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Effective Leadership and Management in Nursing

Eleanor J. Sullivan, PhD, RN, FAAN

Eighth Edition

Boston Columbus Indianapolis New York San Francisco Upper Saddle River Amsterdam Cape Town Dubai London Madrid Milan Munich Paris Montréal Toronto

Delhi Mexico City São Paulo Sydney Hong Kong Seoul Singapore Taipei Tokyo

v

Eleanor J. Sullivan, PhD, RN, FAAN, is the former dean of the University of Kansas School of Nurs- ing, past president of Sigma Theta Tau International, and previous editor of the Journal of Professional Nursing. She has served on the board of directors of the American Association of Colleges of Nursing, testified before the U.S. Senate, served on a National Institutes of Health council, presented papers to international audiences, been quoted in the Chicago Tribune, St. Louis Post-Dispatch, and Rolling Stone Magazine, and named to the “Who’s Who in Health Care” by the Kansas City Business Journal.

She earned nursing degrees from St. Louis Community College, St. Louis University, and Southern Illinois University and holds a PhD from St. Louis University.

Dr. Sullivan is known for her publications in nursing, including this award-winning textbook, Effective Leadership & Management in Nursing, and Becoming Influential: A Guide for Nurses, 2nd edition, from Prentice Hall. Other publica- tions include Creating Nursing’s Future: Issues, Opportunities and Challenges and Nursing Care for Clients with Sub- stance Abuse.

Today, Dr. Sullivan is a mystery writer. Her first three (Twice Dead, Deadly Diversion, and Assumed Dead) feature nurse sleuth Monika Everhardt.

Her latest book, Cover Her Body, A Singular Village Mystery, is the first in a new series of historical mysteries featur- ing a 19th-century midwife and set in the Northern Ohio village of Dr. Sullivan’s ancestors. Dr. Sullivan’s blog posts, found at www.EleanorSullivan.com, reveal the history behind her historical fiction.

Connect with Dr. Sullivan at www.EleanorSullivan.com.

This book is dedicated to my family for their continuing love and support.

Eleanor J. Sullivan

ABOUT THE AUTHOR

www.EleanorSullivan.com
www.EleanorSullivan.com
vi

Our heartfelt thanks go out to our colleagues from schools of nursing across the country who have given their time generously to help us create this exciting new edition of our book. We have reaped the benefit of your collective experi- ence as nurses and teachers and have made many improvements due to your efforts. Among those who gave us their encouragement and comments are:

THANK YOU

Reviewers Theresa Ameri Part-time/adjunct instructor, Marymount University Arlington, VA

Becky Brown, MSN, RN Full-time instructor, College of Southern Idaho Twin Falls, ID

Candace Burns, PhD, ARNP Professor, University of South Florida College of Nursing Tampa, FL

Sandra Janashak Cadena, PhD, APRN, CNE Professor, University of South Florida Tampa, FL

Margaret Decker Full-time instructor, Binghamton University Binghamton, NY

Denise Eccles, MSN/Ed, RN Professor, Miami Dade College Miami, FL

Barb Gilbert, EdD, MSN, RN, CNE Part-time/adjunct instructor, Excelsior College Albany, NY

Karen Joris, MSN, RN Assistant professor, Lorain County Community College Elyria, OH

Jean M. Klein, PhD, PMHCNS, BC Associate professor, Widener University Chester, PA

Jemimah Mitchell-Levy, MSN, ARNP Professor, Miami Dade College Miami, FL

Rorey Pritchard, EdS, MSN, RN, CNOR Full-time instructor, Chippewa Valley Technical College Eau Claire, WI

Heather Saifman, MSN, RN, CCRN Assistant professor, Nova Southeastern University

Miami Kendall, FL Linda Stone Other Cambridge, MA

Sandra Swearingen Part-time/adjunct instructor, UCF Orlando, FL

Diane Whitehead, EdD, RN, ANEF Department chair, Nova Southeastern University Fort Lauderdale, FL

vii

PREFACE

Leading and managing are essential skills for all nurses in today’s rapidly changing health care arena. New graduates find themselves managing unlicensed assistive personnel, and experienced nurses are managing groups of health care providers from a variety of disciplines and educational lev- els. Declining revenues, increasing costs, demands for safe care, and health care reform legislation mandate that every organization use its resources efficiently.

Nurses today are challenged to manage effectively with fewer resources. Never has the information presented in this textbook been needed more. Effective Leadership & Management in Nursing, eighth edition, can help both stu- dent nurses and those with practice experience acquire the skills needed to ensure success in today’s dynamic health care environment.

Features of the Eighth Edition Effective Leadership & Management in Nursing has made a significant and lasting contribution to the education of nurses and nurse managers in its seven previous editions. Used worldwide, this award-winning textbook is now of- fered in an updated and revised edition to reflect changes in the current health care system and in response to sug- gestions from the book’s users. The eighth edition builds upon the work of previous contributors to provide the most up-to-date and comprehensive learning package for today’s busy students and professionals.

This book has been a success for many reasons. It com- bines practicality with conceptual understanding; is respon- sive to the needs of faculty, nurse managers, and students; and taps the expertise of contributors from a variety of dis- ciplines, especially management professionals whose work has been adapted by nurses for current nursing practice. The expertise of management professors in schools of busi- ness and practicing nurse managers is seldom incorporated into nursing textbooks. This unique approach provides students with invaluable knowledge and skills and sets the book apart from others.

Features new or expanded in the eighth edition include:

• Information about the Patient Protection and Afford- able Care Act

• An emphasis on quality initiatives, including Six Sigma, Lean Six Sigma, and DMAIC

• The use of Magnet-certified hospitals as examples of concepts

• The addition of emotional leadership concepts • The use of social media in management • An emphasis on multicratic leadership and interprofes-

sional relationships • Updated legal and legislative content • Tips on how to deal with disruptive staff behaviors,

including bullying • Guidance on preparing for emergencies and mass

casualty incidents • Information on preventing workplace violence

Student-Friendly Learning Tools Designed with the adult learner in mind, the book focuses on the application of the content presented and offers spe- cific guidelines on how to implement the skills included. To further illustrate and emphasize key points, each chapter in this edition includes these features:

• A chapter outline and preview • New MediaLink boxes introduce readers to resources

and activities on the Student Resources site through nursing.pearsonhighered.com.

