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Essentials of Nursing Leadership and Management

SIXTH EDITION

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Essentials of Nursing Leadership and Management

SIXTH EDITION

Sally A. Weiss, MSN, EdD, RN, CNE, ANEF Professor of Nursing

Nova Southeastern University Nursing Department Fort Lauderdale, Florida

Ruth M. Tappen, EdD, RN, FAAN Christine E. Lynn Eminent Scholar and Professor

Florida Atlantic University College of Nursing Boca Raton, Florida

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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2015 by F. A. Davis Company Copyright © 2015, 2010, 2007, 2004, 2001, 1998 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor, Nursing: Megan Klim Developmental Editor: Laurie Sparks Director of Content Development: Darlene D. Pedersen Content Project Manager: Echo Gerhart Electronic Project Editor: Katherine Crowley Design and Illustration Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recommended treat- ments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from appli- cation of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infre- quently ordered drugs. Library of Congress Control Number: 2014945714 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rose- wood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Report- ing Service is: 978-0-8036-3663-7/15 0 + $.25.

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v

Dedication

To my granddaughter Sydni and my grandson Logan, who remind me how important it is to nurture our young nurses

and help them learn and grow. —SALLY A. WEISS

To students, colleagues, family, and friends, who have taught me so much about leadership.

—RUTH M. TAPPEN

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Preface

We are delighted to bring our readers this Sixth Edition of Essentials of Nursing Leadership and Management. This new edition has been updated to reflect the dynamic health care environment, safety initiatives, and changes in nursing practice. As in our previous editions, the content, examples, and diagrams were designed with the goal of assisting the new graduate to make the transition to professional nursing practice.

The Sixth Edition of Essentials of Nursing Leadership and Management focuses on the necessary knowledge and skills needed by the staff nurse as an integral member of the interprofessional health- care team and manager of patient care. Issues related to setting priorities, delegation, quality improve- ment, legal parameters of nursing practice, and ethical issues are updated for this edition.

This edition focuses on the current quality and safety issues and initiatives impacting the current health-care environment. We continue to bring you comprehensive, practical information on develop- ing a nursing career. Updated information on leading, managing, followership, and workplace issues continue to be included.

Essentials of Nursing Leadership and Management provides a strong foundation for the beginning nurse leader. We would like to thank the people at F. A. Davis for their assistance and our contribu- tors, reviewers, and students for their guidance and support.

—SALLY A. WEISS —RUTH M. TAPPEN

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Contributor PATRICIA BRADLEY, MED, PHD, RN Coordinator, Internationally Educated Nurses Program Faculty, Nursing Department York University Toronto, Ontario, Canada

Reviewers

WENDY GREENSPAN, MSN, RN, CCRN, CNE Assistant Professor Rockland Community College Suffem, New York

PAULA HOPPER, MSN, RN, CNE Professor of Nursing Jackson Community College Jackson, Mississippi

CLAIRE MEGGS, MSN, RN Associate Professor Lincoln Memorial University Harrogate, Tennessee

LUISE SPEAKMAN, PHD, RN Adjunct Faculty, Nursing Cape Cod Community College West Barnstable, Massachusetts

JENNIFER SUGG, RN, BSN, MSN, CCRN Nursing Instructor Wayne Community College Goldsboro, North Carolina

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Table of Contents

unit 1 Professional Considerations 1 chapter 1 Leadership and Followership 3 chapter 2 Manager 17 chapter 3 Nursing Practice and the Law 27 chapter 4 Questions of Values and Ethics 49

unit 2 Working Within an Organization 69 chapter 5 Organizations, Power, and Empowerment 71 chapter 6 Communicating With Others and Working

With the Interprofessional Team 87 chapter 7 Delegation and Prioritization of Client Care 103 chapter 8 Dealing With Problems and Conflict 121 chapter 9 People and the Process of Change 133

unit 3 Career Considerations 145 chapter 10 Issues of Quality and Safety 147 chapter 11 Promoting a Healthy Work Environment 173

unit 4 Professional Issues 203 chapter 12 Your Nursing Career 205 chapter 13 Evolution of Nursing as a Profession 225 chapter 14 Looking to the Future 235

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xii ■ Table of Contents

Appendices appendix 1 Codes of Ethics for Nurses 247

American Nurses Association Code of Ethics for Nurses Canadian Nurse Association Code of Ethics for Registered Nurses The International Council of Nurses Code of Ethics for Nurses

appendix 2 Standards Published by the American Nurses Association 249

appendix 3 Guidelines for the Registered Nurse in Giving, Accepting, or Rejecting a Work Assignment 251

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unit 1 Professional Considerations

chapter 1 Leadership and Followership

chapter 2 Manager

chapter 3 Nursing Practice and the Law

chapter 4 Questions of Values and Ethics

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chapter 1 Leadership and Followership

OBJECTIVES After reading this chapter, the student should be able to: ■ Define the terms leadership and followership. ■ Discuss the importance of effective leadership and

followership for the new nurse. ■ Discuss the qualities and behaviors that contribute to

effective leadership. ■ Discuss the qualities and behaviors that contribute to

effective followership. OUTLINE Leadership Are You Ready to Be a Leader? Leadership Defined What Makes a Person a Leader? Leadership Theories

Trait Theories Behavioral Theories

Task Versus Relationship Motivation Theories Emotional Intelligence Situational Theories Transformational Leadership Moral Leadership Caring Leadership

Qualities of an Effective Leader Behaviors of an Effective Leader Followership Followership Defined Becoming a Better Follower Managing Up Conclusion

Nurses study leadership to learn how to work well with other people. We work with an extraordinary variety of people: technicians, aides, unit managers, housekeepers, patients, patients’ families, physi- cians, respiratory therapists, physical therapists, social workers, psychologists, and more. In this chapter, the most prominent leadership theories are introduced. Then, the characteristics and behaviors that can make you, a new nurse, an effective leader and follower are discussed.

