Education:

- Programs developing leadership, courses to improve care. Required to renew RN license.

Planned Change:

- Purposeful, systematic effort to bring about a change. - Nurse managers most often implement these

Factors to Consider Prior to Delegating Patient Care:

- Qualifications and capabilities of the UAP - Stability of the patient condition - Complexity of the activity to be delegated - The potential for harm - The predictability of the outcome - The overall context of other patient needs

Factors Increasing The Power Base Of Nursing:

- Right timing: Consumers and legislators are frustrated with errors reported in the health care system, the number of uninsured people, and overall problems with the health care system in the U.S. Nurses, as the most respected health care providers, are poised to help improve health care and implement health care reform. - Size of the nursing profession: This is one of nursing's greatest assets, with at least 3.6 million RNs in the U.S. Nurses are an impressive voting bloc - Nursing's referent power: The public has expressed a high degree of trust and credibility in the nursing profession - Increasing knowledge base and education for nurses: More nurses are assuming advanced practice roles and nursing graduates are strongly encouraged to achieve higher levels of education - Nursing's unique perspective: The caring component of nursing coupled with evidence-based practice and critical thinking has positioned nurses to deliver complex care to a variety of patients and positively affect quality of care. - Desire of consumers and providers for change: Consumers are increasingly aware of the needs for accessible, affordable, and safe quality care.

Lewin's Theory Of Change: Unfreezing:

- The need for change is recognized

ANA Principles for Delegating Care:

- The nursing profession determines the scope of nursing practice. - The nursing profession defines and supervises UAPs involved in providing direct nursing care. - The RN is responsible and accountable for nursing practice. - The RN supervises any assistant providing direct patient care. - The purpose of UAP is to work in supportive role to the RN.

Conflict Resolution Strategies: Avoiding:

- There is awareness of the conflict situation, but the parties involves decide to either ignore the conflict, or avoid, or postpone its resolution. - Conflict has not been resolved and may resurface later in an exaggerated form.

Conflict Resolution Strategies: Competing:

- This approach results in a win for one party at the expense of the other group. - This win-lose confrontation can leave the loser frustrated, with a desire to "get even" in the future - This strategy may be used when one party has more knowledge regarding the situation, or when resistance is appropriate bc of ethical concerns or unsafe patient care practices.

Reasons For Resistance To Change:

- Threat to self - Lack of understanding - Limited tolerance for change - Disagreements about the benefits of change - Fear of increased responsibility

5 Model Components Of Magnent Status:

- Transformational leadership - Structural empowerment - Exemplary professional practice - New knowledge, innovation, and improvements - Empirical quality results

Considerations For Planned Change:

- What is amenable to change?: Considering this question may reveal a behavior not amenable to change - How does the group function as a unit?: Certain forces within a group may favor change, whereas other forces may resist it. - Is the group ready for change and at what rate?: The pace of change must be consistent with the person's/group's readiness to assimilate change. Readiness involves both the ability and willingness to change. In contemporary health care organizations, change is dynamic, persistent, and very challenging. The concept of flexibility previously mentioned is put to a real test in any clinical/managerial arena. - Are the changes major or minor?: A series of small changes may be more easily accomplished than one large, dramatic change. The nursing leader/manager must support the staff during the difficult task of acquiring new skills and frequently new professional identities. - How will the change effect a person?

Management Structures: Decentralized:

-Decisions are made by those who are most knowledgeable about the issues being decided. -Nurses are thus intimately involved in decisions concerning patient care.

5 Key Practices For Servant Leaders:

1. Develop your vision. 2. Listen and learn before speaking and acting. 3. Envision and invest in others' greatness. 4. Give away your power. 5. Build community by developing strategic relationships.