• Key terms are defined in the glossary at the end of the book

• What You Know Now lists at the end of each chapter • A list of “tools,” or key behaviors, for using the skills

presented in the chapter • Questions to Challenge You to help students relate

concepts to their experiences • Up-to-date references and Web resources identified • Case Studies with a Manager’s Checklist to demonstrate

application of content

Organization The text is organized into four sections that address the es- sential information and key skills that nurses must learn to succeed in today’s volatile health care environment.

Part 1. Understanding Nursing Management and Organizations. Part 1 introduces the context for nursing management, with an emphasis on how organizations are designed, on ways that nursing care is delivered, on the concepts of leading and managing, on how to initiate and manage change, on

viii PREFACE

providing quality care, and on using power and politics— all necessary for nurses to succeed and prosper in today’s chaotic health care world.

Part 2. Learning Key Skills in Nursing Management. Part 2 delves into the essential skills for today’s manag- ers, including thinking critically, making decisions, solv- ing problems, communicating with a variety of individuals and groups, delegating, working in teams, resolving con- flicts, and managing time.

Part 3. Managing Resources. Knowing how to manage resources is vital for nurses to- day. They must be adept at budgeting fiscal resources; recruiting and selecting staff; handling staffing and sched- uling; motivating and developing staff; evaluating staff performance; coaching, disciplining and terminating staff; managing absenteeism, reducing turnover, and retaining staff; and handling disruptive staff behaviors, including bullying. In addition, collective bargaining and preparing for emergencies and preventing workplace violence are in- cluded in Part 3.

Part 4. Taking Care of Yourself. Nurses are their own most valuable resource. Part 4 shows how to manage stress and to advance in a career.

Resources for Teaching and Learning Student and Instructor Resources can be accessed by regis- tering or logging in at nursing.pearsonhighered.com.

Acknowledgments The success of previous editions of this book has been due to the expertise of many contributors. Nursing adminis- trators, management professors, and faculty in schools of nursing all made significant contributions to earlier edi- tions. I am enormously grateful to them for sharing their knowledge and experience to help nurses learn leadership and management skills. Without them, this book would not exist.

At Pearson Health Science, Acquisitions Editor Pamela Fuller and Development Editor Susan Geraghty guided this revision from start to finish. Editorial Assistant Cyn- thia Gates was also especially helpful.

Because health care continues to change, reviewers who are using the book in their management practice and in their classes provided invaluable comments and sugges- tions (see list on pages xi–xii).

I am especially grateful to experienced nurse manager and graduate student Rachel Pepper for her expert research assistance, ability to generate real-life examples, and ex- pertise in creating case scenarios to exemplify the experi- ence of nurses in management roles. She lent assistance throughout with ideas and suggestions. This book and Becoming Influential: A Guide for Nurses, 2nd edition, are better for her contributions.

To everyone who has contributed to this fine book over the years, I thank you.

Eleanor J. Sullivan, PhD, RN, FAAN www.EleanorSullivan.com

www.EleanorSullivan.com
ix

CONTENTS

Thank You vi Preface vii

PART 1 Understanding Nursing Management and Organizations 1

CHAPTER 1 Introducing Nursing Management 1 Learning Outcomes 1

CHANGES IN HEALTH CARE 2 PAYING FOR HEALTH CARE 2

How America Pays for Health Care 2 Pay for Performance 2

DEMAND FOR QUALITY 2 Quality Initiatives 2 The Leapfrog Group 3 Benchmarking 3 Evidence-Based Practice 3 Magnet® Certification 4

EVOLVING TECHNOLOGY 4 Electronic Health Records 5 Virtual Care 5 Robotics 5 Communication Technology 5

CULTURAL, GENDER, AND GENERATIONAL DIFFERENCES 6 VIOLENCE PREVENTION AND DISASTER PREPAREDNESS 6 CHANGES IN NURSING’S FUTURE 6

Even More Change . . . 7 Challenges Facing Nurses and Managers 7

CHAPTER 2 Designing Organizations 11 Learning Outcomes 11

TRADITIONAL ORGANIZATIONAL THEORIES 12

Classical Theory 12 Humanistic Theory 14 Systems Theory 14 Contingency Theory 14 Chaos Theory 15 Complexity Theory 15

TRADITIONAL ORGANIZATIONAL STRUCTURES 15

Functional Structure 16 Hybrid Structure 16

Matrix Structure 16 Parallel Structure 16

SERVICE-LINE STRUCTURES 17 SHARED GOVERNANCE 17 OWNERSHIP OF HEALTH CARE ORGANIZATIONS 18 HEALTH CARE SETTINGS 19

Primary Care 19 Acute Care Hospitals 20 Home Health Care 20 Long-Term Care 20

COMPLEX HEALTH CARE ARRANGEMENTS 21

Health Care Networks 21 Interorganizational Relationships 21 Diversification 22 Managed Health Care Organizations 23 Accountable Care Organizations 23

REDESIGNING HEALTH CARE 23 STRATEGIC PLANNING 24 ORGANIZATIONAL ENVIRONMENT AND CULTURE 25

CHAPTER 3 Delivering Nursing Care 29 Learning Outcomes 29

TRADITIONAL MODELS OF CARE 30 Functional Nursing 30 Team Nursing 31 Total Patient Care 32 Primary Nursing 33

INTEGRATED MODELS OF CARE 34 Practice Partnerships 34 Case Management 34 Critical Pathways 35 Differentiated Practice 36

EVOLVING MODELS OF CARE 36 Patient-Centered Care 36 Synergy Model of Care 37 Clinical Microsystems 37 Chronic Care Model 37