Leadership

Are You Ready to Be a Leader? You may be thinking, “I’m just beginning my career in nursing. How can I be expected to be a leader now?” This is an important question. You will need time to refine your clinical skills and learn how to function in a new environment. But you can begin to assume some leadership functions right away within your new nursing roles. In fact, leadership should be seen as a dimension of nursing practice (Scott & Miles, 2013). Consider the following example:

Billie Thomas was a new staff nurse at Green Valley Nursing Care Center. After orientation, she was assigned to a rehabilitation unit with high ad- mission and discharge rates. Billie noticed that admissions and discharges were assigned rather hap- hazardly. Anyone who was “free” at the moment was directed to handle them. Sometimes, unlicensed as- sistant personnel were directed to admit or discharge residents. Billie believed that this was inappropriate because they are not prepared to do assessments and they had no preparation for discharge planning.

Billie had an idea how discharge planning could be improved but was not sure that she should bring it up because she was so new. “Maybe they’ve already thought of this,” she said to a former classmate. They began to talk about what they had learned in their leadership course before graduation. “I just keep hearing our instructor saying, ‘There’s only one manager, but anyone can be a leader.’ ”

“If you want to be a leader, you have to act on your idea. Why don’t you talk with your nurse manager?” her friend asked.

“Maybe I will,” Billie replied. Billie decided to speak with her nurse manager,

an experienced rehabilitation nurse who seemed not

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only approachable but also open to new ideas. “I have been so busy getting our new electronic health record system on line before the surveyors come that I wasn’t paying attention to that,” the nurse manager told her. “I’m glad you brought it to my attention.”

Billie’s nurse manager raised the issue at the next executive meeting, giving credit to Billie for having brought it to her attention. The other nurse manag- ers had the same response. “We were so focused on the new electronic health record system that we overlooked that. We need to take care of this situa- tion as soon as possible. Billie Thomas has leadership potential.”

Leadership Defined Successful nurse leaders are those who engage others to work together effectively in pursuit of a shared goal. Examples of shared goals in nursing would be providing excellent care, reducing infec- tion rates, designing cost-saving procedures, or challenging the ethics of a new policy.

Leadership is a much broader concept than is management. Although managers need to be leaders, management itself is focused specifically on achievement of organizational goals. Leadership, on the other hand:

. . . occurs whenever one person attempts to influence the behavior of an individual or group—up, down, or sideways in the organization—regardless of the reason. It may be for personal goals or for the goals of others, and these goals may or may not be congru- ent with organizational goals. Leadership is influ- ence (Hersey & Campbell, 2004, p. 12).

In order to lead, one must develop three important competencies: (1) diagnose: ability to understand the situation you want to influence, (2) adapt: make changes that will close the gap between the current situation and what you are hoping to achieve, and (3) communicate. No matter how much you diag- nose or adapt, if you cannot communicate effec- tively, you will probably not meet your goal (Hersey & Campbell, 2004).

What Makes a Person a Leader?

Leadership Theories There are many different ideas about how a person becomes a good leader. Despite years of research on this subject, no one idea has emerged as the clear

winner. The reason for this may be that different qualities and behaviors are most important in dif- ferent situations. In nursing, for example, some situations require quick thinking and fast action. Others require time to figure out the best solution to a complicated problem. Different leadership qualities and behaviors are needed in these two instances. The result is that there is not yet a single best answer to the question, “What makes a person a leader?”

Consider some of the best-known leadership theories and the many qualities and behaviors that have been identified as those of the effective nurse leader (Pavitt, 1999; Tappen, 2001):

Trait Theories At one time or another, you have probably heard someone say, “She’s a born leader.” Many believe that some people are natural leaders, while others are not. It is true that leadership may come more easily to some than to others, but everyone can be a leader, given the necessary knowledge and skill.

An important 5-year study of 90 outstanding leaders by Warren Bennis published in 1984 identi- fied four common traits. These traits hold true today:

1. Management of attention. These leaders communicated a sense of goal direction that attracted followers.

2. Management of meaning. These leaders created and communicated meaning and purpose.

3. Management of trust. These leaders demonstrated reliability and consistency.

4. Management of self. These leaders knew themselves well and worked within their strengths and weaknesses (Bennis, 1984).

Behavioral Theories The behavioral theories focus on what the leader does. One of the most influential behavioral theo- ries is concerned with leadership style (White & Lippitt, 1960) (Table 1-1).