Planned Change: 8 Step Process:

1. Recognize symptoms that indicate a change is needed and collect data. 2. Identify a problem to be solved through change: Analyze the symptoms and reach a conclusion. Note resistance or barriers to change and factors that promote the desired change. 3. Determine/analyze alternative solutions to the problem: Consider the advantages, disadvantages, consequences of each alternative. An analysis of various proposed solutions to a problem may result in using a combination of alternatives. 4. Select a course of action from possible alternatives: Avoid initiating too many courses of action and thereby dissipating resources and energy 5. Plan for making the change: CRUCIAL to effect change successfully. Start by stating specific objectives, designing a plan for change, developing timetables, selecting people to assist with making the change, and anticipating how to stabilize change and deal with resistance to change. Unless a plan is clearly designed, effecting change is likely to be a chaotic experience. 6. Implement the selected course of action to effect change: Put the plan for change into effect. During this period, flexibility is important to adapt to unforseseen problems. 7. Evaluate the effects of change by comparing them with objectives stated in the plan for change: Adjustments can be made in the plan as necessary after evaluation. If the results of evaluation indicate that the course of action selected to solve a problem has been unsuccessful, an adjustment should be made or another course of action selected. 8. Stabilize the change: When a solution has been found, take measures to make the change permanent. Continue follow-up until change is firmly established.

2. A nurse who is newly hired to manage a busy pediatric office is encouraged to use a transactional leadership style when dealing with subordinates. Which activities best exemplify the use of this type of leadership? Select all that apply. A) The manager institutes a reward program for employees who meet goals and work deadlines. B) The manager encourages the other nurses to participate in health care reform by joining nursing organizations. C) The manager promotes compliance by reminding subordinates that they have a good salary and working conditions. D) The manager makes sure all the employees are kept abreast of new developments in pediatric nursing. E) The manager works with subordinates to accomplish all the nursing tasks and goals for the day. F) The manager allows the other nurses to set their own schedules and perform nursing care as they see fit.

A) The manager institutes a reward program for employees who meet goals and work deadlines. C) The manager promotes compliance by reminding subordinates that they have a good salary and working conditions.

9. A nurse is using time management techniques when planning activities for patients. Which nursing action reflects effective time management? A) The nurse asks patients to prioritize what they want to accomplish each day B) The nurse includes a "nice to do" for every "need to do" task on the list C) The nurse "front loads" the schedule with "must do" priorities D) The nurse avoids helping other nurses if scheduling does not permit it

A) The nurse asks patients to prioritize what they want to accomplish each day

4. A nurse is a servant leader working in an economically depressed community to set up a free mobile health clinic for the residents. Which actions by the leader BEST exemplify a key practice of servant leaders? Select all that apply A) The nurse motivates coworkers to solicit funding to set up the clinic. B) The nurse sets only realistic goals that are present oriented and easily achieved. C) The nurse forms an autocratic governing body to keep the project on track. D) The nurse spends time with supporters to help them grow in their roles. E) The nurse first ensures that other's lowest priority needs are served. F) The nurse prizes leadership because of the need to serve others.

A) The nurse motivates coworkers to solicit funding to set up the clinic. D) The nurse spends time with supporters to help them grow in their roles. F) The nurse prizes leadership because of the need to serve others.

Which style of leadership describes a nurse leader who assumes control over the decisions and activities of the group? A. Autocratic leadership B. Democratic leadership C. Laissez-faire leadership D. Transformational leadership

Answer: A. Autocratic leadership

It is increasingly difficult for the nurse manager to be both a clinical and managerial expert. A. True B. False

Answer: A. True Rationale: It is increasingly difficult for the nurse manager to be both a clinical and managerial expert.

A good example of explicit power is a class bully who gets his way by intimidating his classmates. A. True B. False

Answer: B. False Rationale: A good example of implied power is a class bully who gets his way by intimidating his classmates.

6. A nurse manager who is attempting to institute the SBAR process to communicate with health care providers and transfer patient information to other nurses is meeting staff resistance to the change. Which action would be most effective in approaching this resistance? A) Containing the anxiety in a small group and moving forward with the initiative B) Explaining the change and listing the advantages to the person and the organization C) Reprimanding those who oppose the new initiative and praising those who willingly accept the change D) Introducing the change quickly and involving the staff in the implementation of the change

B) Explaining the change and listing the advantages to the person and the organization

10. A new nurse manager at a small hospital is interested in achieving Magnet status. Which action would help the hospital to achieve this goal? A) Centralizing the decision-making process B) Promoting self-governance at the unit level C) Deterring professional autonomy to promote teamwork D) Promoting evidence-based practice over innovative nursing practice

B) Promoting self-governance at the unit level

1. A charge nurse in a busy hospital manages a skilled nursing unit using an autocratic style of leadership. Which leadership tasks BEST represent this style of leadership? Select all that apply. A) The charge nurse polls the other nurses for input on nursing protocols. B) The charge nurse dictates break schedules for the other nurses. C) The charge nurse schedules a mandatory in-service training on new equipment. D) The charge nurse allows the other nurses to divide up nursing tasks. E) The charge nurse delegates nursing responsibilities to the staff. F) The charge nurse encourages the nurses to work independently.