CHAPTER 4 Leading, Managing, Following 40 Learning Outcomes 40

LEADERS AND MANAGERS 41 LEADERSHIP 41 TRADITIONAL LEADERSHIP THEORIES 42

x CONTENTS

CONTEMPORARY THEORIES 42 Quantum Leadership 42 Transactional Leadership 42 Transformational Leadership 43 Shared Leadership 43 Servant Leadership 44 Emotional Leadership 44

TRADITIONAL MANAGEMENT FUNCTIONS 45

Planning 46 Organizing 46 Directing 47 Controlling 47

NURSE MANAGERS IN PRACTICE 47 Nurse Manager Competencies 47 Staff Nurse 48 First-Level Management 48 Charge Nurse 49 Clinical Nurse Leader 50

FOLLOWERSHIP: AN ESSENTIAL COMPONENT OF LEADERSHIP 51 WHAT MAKES A SUCCESSFUL LEADER? 51

CHAPTER 5 Initiating and Managing Change 55 Learning Outcomes 55

WHY CHANGE? 56 THE NURSE AS CHANGE AGENT 56 CHANGE THEORIES 57 THE CHANGE PROCESS 58

Assessment 58 Planning 60 Implementation 60 Evaluation 61

CHANGE STRATEGIES 61 Power-Coercive Strategies 61 Empirical–Rational Model 62 Normative–Reeducative Strategies 62

RESISTANCE TO CHANGE 62 THE NURSE’S ROLE 64

Initiating Change 64 Implementing Change 65

HANDLING CONSTANT CHANGE 66

CHAPTER 6 Managing and Improving Quality 69 Learning Outcomes 69

QUALITY MANAGEMENT 70 Total Quality Management 70 Continuous Quality Improvement 71 Components of Quality Management 72 Six Sigma 73 Lean Six Sigma 73 DMAIC Method 74

IMPROVING THE QUALITY OF CARE 74 National Initiatives 74 How Cost Affects Quality 75 Evidence-Based Practice 75 Electronic Medical Records 75 Dashboards 76 Nurse Staffing 76 Reducing Medication Errors 76 Peer Review 76

RISK MANAGEMENT 77 Nursing’s Role in Risk Management 77 Incident Reports 78 Examples of Risk 78 Root Cause Analysis 80 Role of the Nurse Manager 80 Creating a Blame-Free Environment 81

CHAPTER 7 Understanding Power and Politics 86 Learning Outcomes 86

POWER DEFINED 87 POWER AND LEADERSHIP 87 POWER: HOW MANAGERS AND LEADERS GET THINGS DONE 87 USING POWER 88

Image as Power 89 Using Power Appropriately 91

SHARED VISIONING AS A POWER TOOL 92 POWER, POLITICS, AND POLICY 92

Nursing’s Political History 93 Using Political Skills to Influence Policies 93 Influencing Public Policies 94

USING POWER AND POLITICS FOR NURSING’S FUTURE 96

PART 2 Learning Key Skills in Nursing Management 99

CHAPTER 8 Thinking Critically, Making Decisions, Solving Problems 99 Learning Outcomes 99

CRITICAL THINKING 100 Critical Thinking in Nursing 100 Using Critical Thinking 101 Creativity 101

DECISION MAKING 103 Types of Decisions 104 Decision-Making Conditions 104 The Decision-Making Process 106

CONTENTS xi

Decision-Making Techniques 107 Group Decision Making 108

PROBLEM SOLVING 109 Problem-Solving Methods 109 The Problem-Solving Process 110 Group Problem Solving 112

STUMBLING BLOCKS 114 INNOVATION 115

CHAPTER 9 Communicating Effectively 117 Learning Outcomes 117

COMMUNICATION 118 Modes of Communication 118 Distorted Communication 118 Directions of Communication 120 Effective Listening 120

EFFECTS OF DIFFERENCES IN COMMUNICATION 121

Gender Differences in Communication 121 Generational and Cultural Differences in Communication 121 Differences in Organizational Culture 122

THE ROLE OF COMMUNICATION IN LEADERSHIP 123

Employees 123 Administrators 123 Coworkers 125 Medical Staff 125 Other Health Care Personnel 126 Patients and Families 126

COLLABORATIVE COMMUNICATION 126 ENHANCING YOUR COMMUNICATION SKILLS 129

CHAPTER 10 Delegating Successfully 131 Learning Outcomes 131

DELEGATION 132 BENEFITS OF DELEGATION 132

Benefits to the Nurse 132 Benefits to the Delegate 133 Benefits to the Manager 133 Benefits to the Organization 133

THE FIVE RIGHTS OF DELEGATION 133 The Delegation Process 134

ACCEPTING DELEGATION 137 INEFFECTIVE DELEGATION 138

Organizational Culture 138 Lack of Resources 138 An Insecure Delegator 138 An Unwilling Delegate 139 Underdelegation 140

Reverse Delegation 140 Overdelegation 140

CHAPTER 11 Building and Managing Teams 143 Learning Outcomes 143

GROUPS AND TEAMS 144 GROUP AND TEAM PROCESSES 146

Norms 147 Roles 148

BUILDING TEAMS 149 Assessment 149 Team-Building Activities 150

MANAGING TEAMS 150 Task 151 Group Size and Composition 151 Productivity and Cohesiveness 151 Development and Growth 152 Shared Governance 152

THE NURSE MANAGER AS TEAM LEADER 153

Communication 153 Evaluating Team Performance 153

LEADING COMMITTEES AND TASK FORCES 154

Guidelines for Conducting Meetings 155 Managing Task Forces 156

PATIENT CARE CONFERENCES 157

CHAPTER 12 Handling Conflict 160 Learning Outcomes 160 CONFLICT 161 INTERPROFESSIONAL CONFLICT 161 CONFLICT PROCESS MODEL 162

Antecedent Conditions 163 Perceived and Felt Conflict 164 Conflict Behaviors 165 Conflict Resolved or Suppressed 165 Outcomes 165

MANAGING CONFLICT 165 Conflict Responses 166 Filley’s Strategies 168 Alternative Dispute Strategies 169