The three styles are:

1. Autocratic leadership (also called directive, controlling, or authoritarian). The autocratic leader gives orders and makes decisions for the group. For example, when a decision needs to be made, an autocratic leader says, “I’ve decided that this is the way we’re going to solve our

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chapter 1 ■ Leadership and Followership 5

problem.” Although this is an efficient way to run things, it squelches creativity and may reduce team member motivation.

2. Democratic leadership (also called participative). Democratic leaders share leadership. Important plans and decisions are made with the team (Chrispeels, 2004). Although this appears to be a less efficient way to run things, it is more flexible and usually increases motivation and creativity. In fact, involving team members, giving them “permission to think, speak and act” brings out the best in them and makes them more productive, not less (Wiseman & McKeown, 2010, p. 3). Decisions may take longer to make, but once made everyone supports them (Buchanan, 2011).

3. Laissez-faire leadership (also called permissive or nondirective). The laissez-faire (“let someone do”) leader does very little planning or decision making and fails to encourage others to do it. It is really a lack of leadership. For example, when a decision needs to be made, a laissez- faire leader may postpone making the decision or never make the decision at all. In most instances, the laissez-faire leader leaves people feeling confused and frustrated because there is no goal, no guidance, and no direction. Some mature, self-motivated individuals thrive under laissez-faire leadership because they need little direction. Most people, however, flounder under this kind of leadership.

Pavitt summed up the differences among these three styles: a democratic leader tries to move the group toward its goals; an autocratic leader tries to move the group toward the leader’s goals; and a

laissez-faire leader makes no attempt to move the group (1999, pp. 330ff ).

Task Versus Relationship Another important distinction is between a task focus and a relationship focus (Blake, Mouton, & Tapper, 1981). Some nurses emphasize the tasks (e.g., administering medication, completing patient records) and fail to recognize that interpersonal relationships (e.g., attitude of physicians toward nursing staff, treatment of housekeeping staff by nurses) affect the morale and productivity of employees. Others focus on the interpersonal aspects and ignore the quality of the job being done as long as people get along with each other. The most effective leader is able to balance the two, attending to both the task and the relationship aspects of working together.

Motivation Theories The concept of motivation seems simple: we will act to get what we want but avoid whatever we don’t want to do. However, motivation is still sur- rounded in mystery. The study of motivation as a focus of leadership began in the 1920s with the historic Hawthorne studies. Several experi- ments were conducted to see if increasing light and, later, improving other working conditions would increase the productivity of workers in the Haw- thorne, Illinois, electrical plant. This proved to be true, but then something curious happened: when the improvements were taken away, the workers continued to show increased productivity. The researchers concluded that the explanation was found not in the conditions of the experiments but in the attention given to the workers by the experimenters.

table 1-1

Comparison of Autocratic, Democratic, and Laissez-Faire Leadership Styles Autocratic Democratic Laissez-Faire

Amount of freedom Little freedom Moderate freedom Much freedom Amount of control High control Moderate control Little control Decision making By the leader Leader and group together By the group or by no one Leader activity level High High Minimal Assumption of responsibility Leader Shared Abdicated Output of the group High quantity, good quality Creative, high quality Variable, may be poor quality Efficiency Very efficient Less efficient than autocratic style Inefficient

Source: Adapted from White, R.K., & Lippitt, R. (1960). Autocracy and democracy: An experimental inquiry. New York: Harper & Row.

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Frederick Herzberg and David McClelland also studied factors that motivated workers in the work- place. Their findings are similar to the elements in Maslow’s Hierarchy of Needs. Table 1-2 summa- rizes these three historical motivation theories that continue to be used by leaders today (Herzberg, 1966; Herzberg, Mausner, & Snyderman, 1959; Maslow, 1970; McClelland, 1961).

Emotional Intelligence The relationship aspects of leadership are also the focus of the work on emotional intelligence and leadership (Goleman, Boyatzes, & McKee, 2002). From the perspective of emotional intelligence, what distinguishes ordinary leaders from leadership “stars” is that the “stars” are consciously addressing the effect of people’s feelings on the team’s emo- tional reality.

How is this done? First, the emotionally intel- ligent leader recognizes and understands his or her own emotions. When a crisis occurs, he or she is able to manage them, channel them, stay calm and clearheaded, and suspend judgment until all the facts are in (Baggett & Baggett, 2005).

Second, the emotionally intelligent leader welcomes constructive criticism, asks for help when needed, can juggle multiple demands with- out losing focus, and can turn problems into opportunities.

Third, the emotionally intelligent leader listens attentively to others, recognizes unspoken concerns, acknowledges others’ perspectives, and brings people together in an atmosphere of respect, coop- eration, collegiality, and helpfulness so they can direct their energies toward achieving the team’s goals. “The enthusiastic, caring, and supportive leader generates those same feelings throughout the team,” wrote Porter-O’Grady of the emotionally intelligent leader (2003, p. 109).

Situational Theories People and leadership situations are far more complex than the early theories recognized. Situa- tions can also change rapidly, requiring more complex theories to explain leadership (Bennis, Spreitzer, & Cummings, 2001).