B) The charge nurse dictates break schedules for the other nurses. C) The charge nurse schedules a mandatory in-service training on new equipment. E) The charge nurse delegates nursing responsibilities to the staff.

5. A nurse manager is attempting to update a health care provider's office from paper to electronic health records (EHR) by using the eight-step process for planned change. Place the following actions in the order in which they should be initiated: A) The nurse devises a plan to switch to EHR. B) The nurse records the time spent on written records versus EHR. C) The nurse attains approval from management for new computers. D) The nurse analyzes all options for converting to EHR. E) The nurse installs new computers and provides an in-service for the staff. F) The nurse explores possible barriers to changing to EHR. G) The nurse follows up with the staff to check compliance with the new system. H) The nurse evaluates the effects of changing to EHR

B) The nurse records the time spent on written records versus EHR. F) The nurse explores possible barriers to changing to EHR. D) The nurse analyzes all options for converting to EHR. C) The nurse attains approval from management for new computers. A) The nurse devises a plan to switch to EHR. E) The nurse installs new computers and provides an in-service for the staff. H) The nurse evaluates the effects of changing to EHR G) The nurse follows up with the staff to check compliance with the new system.

8. An RN on a surgical unit is behind schedule administering medications. Which of the RN's other tasks can be safely delegated to a UAP? A) The assessment of a patient who has just arrived on the unit B) Teaching a patient with newly diagnosed diabetes about foot care C) Documentation of a patient's I & O on the flow chart D) Helping a patient who has recently undergone surgery out of bed for the first time

C) Documentation of a patient's I & O on the flow chart

3. A nurse manager of a busy cardiac unit observes disagreements between the RNs and the LPNs related to schedules and nursing responsibilities. At a staff meeting, the manager compliments all the nurses on a job well done and points out that expected goals and outcomes for the month have been met. The nurse concludes the meeting without addressing the disagreements between the two groups of nurses. Which conflict resolution strategy is being employed by this manager? A) Collaborating B) Competing C) Compromising D) Smoothing

D) Smoothing

7. A nurse is asked to act as a mentor to a new nurse. Which nursing action is related to this process? A) The nurse mentor accepts payment to introduce the new nurse to his or her responsibilities B) The nurse mentor hires the new nurse and assigns duties related to the position C) The nurse mentor makes it possible for the new nurse to participate in professional organizations D) The nurse mentor advises and assists the new nurse to adjust to the work environment of a busy emergency department

D) The nurse mentor advises and assists the new nurse to adjust to the work environment of a busy emergency department

Developing Leadership Responsibilities:

Developing leadership at any level, nursing student to clinical leader, first must use skill of self-evaluation. - Mentorship - Preceptorship - Nursing organizations - Continuing education

Significance Of Magnent Status:

Empowerment to: -Attract and retain top talent -Improve care, safety, and satisfaction -Foster a collaborative culture -Advance nursing standards and practice -Grow business and financial success

Types Of Power:

Explicit: power by virtue of position Implied: power due to other factors, such as personality

Management Structures: Centralized:

Senior managers generally make decisions with little input from the group.

Lewin's Theory Of Change:

Unfreezing: The need for change is recognized. Moving: Change is initiated after a careful process of planning. Refreezing: Change becomes operational. Ex: Not too long ago, childbirth in the U.S was routinely medicalized. Women came to the hospital to deliver their babies; pain medications that interfered with the natural process of labor were routinely administered, necessitating forceps and assisted deliveries; husbands/siblings were banished from delivery room. The nurse midwives and others recognized the need for change (EXAMPLE OF UNFREEZING) and set about researching childbirth and ways to improve infant and family outcomes. After a careful process of planning (EXAMPLE OF MOVING), multiple natural childbirth options in health care facilities and in the home were made available to women and couples; today they represent mainstream care (REFREEZING)