CHAPTER 13 Managing Time 172 Learning Outcomes 172

TIME WASTERS 173 Time Analysis 174 The Manager’s Time 175

SETTING GOALS 175 Determining Priorities 176 Daily Planning and Scheduling 176

xii CONTENTS

Grouping Activities and Minimizing Routine Work 177 Personal Organization and Self-Discipline 177

CONTROLLING INTERRUPTIONS 178 Phone Calls, Voice Mail, Text Messages 179 E-Mail 180 Drop-In Visitors 181 Paperwork 181

CONTROLLING TIME IN MEETINGS 182 RESPECTING TIME 182

PART 3 Managing Resources 184

CHAPTER 14 Budgeting and Managing Fiscal Resources 184 Learning Outcomes 184

THE BUDGETING PROCESS 185 APPROACHES TO BUDGETING 186

Incremental Budget 186 Zero-Based Budget 187 Fixed or Variable Budgets 187

THE OPERATING BUDGET 187 The Revenue Budget 187 The Expense Budget 188

DETERMINING THE SALARY (PERSONNEL) BUDGET 189

Benefits 189 Shift Differentials 190 Overtime 190 On-Call Hours 190 Premiums 190 Salary Increases 191 Additional Considerations 191

MANAGING THE SUPPLY AND NONSALARY EXPENSE BUDGET 191 THE CAPITAL BUDGET 192 TIMETABLE FOR THE BUDGETING PROCESS 192 MONITORING BUDGETARY PERFORMANCE DURING THE YEAR 193

Variance Analysis 193 Position Control 195

PROBLEMS AFFECTING BUDGETARY PERFORMANCE 195

Reimbursement Problems 195 Staff Impact on Budget 196

CHAPTER 15 Recruiting and Selecting Staff 199 Learning Outcomes 199

THE RECRUITMENT AND SELECTION PROCESS 200

RECRUITING APPLICANTS 200 Where to Look 201 How to Look 202 When to Look 202 How to Promote the Organization 202 Cross-Training as a Recruitment Strategy 203

SELECTING CANDIDATES 204 INTERVIEWING CANDIDATES 205

Principles for Effective Interviewing 205 Involving Staff in the Interview Process 209 Interview Reliability and Validity 209

MAKING A HIRE DECISION 210 Education, Experience, and Licensure 210 Integrating the Information 210 Making an Offer 211

LEGALITY IN HIRING 211

CHAPTER 16 Staffing and Scheduling 217 Learning Outcomes 217

STAFFING 218 Patient Classification Systems 218 Determining Nursing Care Hours 219 Determining FTEs 219 Determining Staffing Mix 220 Determining Distribution of Staff 220

SCHEDULING 221 Creative and Flexible Staffing 221 Automated Scheduling 222 Supplementing Staff 223

CHAPTER 17 Motivating and Developing Staff 227 Learning Outcomes 227 A MODEL OF JOB PERFORMANCE 228

Employee Motivation 229 Motivational Theories 229

MANAGER AS LEADER 231 STAFF DEVELOPMENT 231

Orientation 231 On-the-Job Instruction 232 Preceptors 233 Mentoring 233 Coaching 234 Nurse Residency Programs 234 Career Advancement 234 Leadership Development 235

SUCCESSION PLANNING 235

CONTENTS xiii

CHAPTER 18 Evaluating Staff Performance 239 Learning Outcomes 239

THE PERFORMANCE APPRAISAL 240 Evaluation Systems 241 Evidence of Performance 244 Evaluating Skill Competency 247 Diagnosing Performance Problems 247 The Performance Appraisal Interview 248

POTENTIAL APPRAISAL PROBLEMS 251 Leniency Error 251 Recency Error 251 Halo Error 252 Ambiguous Evaluation Standards 252 Written Comments Problem 252

IMPROVING APPRAISAL ACCURACY 253 Appraiser Ability 253 Appraiser Motivation 253

RULES OF THUMB 255

CHAPTER 19 Coaching, Disciplining, and Terminating Staff 257 Learning Outcomes 257

DAY-TO-DAY COACHING 258 POSITIVE COACHING 259 DEALING WITH A POLICY VIOLATION 259 DISCIPLINING STAFF 260 TERMINATING EMPLOYEES 262

CHAPTER 20 Managing Absenteeism, Reducing Turnover, Retaining Staff 268 Learning Outcomes 268 ABSENTEEISM 269

A Model of Employee Attendance 269 Managing Employee Absenteeism 272 Absenteeism Policies 273 Selecting Employees and Monitoring Absenteeism 274 Family and Medical Leave 274

REDUCING TURNOVER 275 Cost of Nursing Turnover 275 Causes of Turnover 276 Understanding Voluntary Turnover 276

RETAINING STAFF 277 Employee Engagement 277 Healthy Work Environment 277 Improving Salaries 277 Recognizing Staff Performance 278 Additional Retention Strategies 279

CHAPTER 21 Dealing with Disruptive Staff Problems 283 Learning Outcomes 283

HARASSING BEHAVIORS 284 Bullying 284 Lack of Civility 284 Lateral Violence 285

HOW TO HANDLE PROBLEM BEHAVIORS 286 Marginal Employees 286 Disgruntled Employees 287

THE EMPLOYEE WITH A SUBSTANCE ABUSE PROBLEM 288

State Board of Nursing 289 Strategies for Intervention 289 Reentry 290 The Americans with Disabilities Act and Substance Abuse 291

CHAPTER 22 Preparing for Emergencies 294 Learning Outcomes 294

PREPARING FOR EMERGENCIES 295 TYPES OF EMERGENCIES 295

Natural Disasters 295 Man-Made Disasters 295 Levels of Disasters 295

NATIONAL RESPONSES TO EMERGENCY PREPAREDNESS 296 HOSPITAL PREPAREDNESS FOR EMERGENCIES 296

Emergency Operations Plan 296 Disaster Triage 297 Core Competencies for Nurses 297 Continuation of Services 297 Impact on Employees 298