Instead of assuming that one particular approach works in all situations, situational theories recog- nize the complexity of work situations and encour- age the leader to consider many factors when deciding what action to take. Adaptability is the key to the situational approach (McNichol, 2000).

Situational theories emphasize the importance of understanding all the factors that affect a par- ticular group of people in a particular environment. The most well-known is the Situational Leader- ship Model by Dr. Paul Hersey. The appeal of this model is that it focuses on the task and the follower.

table 1-2

Leading Motivation Theories Theory Summary of Motivation Requirements

Maslow, 1954 Categories of Need: Lower needs (listed first below) must be fulfilled before others are activated. Physiological Safety Belongingness Esteem Self-actualization

Herzberg, 1959 Two factors that influence motivation. The absence of hygiene factors can create job dissatisfaction, but their presence does not motivate or increase satisfaction.

1. Hygiene factors: Company policy, supervision, interpersonal relations, working conditions, salary 2. Motivators: Achievement, recognition, the work itself, responsibility, advancement

McClelland, 1961

Motivation results from three dominant needs. Usually all three needs are present in each individual but vary in importance depending on the position a person has in the workplace. Needs are also shaped over time by culture and experience.

1. Need for achievement: Performing tasks on a challenging and high level 2. Need for affiliation: Good relationships with others 3. Need for power: Being in charge

Source: Adapted from Hersey, P., & Campbell, R. (2004). Leadership: A behavioral science approach. Calif.: Leadership Studies Publishing.

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chapter 1 ■ Leadership and Followership 7 The key is to marry the readiness of the follower with the tasks at hand. “Readiness is defined as the extent to which a follower demonstrates the ability and willingness to accomplish a specific task” (Hersey & Campbell, 2004, p. 114). “The leader needs to spell out the duties and responsibilities of the individual and the group” (Hersey & Campbell, 2004).

Followers’ readiness levels can range from unable, unwilling, and insecure to able, willing, and confi- dent. The leader’s behavior will focus on appropri- ately fulfilling the followers’ needs, which are identified by their readiness level and the task. Leader behaviors will range from telling, guid- ing, and directing to delegating, observing, and monitoring.

Where did you fall in this model during your first clinical rotation? Compare this with where you are now. In the beginning, the clinical instructor gave you clear instructions, closely guiding and directing you. Now, she or he is most likely delegat- ing, observing, and monitoring. As you move into your first nursing position, you may return to the needing, guiding, and directing stage. But, you may soon become a leader/instructor for new nursing students, guiding and directing them.

Transformational Leadership Although the situational theories were an improve- ment over earlier theories, there was still something missing. Meaning, inspiration, and vision were not given enough attention (Tappen, 2001). These are the distinguishing features of transformational leadership.

The transformational theory of leadership emphasizes that people need a sense of mission that goes beyond good interpersonal relationships or an appropriate reward for a job well done (Bass & Avolio, 1993). This is especially true in nursing. Caring for people, sick or well, is the goal of the profession. Most people chose nursing in order to do something for the good of humankind; this is their vision. One responsibility of nursing leader- ship is to help nurses see how their work helps them achieve their vision.

Transformational leaders can communicate their vision in a manner that is so meaningful and excit- ing that it reduces negativity (Leach, 2005) and inspires commitment in the people with whom they work (Trofino, 1995). Dr. Martin Luther King Jr. had a vision for America: “I have a dream that

one day my children will be judged by the content of their character, not the color of their skin” (quoted by Blanchard & Miller, 2007, p. 1). A great leader shares his or her vision with his followers. You can do the same with your colleagues and team. If suc- cessful, the goals of the leader and staff will “become fused, creating unity, wholeness, and a collective purpose” (Barker, 1992, p. 42). See Box 1-1 for an example of a leader with visionary goals.

Moral Leadership A series of highly publicized corporate scandals redirected attention to the values and ethics that underlie the practice of leadership as well as that of patient care (Dantley, 2005). Moral leadership involves deciding how one ought to remain honest, fair, and socially responsible (Bjarnason & LaSala, 2011) under any circumstances. Caring about one’s patients and the people who work for you as people as well as employees (Spears & Lawrence, 2004) is part of moral leadership. This can be a great chal- lenge in times of limited financial resources.

Molly Benedict was a team leader on the acute geri- atric unit (AGU) when a question of moral leader- ship arose. Faced with large budget cuts in the middle of the year and feeling a little desperate to f igure out how to run the AGU with fewer staff, her nurse manager suggested that reducing the time that unlicensed assistive personnel (UAP) spent ambulating patients would enable UAPs to care for 15 patients, up from the current 10 per UAP.

This is leadership on the very grandest scale. BHAGs are Big, Hairy, Audacious Goals. Coined by Jim Collins, BHAGs are big ideas, visions for the future. Here is an example: Gigi Mander, originally from the Philippines, dreams of buying hundreds of acres of farmland for peasant families in Asia or Africa. She would install irrigation systems, provide seed and modern farming equipment, and help them market their crops. This is not just a dream, however; she has a business plan for her BHAG and is actively seeking investors. Imagination, creativity, planning, persistence, audacity, courage: these are all needed to put a BHAG into practice. Do you have a BHAG? How would you make it real?

box 1-1

BHAGs, Anyone?

Adapted from Buchanan, L. (2012). The world needs big ideas. INC Magazine, 34(9), 57–58.

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“George,” responded Molly, “you know that inactiv- ity has many harmful effects, from emboli to disori- entation, in our very elderly population. Let’s try to f igure out how to encourage more self-care and even family involvement in care so the UAPs can still have time to walk patients and prevent their becom- ing nonambulatory.”

Molly based her action on important values, par- ticularly those of providing the highest quality care possible. Stewart and colleagues (2012) urge that caring not be sacrificed at the altar of efficiency (p. 227). This example illustrates how great a chal- lenge that can be for today’s nurse leaders. The American Nurses Association Code of Ethics (2001) provides the moral compass for nursing practice and leadership (ANA, 2001; Bjarnason & LaSala, 2011).

Box 1-2 summarizes a contemporary list of 13 distinctive leadership styles, most of which match up to the eight theories just discussed.

Caring Leadership Caring leadership in nursing comes from two primary sources: servant leadership and emotional

intelligence in the management literature, and caring as a foundational value in nursing (Green- leaf, 2008; McMurry, 2012; Rhodes, Morris, & Lazenby, 2011; Spears, 2010). While it is uniquely suited to nursing leadership, it is hard to imagine any situation in which an uncaring leader would be preferred over a caring leader.

Servant-leaders choose to serve first and lead second, making sure that people’s needs within the work setting are met (Greenleaf, 2008). Emotion- ally intelligent leaders are especially aware of not only their own feelings but others’ feelings as well (see Box 1-1). Combining these leadership and management theories and the philosophy of caring in nursing, you can see that caring leadership is fundamentally people-oriented. The following are the characteristics and behaviors of caring leaders:

■ They respect their coworkers as individuals. ■ They listen to other people’s opinions and

preferences, giving them full consideration. ■ They maintain awareness of their own and

others’ feelings. ■ They empathize with others, understanding

their needs and concerns. ■ They develop their own and their team’s

capacities. ■ They are competent, both in leadership and in

clinical practice. This includes both knowledge and skill in leadership and clinical practice.

As you can see, caring leadership cuts across the leadership theories discussed so far and encom- passes some of their best features. An authoritarian leader, for example, can be as caring as a democratic leader (Dorn, 2011). Caring leadership is attractive to many nurses because it applies many of the prin- ciples of working with patients and working with nursing staff to the interdisciplinary team.

Qualities of an Effective Leader If leadership is seen as the ability to influence, what qualities must the leader possess in order to be able to do that? Integrity, courage, positive attitude, ini- tiative, energy, optimism, perseverance, generosity, balance, ability to handle stress, and self-awareness are some of the qualities of effective leaders in nursing (Fig. 1.1):

■ Integrity. Integrity is expected of health-care professionals. Patients, colleagues, and

1. Adaptive: flexible, willing to change and devise new approaches.

2. Emotionally Intelligent: aware of his/her own and others’ feelings.

3. Charismatic: magnetic personalities who attract people to follow them.

4. Authentic: demonstrates integrity, character, and honesty in relating to others.

5. Level 5: ferociously pursues goals but gives credit to others and takes responsibility for his/her mistakes.

6. Mindful: thoughtful, analytic, and open to new ideas. 7. Narcissistic: doesn’t listen to others and doesn’t

tolerate disagreement but may have a compelling vision.

8. No Excuse: mentally tough, emphasizes accountability and decisiveness.

9. Resonant: motivates others through their energy and enthusiasm.

10. Servant: “empathic, aware and healing,” (p. 76) leads to serve others.

11. Storyteller: uses stories to convey messages in a memorable, motivating fashion.

12. Strength-Based: focuses and capitalizes on his/her own and others’ talents.

13. Tribal: build a common culture with strong sharing of values and beliefs.

box 1-2

Distinctive Styles of Leadership

Adapted from Buchanan, L. (2012/June). 13 ways of looking at a leader. INC Magazine, 74–76.

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chapter 1 ■ Leadership and Followership 9

employers all expect nurses to be honest, law-abiding, and trustworthy. Adherence to both a code of personal ethics and a code of professional ethics (Appendix 1, American Nurses Association Code of Ethics for Nurses) is expected of every nurse. Would-be leaders who do not exhibit these characteristics cannot expect them of their followers. This is an essential component of moral leadership.

■ Courage. Sometimes, being a leader means taking some risks. In the story of Billie Thomas, for example, Billie needed some courage to speak to her nurse manager about a problem she had observed.

■ Positive attitude. A positive attitude goes a long way in making a good leader. In fact, many outstanding leaders cite negative attitude as the single most important reason for not hiring someone (Maxwell, 1993, p. 98). Sometimes a leader’s attitude is noticed by followers more quickly than are the leader’s actions.

■ Initiative. Good ideas are not enough. To be a leader, you must act on those good ideas. No one will make you do this; this requires initiative on your part.

■ Energy. Leadership requires energy. Both leadership and followership are hard but satisfying endeavors that require effort. It

is also important that the energy be used wisely.