CHAPTER 23 Preventing Workplace Violence 302 Learning Outcomes 302

VIOLENCE IN HEALTH CARE 303 Incidence of Workplace Violence 303 Consequences of Workplace Violence 303 Factors Contributing to Violence in Health Care 303

PREVENTING VIOLENCE 304 Zero-Tolerance Policies 304 Reporting and Education 304 Environmental Controls 304

DEALING WITH VIOLENCE 305 Verbal Intervention 305 A Violent Incident 305 Other Dangerous Incidents 306 Post-Incident Follow-Up 306

xiv CONTENTS

CHAPTER 24 Handling Collective Bargaining Issues 310 Learning Outcomes 310

LAWS GOVERNING UNIONS 311 PROCESS OF UNIONIZATION 311

The Grievance Process 312 The Nurse Manager’s Role 312

STATUS OF COLLECTIVE BARGAINING FOR NURSES 313

Legal Status of Nursing Unions 313 The Future of Collective Bargaining for Nurses 314

PART 4 Taking Care of Yourself 316

CHAPTER 25 Managing Stress 316 Learning Outcomes 316

THE NATURE OF STRESS 317 CAUSES OF STRESS 318

Organizational Factors 318 Interpersonal Factors 318 Individual Factors 319

CONSEQUENCES OF STRESS 320 MANAGING STRESS 320

Personal Methods 320 Organizational Methods 321

CHAPTER 26 Advancing Your Career 325 Learning Outcomes 325

ENVISIONING YOUR FUTURE 326 MANAGING YOUR CAREER 326 ACQUIRING YOUR FIRST POSITION 326

Applying for the Position 327 The Interview 328 Accepting the Position 331 Declining the Position 331

BUILDING A RÉSUMÉ 331 Tracking Your Progress 333 Identifying Your Learning Needs 334

FINDING AND USING MENTORS 336 CONSIDERING YOUR NEXT POSITION 336

Finding Your Next Position 337 Leaving Your Present Position 337

WHEN YOUR PLANS FAIL 337 Taking the Wrong Job 337 Adapting to Change 338

Glossary 340 Index 348

CHAPTER

Changes in Health Care

Paying for Health Care HOW AMERICA PAYS FOR HEALTH CARE

PAY FOR PERFORMANCE

Demand for Quality QUALITY INITIATIVES

THE LEAPFROG GROUP

BENCHMARKING

EVIDENCE-BASED PRACTICE

MAGNET® CERTIFICATION

Evolving Technology ELECTRONIC HEALTH RECORDS

VIRTUAL CARE

ROBOTICS

COMMUNICATION TECHNOLOGY

Cultural, Gender, and Generational Differences

Violence Prevention and Disaster Preparedness

Changes in Nursing’s Future EVEN MORE CHANGE . . .

CHALLENGES FACING NURSES AND MANAGERS

Introducing Nursing Management 1

1. Describe the forces that are changing the health care system.

2. Discuss changes in paying for health care. 3. Explain how quality initiatives can reduce

medical errors. 4. Describe how evidence-based practice is

changing nursing. 5. Explain how to become a Magnet-certified

hospital.

6. Explain what emerging technologies mean for nursing.

7. Describe how cultural, gender, and genera- tional differences affect management.

8. Explain why preparation is the best defense against violence and disasters.

9. Discuss the changes and challenges that nurses face now and into the future.

Learning Outcomes After completing this chapter, you will be able to:

Key Terms Benchmarking Electronic health records

(EHRs) Evidence-based practice Leapfrog Group

Magnet Recognition Program®

Patient Protection and Affordable Care Act (PPACA)

Quality initiatives Robotics Social media Virtual care

2 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

T oday, all nurses are managers. Whether you work in a freestanding clinic, an ambula-tory surgical center, a critical unit in an acute care hospital, or in hospice care for a home care agency, you must deal with staff, including other nurses and unlicensed as- sistive personnel, who work with you and for you. At the same time, you must be vigilant about costs. To manage well, you must understand the health care system and the organizations where you work. You need to recognize what external forces affect your work and how to influence those forces. You need to know what motivates people and how you can help create an environ- ment that inspires and sustains the individuals who work in it. You must be able to collaborate with others, as a leader, a follower, and a team member, in order to become confident in your ability to be a leader and a manager.

This book is designed to provide new graduates or novice managers with the information they need to become effective managers and leaders in health care. More than ever before, today’s rapidly changing health care environment demands highly refined management skills and superb leadership.

Changes in Health Care Today’s health care system is continuing to undergo significant changes. Costly lifesaving medi- cines, robotics, virtual care, and innovations in imaging technologies, noninvasive treatments, and surgical procedures have combined to produce the most sophisticated and effective health care ever—and the most expensive. Skyrocketing costs and inaccessibility to health care are ongoing concerns for employers, health care providers, policy makers, and the public at large. A number of factors are forcing change on the health care system.

Paying for Health Care

How America Pays for Health Care The United States spends more money on health care than any other country, and health care spending continues to rise with costs of $2.5 trillion in 2009, consuming more than 17 percent of the country’s gross domestic product (GDP) (CMS, 2011). With the goal of providing access to health care to most U.S. citizens and containing costs, Congress passed a health care reform bill known as the Patient Protection and Affordable Care Act (PPACA) that was signed into law March 23, 2010. While implementation of the bill is pending court challenges, the promise of providing adequate and affordable care to more Americans is on the horizon.

Pay for Performance In 1999, the Institute of Medicine (IOM, 1999) reported that 98,000 deaths occurred each year from preventable medical mistakes, such as falls, wrong site surgeries, avoidable infections, and pressure ulcers, among others. By 2008, researchers learned that “the effects of medical mistakes continue long after the patient leaves the hospital” (Encinosa & Hellinger, 2008, p. 2067). In spite of numerous efforts to prevent mistakes, the cost of medical errors has con- tinued to climb. Recent estimates put such costs at $19.5 billion annually (Shreve et al., 2010).