■ Optimism. When the work is difficult and one crisis seems to follow another in rapid succession, it is easy to become discouraged. It is important not to let discouragement keep you and your coworkers from seeking ways to resolve the problems. In fact, the ability to see a problem as an opportunity is part of the optimism that makes a person an effective leader. Like energy, optimism is “catching.” Holman (1995) called this being a winner instead of a whiner (Table 1-3).

■ Perseverance. Effective leaders do not give up easily. Instead, they persist, continuing their efforts when others are tempted to stop trying. This persistence often pays off.

■ Generosity. Freely sharing your time, interest, and assistance with your colleagues is a trait of a generous leader. Sharing credit for successes and support when needed are other ways to be a generous leader (Buchanan, 2013; Disch, 2013).

■ Balance. In the effort to become the best nurses they can be, some nurses may forget that other aspects of life are equally important. As important as patients and colleagues are, family and friends are important, too. Although school and work are meaningful activities, cultural, social, recreational, and spiritual activities also have meaning. You need to find a balance between work and play.

■ Ability to handle stress. There is some stress in almost every job. Coping with stress in as positive and healthy a manner as possible helps to conserve energy and can be a model for

Qualities

Behaviors

Integrity

Courage

Initiative

Energy

Optimism

Perseverance

Balance

Ability to handle stress

Self-awareness

Think critically

Solve problems

Communicate skillfully

Set goals, share vision

Develop self and others

Figure 1.1 Keys to effective leadership.

table 1-3

Winner or Whiner—Which Are You? A winner says: A whiner says:

“We have a real challenge here.”

“This is really a problem.”

“I’ll give it my best.” “Do I have to?” “That’s great!” “That’s nice, I guess.” “We can do it!” “That will never succeed.” “Yes!” “Maybe . . .”

Source: Adapted from Holman, L. (1995). Eleven lessons in self- leadership: Insights for personal and professional success. Lexington, Ky.: A Lesson in Leadership Book.

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Rocio Quintana
10 unit 1 ■ Professional Considerations

others. Maintaining balance and handling stress are reviewed in Chapter 11.

■ Self-awareness. How sharp is your emotional intelligence? People who do not understand themselves are limited in their ability to understand people with whom they are working. They are far more likely to fool themselves than are self-aware people. For example, it is much easier to be fair with a coworker you like than with one you do not like. Recognizing that you like some people more than others is the first step in avoiding unfair treatment based on personal likes and dislikes.

Behaviors of an Effective Leader Leadership requires action. The effective leader chooses the action carefully. Important leadership behaviors include setting priorities, thinking criti- cally, solving problems, respecting people, commu- nicating skillfully, communicating a vision for the future, and developing oneself and others.

■ Setting priorities. Whether planning care for a group of patients or creating a strategic plan for an organization, priorities continually shift and demand your attention. As a leader you will need to remember the three E’s of prioritization: evaluate, eliminate, and estimate. Continually evaluate what you need to do, eliminate tasks that someone else can do, and estimate how long your top priorities will take you to complete.

■ Thinking critically. Critical thinking is the careful, deliberate use of reasoned analysis to reach a decision about what to believe or what to do (Feldman, 2002). The essence of critical thinking is a willingness to ask questions and to be open to new ideas or new ways to do things. To avoid falling prey to assumptions and biases of your own or others, ask yourself frequently, “Do I have the information I need? Is it accurate? Am I prejudging a situation?” ( Jackson, Ignatavicius, & Case, 2004).

■ Solving problems. Patient problems, paperwork problems, staff problems: these and others occur frequently and need to be solved. The effective leader helps people identify problems and work through the problem- solving process to find a reasonable solution.

■ Respecting and valuing the individual. Although people have much in common, each individual has different wants and needs and has had different life experiences. For example, some people really value the psychological rewards of helping others; other people are more concerned about earning a decent salary. There is nothing wrong with either of these points of view; they are simply different. The effective leader recognizes these differences in people and helps them find the rewards in their work that mean the most to them.

■ Skillful communication. This includes listening to others, encouraging exchange of information, and providing feedback: 1. Listening to others. Listening is separate

from talking with other people; listening involves both giving and receiving information. The only way to find out people’s individual wants and needs is to watch what they do and to listen to what they say. It is amazing how often leaders fail simply because they did not listen to what other people were trying to tell them.

2. Encouraging exchange of information. Many misunderstandings and mistakes occur because people fail to share enough information with each other. The leader’s role is to make sure that the channels of communication remain open and that people use them.

3. Providing feedback. Everyone needs some information about the effectiveness of their performance. Frequent feedback, both positive and negative, is needed so people can continually improve their performance. Some nurse leaders find it difficult to give negative feedback because they fear that they will upset the other person. How else can the person know where improvement is needed? Negative feedback can be given in a manner that is neither hurtful nor resented by the individual receiving it. In fact, it is often appreciated. Other nurse leaders, however, fail to give positive feedback, assuming that coworkers will know when they are doing a good job. This is also a mistake because everyone appreciates positive feedback. In fact, for some people, it is the most important reward they get from their jobs.

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chapter 1 ■ Leadership and Followership 11 ■ Communicating a vision for the future. The

effective leader has a vision for the future. Communicating this vision to the group and involving everyone in working toward that vision generate the inspiration that keeps people going when things become difficult. Even better, involving people in creating the vision is not only more satisfying for employees but also has the potential to produce the most creative and innovative outcomes (Kerfott, 2000). It is this vision that helps make work meaningful.

■ Developing oneself and others. Learning does not end upon leaving school. In fact, experienced nurses say that school is just the beginning, that school only prepares you to continue learning throughout your career. As new and better ways to care for patients are developed, it is your responsibility as a professional to critically analyze them and decide whether they would be better for your patients than current ones. Effective leaders not only continue to learn but also encourage others to do the same. Sometimes, leaders function as teachers. At other times, their role is primarily to encourage others to seek more knowledge.

Anderson, Manno, O’Connor, and Gallagher (2010) invited five nurse managers from Penn Presbyterian Medical Center who had received top ratings in leadership from their staff to participate in a focus group on successful leadership. They reported that visibility, communication, and the values of respect and empathy were the key elements of successful leadership. The authors quoted participants to illustrate each of these elements (p. 186):

Visibility: “I try to come in on the off shifts even for an hour or two just to have them see you.”

Communication: “Candid feedback” “A lot of rounding.” (Note: this could also be visibility.)

Respect and Empathy: “Do I expect you to take seven patients? No, because I wouldn’t be able to do it.” (punctuation adjusted).

These three key elements draw on components from several leadership qualities and behaviors: skillful communication, respecting and valuing the individual, and energy. Visibility is not as pro- minent in many of the leadership theories but

deserves a place in the description of what effective leaders do.

Followership

Followership and leadership are separate but com- plementary roles. The roles are also reciprocal: without followers, one cannot be a leader. One also cannot be a follower without having a leader (Lyons, 2002).

It is as important to be an effective follower as it is to be an effective leader. In fact, most of us are followers: members of a team, attendees at a meeting, staff of a nursing care unit, and so forth.

Followership Defined Followership is not a passive role. On the contrary, the most valuable follower is a skilled, self-directed professional, one who participates actively in deter- mining the group’s direction, invests his or her time and energy in the work of the group, thinks criti- cally, and advocates for new ideas (Grossman & Valiga, 2000).

Imagine working on a patient care unit where all staff members, from the unit secretary to the assistant nurse manager, willingly take on extra tasks without being asked (Spreitzer & Quinn, 2001), come back early from coffee breaks if they are needed, complete their charting on time, support ways to improve patient care, and are proud of the high-quality care they provide. Wouldn’t it be won- derful to be a part of that team?

Becoming a Better Follower There are a number of things you can do to become a better follower:

■ If you discover a problem, inform your team leader or manager right away.

■ Even better, include a suggestion for solving the problem in your report.

■ Freely invest your interest and energy in your work.

■ Be supportive of new ideas and new directions suggested by others.

■ When you disagree, explain why. ■ Listen carefully and reflect on what your leader

or manager says. ■ Continue to learn as much as you can about

your specialty area. ■ Share what you learn.

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12 unit 1 ■ Professional Considerations

Being an effective follower not only will make you a more valuable employee but will also increase the meaning and satisfaction that you get from your work.

Managing Up Most team leaders and nurse managers respond positively to having staff who are good followers. Occasionally, you will encounter a poor leader or manager who can confuse, frustrate, and even dis- tress you. Here are a few suggestions for handling this:

■ Avoid adopting the ineffective behaviors of this individual.

■ Continue to do your best work and to contribute leadership to the group.

■ If the situation worsens, enlist the support of others on your team to seek a remedy; do not try to do this alone as a new graduate.

■ If the situation becomes intolerable, consider the option of transferring to another unit or seeking another position (Deutschman, 2005; Korn, 2004).

There is still more a good follower can do. This is called managing up. Managing up is defined as “the process of consciously working with your boss to obtain the best possible results for you, your boss, and your organization” (Zuber & James quoted by Turk, 2007, p. 21). This is not a scheme to mani- pulate your manager or to get more rewards than you have earned. Instead, it is a guide for better understanding your manager, what he or she expects of you, and what your manager’s own needs might be.

Every manager has areas of strength and weak- ness. A good follower recognizes these and helps the manager capitalize on areas of strength and compensate for areas of weakness. For example, if your nurse manager is slow completing quality improvement reports, you can offer to help get them done. On the other hand, if your nurse manager seems to be especially skilled in defusing

conflicts between attending physicians and nursing staff, you can observe how he handles these situa- tions and ask him how he does it. Remember that your manager is human, a person with as many needs, concerns, distractions, and ambitions as anyone else. This will help you keep your expecta- tions of your manager realistic and reduce the dis- tance between you and your manager.

There are several other ways in which to manage up. U.S. Army General and former Secretary of State Colin Powell said, “You can’t make good deci- sions unless you have good information” (Powell, 2012, p. 42). Keep your manager informed. No one likes to be surprised, least of all a manager who finds that you have known about a problem (a nursing assistant who is spending too much time in the staff lounge, for example) and not brought it to her attention until it became critical. When you do bring a problem to your manager’s attention, try to have a solution to offer. This is not always possible, but when it is, it will be very much appreciated.