In 2008, the Centers for Medicare and Medicaid Services, the agency that oversees gov- ernment payments for care, tied payment to the quality of care by changing its reimbursement policy to no longer cover costs incurred by medical mistakes (Wachter, Foster, & Dudley, 2008). If medical mistakes occur, the hospital must absorb the costs. Thus, pay for performance became the norm, and performance is now measured by the quality of care (Milstein, 2009).

Demand for Quality

Quality Initiatives In an effort to ameliorate medical mistakes, a number of quality initiatives have emerged. Quality management is a preventive approach designed to address problems before they become crises. The quality movement actually began in post–World War II Japan, when Japanese industries adopted a

CHAPTER 1 • INTRODUCING NURSING MANAGEMENT 3

system that W. Edwards Deming designed to improve the quality of manufactured products. The philosophy of the system is that consumers’ needs should be the focus and that employees should be empowered to evaluate and improve quality. In addition to businesses in the United States and else- where, the health care industry has adopted total quality management or variations on it.

Built into the system is a mechanism for continuous improvement of products and services through constant evaluation of how well consumers’ needs are met and plans adjusted to per- fect the process. Patient satisfaction surveys are one example of how health care organizations evaluate their customers’ needs. Today, quality initiatives address all aspects of patient care and include government efforts as well as private sector endeavors.

Public reporting of heath care organizations has emerged as a strategy to improve quality (Christianson et al., 2010). To further that goal, the Agency for Healthcare Research and Quality (AHRQ)—whose mission is to improve the quality, safety, efficiency, and effectiveness of health care—funds projects that address three quality indicators: prevention, inpatient, quality, and patient safety (Dunton et al., 2011).

The Leapfrog Group Efforts by the Leapfrog Group constitute one private sector initiative to address quality. The Leapfrog Group is a consortium of public and private purchasers established to reduce prevent- able medical mistakes. The organization uses its mammoth purchasing power to leverage quality care for its consumers by rewarding health care organizations that demonstrate quality outcome measures. The quality indicators the group focuses on include ICU staffing, electronic medi- cation ordering systems, and the use of higher performing hospitals for high-risk procedures. Leapfrog estimates that if these three patient safety practices were implemented, more than 57,000 lives could be saved, more than $12 billion dollars could be saved, and more than 3 mil- lion adverse drug events could be avoided (Binder, 2010).

Benchmarking In contrast to quality management strategies that compare internal measures across comparable units, such as the Leapfrog Group, benchmarking compares an organization’s data with similar organizations. Outcome indicators are identified that can be used to compare performance across disciplines or organizations. Once the results are known, health care organizations can address areas of weakness and enhance areas of strength (Nolte, 2011). Interestingly, one study found that hospital size didn’t affect the ability of institutions to compare results (Brown et al., 2010).

Evidence-Based Practice Evidence-based practice has emerged as a strategy to improve quality by using the best avail- able knowledge integrated with clinical experience and the patient’s values and preferences to provide care (Houser & Oman, 2010).

Similar to the nursing process, the steps in EBP are:

1. Identify the clinical question.

2. Acquire the evidence to answer the question.

3. Evaluate the evidence.

4. Apply the evidence.

5. Assess the outcome.

Research findings with conflicting results puzzle consumers daily, and nurses are no excep- tion, especially when they search for practice evidence. Hader (2010) suggests that evidence falls into several categories:

● Anecdotal—derived from experience ● Testimonial—reported by an expert in the field

4 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

● Statistical—built from a scientific approach ● Case study—an in-depth analysis used to translate to other clinical situations ● Nonexperimental design research—gathering factors related to a clinical condition ● Quasi-experimental design research—a study limited to one group of subjects ● Randomized control trial—uses both experimental and control groups to determine the

effectiveness of an intervention

While all forms of evidence are useful for clinical decision making, a randomized control design and statistical evidence are the most rigorous (Hader, 2010).

Magnet® Certification The Magnet Recognition Program® designates organizations that “recognize health care orga- nizations that provide nursing excellence” (ANCC, 2011). To qualify for recognition as a mag- net hospital the organization must demonstrate that they are:

● Promoting quality in a setting that supports professional practice ● Identifying excellence in the delivery of nursing services to patients/residents ● Disseminating “best practices” in nursing services.

Becoming a magnet hospital requires a significant investment of time and financial resources. Research shows, however, that patient safety is improved when nurse staffing meets Magnet standards (Lake et al., 2010).

Systems involving participatory management and shared governance create organizational environments that reward decision making, creativity, independence, and autonomy. These orga- nizations retain and recruit independent, accountable professionals. Organizations that empower nurses to make decisions will better meet consumer requests. As the health care environment continues to evolve, more and more organizations are adopting consumer-sensitive cultures that require accountability and decision making from nurses.

Magnet hospitals are those institutions that have met the stringent guidelines for nurses and are credentialed by the American Nurses Credentialing Center. Characteristics common in mag-

net hospitals include:

● Higher ratios of nurses to patients ● Flexible schedules ● Decentralized administration ● Participatory management ● Autonomy in decision making ● Recognition ● Advancement opportunities

To retain the current workforce and attract other nurses, health care organizations can take from the magnet program characteristics to improve work-life conditions for nurses. Encourag- ing nurses to be full participants and to share a vested interest in the success of the organization can help alleviate the nursing shortage in those organizations and in the profession.

See Chapter 6 , Managing and Improving Quality, to learn more about improving quality in health care.

Evolving Technology Rapid changes in technology seem, at times, to overwhelm us. Hospital information systems (HIS); electronic health records (EHR); point-of-care data entry (POC); provider order entry; bar-code medication administration; dashboards to manage, report, and compare data across plat- forms; virtual care provided from a distance; and robotics—to name a few of the many evolving technologies—both fascinate and frighten us simultaneously. At the same time, communication

CHAPTER 1 • INTRODUCING NURSING MANAGEMENT 5

technology—from smartphones to social media—continues to march into the future. It is no wonder that people who work in health care complain that they can’t keep up! The rapidity of technological change promises, unfortunately, to continue unabated.