Finally, show your appreciation whenever pos- sible (Bing, 2010). Show respect for your manager’s authority and appreciation for what your manager does for the staff of your unit. Let others know of your appreciation, particularly those to whom your manager must answer.

Conclusion

To be an effective nurse, you need to be an effective leader. Your patients, peers, and employer are depending on you to lead. Successful leaders never stop learning and growing. John Maxwell (1998), an expert on leadership, wrote, “Who we are is who we attract” (p. xi). To attract leaders, people need to start leading and never stop learning to lead.

The key elements of leadership and followership have been discussed in this chapter. Many of the leadership and followership qualities and behaviors mentioned here are discussed in more detail in later chapters.

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chapter 1 ■ Leadership and Followership 13

Study Questions

1. Why is it important for nurses to be good leaders? What qualities have you observed from nurses that exemplify effective leadership in action? How do you think these behaviors might have improved the outcomes of their patients?

2. Why are effective followers as important as effective leaders? 3. Review the various leadership theories discussed in the chapter. Which ones especially apply to

leading in today’s health-care environment? Support your answer with specific examples. 4. Select an individual whose leadership skills you particularly admire. What are some qualities

and behaviors that this individual displays? How do these relate to the leadership theories discussed in this chapter? In what ways could you emulate this person?

5. As a new graduate, what leadership and followership skills will you work on developing during the first 3 months of your first nursing position? Why?

Case Study to Promote Critical Reasoning

Two new associate-degree graduate nurses were hired for the pediatric unit. Both worked three 12-hour shifts a week, Jan on the day-to-evening shift and Ronnie at night. Whenever their shifts overlapped, they would compare notes on their experience. Jan felt she was learning rapidly, gaining clinical skills, and beginning to feel at ease with her colleagues.

Ronnie, however, still felt unsure of herself and often isolated. “There have been times,” she told Jan, “that I am the only registered nurse on the unit all night. The aides and LPNs are really experienced, but that’s not enough. I wish I could work with an experienced nurse as you are doing.”

“Ronnie, you are not even finished with your 3-month orientation program,” said Jan. “You should never be left alone with all these sick children. Neither of us is ready for that kind of responsibility. And how will you get the experience you need with no experienced nurses to help you? You must speak to our nurse manager about this.”

“I know I should, but she’s so hard to reach. I’ve called several times, and she’s never available. She leaves all the shift assignments to her assistant. I’m not sure she even reviews the schedule before it’s posted.”

“You will have to try harder to reach her. Maybe you could stay past the end of your shift one morning and meet with her,” suggested Jan. “If something happens when you are the only nurse on the unit, you will be held responsible.” 1. In your own words, summarize the problem that Jan and Ronnie are discussing. To what extent

is this problem due to a failure to lead? Who has failed to act? 2. What style of leadership was displayed by Jan, Ronnie, and the nurse manager? How effective

was their leadership? Did Jan’s leadership differ from that of Ronnie and the nurse manager? In what way?

3. In what ways has Ronnie been an effective follower? In what ways has Ronnie not been so effective as a follower?

4. If an emergency occurred and was not handled well while Ronnie was the only nurse on the unit, who would be responsible? Explain why this person or persons would be responsible.

5. If you found yourself in Ronnie’s situation, what steps would you take to resolve the problem? Show how the leader characteristics and behaviors found in this chapter support your solution to the problem.

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14 unit 1 ■ Professional Considerations

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17

chapter 2 Manager

OBJECTIVES After reading this chapter, the student should be able to: ■ Define the term management. ■ Distinguish scientific management and human relations–

based management. ■ Explain servant leadership. ■ Discuss the qualities and behaviors that contribute to

effective management. OUTLINE Management Are You Ready to Be a Manager? What Is Management?

Management Theories Scientific Management Human Relations–Based Management Servant Leadership Qualities of an Effective Manager Behaviors of an Effective Manager Interpersonal Activities Decisional Activities Informational Activities Conclusion

Every nurse needs to be a good leader and a good follower. In Chapter 1 we defined leadership and followership, and showed that even as a new nurse, you can be an effective leader. Not everyone needs to be a manager, however. New graduates are not ready to take on management responsibilities. Once you have had time to develop your clinical and leadership skills, then you can begin to think about taking on management responsibilities (Table 2-1).

Management

Are You Ready to Be a Manager? For most new nurses, the answer is no, you should not accept managerial responsibility. Your clinical skills are still underdeveloped. You need to direct your energies to building your own skills, including your leadership skills, before you begin supervising other people.

What Is Management? The essence of management is getting work done through others. The classic definition of manage- ment was Henri Fayol’s 1916 list of managerial tasks: planning, organizing, commanding, coordi- nating, and controlling the work of a group of employees (Wren, 1972). But Mintzberg (1989) argued that managers really do whatever is needed

to make sure that employees do their work and do it well. Lombardi (2001) added that two-thirds of a manager’s time is spent on people problems. The rest is taken up by budget work, going to meetings, preparing reports, and other administrative tasks.

Management Theories

There are two major but opposing schools of thought in management: scientific management and the human relations–based approach. As its name implies, the human-relations approach emphasizes the interpersonal aspects of managing people, whereas scientific management emphasizes the task aspects.