Electronic Health Records Electronic health records (EHRs) represent a technology destined for rapid expansion. While banks, retailers, airlines, and other industries began to rely on fully integrated systems to man- age communication and reduce redundancies, health care was still continuing to rely on volu- minous paper records duplicated in multiple locations. Keeping data safe continues to worry health care organizations, consumers, and policy makers, but the benefits of integrated systems outweigh the risks (Trossman, 2009a).

EHRs reduce redundancies, improve efficiency, decrease medical errors, and lower health care costs. Continuity of care, discharge planning and follow-up, ambulatory care collaboration, and patient safety are just a few of the additional advantages of EHRs. Furthermore, fully integrated systems allow for collective data analysis across clinical conditions, health care organizations, or worldwide and sup- port evidence-based decision making. With the federal government funding health systems to upgrade to EHRs, the current 12 percent of hospitals with EHRs is expected to increase (Gomez, 2010).

Virtual Care Virtual care, previously known as telemedicine and now more commonly called telehealth, has evolved as technologies to assess, intervene, and monitor patients remotely improved. Both communication technology (i.e., audio and video) and improvements in mobile care technology contribute to the ability of health care professionals to provide care from a distance. Nurses, for example, can watch banks of video screens monitoring ICU patients’ vitals signs miles away from the hospital. Electronic equipment, such as a stethoscope, can be accessed by a health care provider in a distant location. Such systems are especially useful in providing expert consulta- tion for specialty care (Zapatochny-Rufo, 2010).

Robotics Another technological advance is robotics. In the hospital, supplies can be ordered electroni- cally, and then laser-guided robots can fill the order in the pharmacy or central supply and de- liver the requested supplies to nursing units via their own elevators more efficiently, accurately, and in less time than individuals can. Mobile robots can also monitor patients, report changes and conditions, and allow caregivers to communicate from a distance (Markoff, 2010) via a wireless connection to a laptop or a smart phone. Robot functionality will continue to expand, limited only by resources and ingenuity.

Communication Technology Just as rapidly as clinical and data technology are evolving, so are communication technolo- gies, changing forever the ways people keep informed and interact (Sullivan, 2013). Informa- tion (accurate or inaccurate) is disseminated with lightening speed while smartphones capture real-time events and broadcast images instantaneously.

Social media has revolutionized communication beyond the realm of possibilities from just a few years ago (Kaplan & Haenlein, 2010). Social media connects diverse populations and en- courages collaboration, the exchange of images, ideas, opinions, and preferences in networking Web sites, online forums, Web blogs, social blogs, wikis, podcasts, RSS feeds, photos, video content communities, social bookmarking, online chat rooms, microblogs, such as Twitter, and online communities, such as Facebook and LinkedIn (Sullivan, 2013).

Similar to other enterprises, most health care organizations have an online presence with a Web site and social media sites, such as Facebook, Twitter, and blogs. Units within the organiza- tion may have Facebook pages as well, with staff who post on those sites. These opportunities

6 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

for information sharing and relationship building also come with risks (Raso, 2010; Trossman, 2010b). Patient confidentiality, the organization’s reputation, and recruiting efforts can be en- hanced or put in jeopardy by posts to the site (Sullivan, 2013).

Cultural, Gender, and Generational Differences According to the U.S. Census Bureau, the minority population in the U.S. increased from 31 to 36 percent from 2000 to 2010 (U.S. Census, 2011). The largest minority population is Hispanic, and that population increased to 50 million (16 percent of the total U.S. population) in 2010. The Asian population grew to 14 million (5 percent) in the same time period, and the African American population stands at 42 million (14 percent).

The cultural diversity seen in the general population is also reflected in nursing. The Health Resources and Services Administration (HRSA, 2011) reports that 16 percent of nurses are Asian, African American, Hispanic, or other ethnic minorities, an increase from 12 percent in 2004.

The gender mix found in nursing, however, differs from the general population, with men greatly outnumbered by women. Of the population of more than 3 million nurses in the U.S., only 6 percent are men, although changes suggest the ratio is improving. The proportion of men to women has risen to 1 in 10 in the decades since 1990 (HRSA, 2011). Both cultural diversity and gender diversity challenge the nurse manager to consider such differences when working with staff, colleagues, and administrators as well as mediating conflicts between individuals.

Generational differences in the nursing population is unprecedented, with four generational cohorts working together (Keepnews et al., 2010). Referred to as traditionals, baby boomers, Generation X, and Generation Y, each generational group has different expectations in the work- place. Traditionals value loyalty and respect authority. Baby boomers value professional and personal growth and expect that their work will make a difference.

Generation X members strive to balance work with family life and believe that they are not rewarded given their responsibilities (Keepnews et al., 2010). Generation Y (also called milleni- als) are technically savvy and expect immediate access to information electronically.

Similar to dealing with cultural and gender differences, the challenge for managers is to avoid stereotyping within the generations, to value the unique contributions of each generation, to encourage mutual respect for differences, and to leverage these differences to enhance team work (Chambers, 2010).

Violence Prevention and Disaster Preparedness Sadly, violence invades workplaces, and health care is no exception. Moreover, nearly 500,000 nurses are victims of workplace violence (Trossman, 2010c). In addition, recent disasters (e. g., the earthquake and tsunami in Japan, tornadoes in the U.S.) and the threats of terrorism and pan- demics challenge health care organizations to prepare for the unthinkable.

Extensive staff training is required (AHRQ, 2011). Techniques include computer simula- tions, video demonstrations, disaster drills, and a clear understanding of communication sys- tems and the incident command center. A natural disaster, an attack of terrorism, an epidemic, or other mass casualty events may, and probably will, occur at some time. All health care organizations must be prepared to care for a surge in casualties while reducing the impact on patients and staff.

Changes in Nursing’s Future Nurses will face many changes in the future, including an increasing demand for nurses as the population ages, a worsening shortage as nurses age, and recommendations for changes to prac- tice and education. The aging population is surviving previously fatal diseases and conditions

CHAPTER 1 • INTRODUCING NURSING MANAGEMENT 7

due to ever-evolving health care technologies. These patients often require ongoing care for chronic illnesses as well as for acute episodes of illness.

Just as the population is aging and requiring more and more care, nurses too are growing older. The average age of the registered nurse is 46 years, although the number of RNs under age 30 is increasing at a faster pace than before (HRSA, 2011).

Slightly more than 3 million nurses are currently licensed as registered nurses in the U.S., and 85 percent of them practice full- or part-time in the profession (HRSA, 2011). Jobs for nurses, however, are expected to grow to 3.2 million by 2018, much faster than the average for all occupations (U.S. Department of Labor, 2011). Also, with implementation of health care reform, increases in the demand for nurses in primary care and acute care settings are expected.

The Institute of Medicine’s report on the future of nursing makes sweeping recommenda- tions for nursing’s future, including that “nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States” (IOM, 2010, p. 3). In addition, IOM posits that today’s health care environment necessitates better-educated nurses and recommends that 80 percent of nurses be prepared at the baccaluareate or higher level by 2020.

At the same time, the Carnegie Foundation recommends radically transforming nursing education (Benner et al., 2009). Its recommendations include:

1. Focus on how to apply knowledge, not only acquire it.

2. Integrate clinical and classroom teaching, rather than separately.

3. Emphasize clinical reasoning, not only critical thinking.

4. Emphasize formation, rather than socialization and role taking (Benner et al., 2009).

Even More Change . . . What does the future hold for health care? Change is the one constant. Quality of care will continue to be monitored and reported with accompanying demands to tie pay to performance. Technology of care, communication, and data management will become more and more com- plex as computer processing power and storage capacity expand (Clancy, 2010) and equipment becomes smaller and more mobile. Access to care and how to pay for it will continue to drive policy and funding decisions. Everyone in health care must learn to live with ambiguity and be flexible enough to adapt to the changes it brings.

Challenges Facing Nurses and Managers Every nurse must be prepared to manage. Specific training in management skills is needed in nursing school as well as in the work setting. Most important, however, is that nurses be able to transfer their newly acquired skills to the job itself. Thus, nurse managers must be experienced in management themselves and be able to assist their staff in developing adequate management skills. Management training for nurses at all levels is essential for any organization to be effi- cient and effective in today’s cost-conscious and competitive environment.

The challenge for nurse managers and administrators is how to manage in a constantly changing system. Working with teams of administrators and providers to deliver quality health care in the most cost-effective manner offers opportunity as well. Nurses’ unique skills in communication, negotiation, and collaboration position them well for the system of today and for the future.

Nurse managers today are challenged to monitor and improve quality care, manage with limited resources, help design new systems of care, supervise teams of professionals and nonprofessionals from a variety of cultures, and, finally, teach personnel how to function well in

8 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

the new system. This is no small task. It requires that nurses and their managers be committed, involved, enthusiastic, flexible, and innovative; above all else, it requires that they have good mental and physical health. Because the nurse manager of today is responsible for others’ work, the nurse manager must also be a coach, a teacher, and a facilitator. The manager works through others to meet the goals of individuals, of the unit, and of the organization. Most of all, the man- ager must be a leader who can motivate and inspire.

Nurse managers must address the interests of administrators, colleagues in other disciplines, and employees. All want the same result—quality care. Administrators, however, must focus on cost and efficiency in order for the organization to compete and survive. Colleagues want col- laborative and efficient systems of care. Employees want to be supported in their work with ad- equate staffing, supplies, equipment, and, most of all, time. Therein lies the conflict. Between all of them is the nurse manager, who must balance the needs of all. Being a nurse manager today is the most challenging opportunity in health care. This book is designed to prepare you to meet these challenges.

What You Know Now • Health care is radically changing and is expected to continue to change in the foreseeable future. • The tension between providing adequate nursing care and paying for that care will continue to dominate

health policy decisions. • Reducing medical errors is the goal of quality initiatives. • Cultural, gender, and generational diversity will continue to shape the nursing workforce. • Evidence-based practice will guide nursing decisions into the future. • Electronic health records, robotics, and virtual care are just a few of the many technologies continuing to

evolve. • Expansion in communication technologies will continue to offer opportunities and challenges to health

care organizations. • Threats of natural disasters, terrorism, and pandemics require all health care organizations to plan and

prepare for mass casualties. • The nurse manager is challenged to manage in a constantly changing environment.

Questions to Challenge You 1. Name three changes that you would suggest to reduce the cost of health care without compromising

patients’ health and safety. Talk about how you could help make these changes. 2. What mechanisms could you suggest to improve and ensure the quality of care? (Don’t just suggest

adding nursing staff!) 3. How could you help reduce medical errors? What can you suggest that a health care organization

could do? 4. Do your clinical decisions rely on evidence-based practice? If you answer no, why not? 5. What are some ways that nurses could take advantage of emerging technologies in health care and

information systems? Think big. 6. Have you participated in a disaster drill? Did you notice ways to improve the organization’s readi-

ness for mass casualties? Name at least one. 7. What steps can you take to transfer the knowledge and skills you learn in this book into your work

setting?

CHAPTER 1 • INTRODUCING NURSING MANAGEMENT 9

Pearson Nursing Student Resources Find additional review materials at www.nursing.pearsonhighered.com

Prepare for success with additional NCLEX®-style practice questions, interactive assignments and activities, Web links, animations and videos, and more!

Agency for Healthcare Research and Quality. (2011). AHRQ disaster response tools and resources. Retrieved May 25, 2011 from http://www.ahrq. gov/research/altstand

American Nurses Credential- ing Center (2011). Magnet Recognition Program. Retrieved April 27, 2011 from http://www. nursecredentialing.org/ Magnet.aspx

Benner, P., Sutphen, M., Leonard, V., and Day, L. (2009). Educating nurses: A call for radical trans- formation. San Francisco: Jossey-Bass.

Binder, L. (2010). Leapfrog: Unique and salient mea- sures of hospital quality and safety. Prescriptions for Excellence in Health Care, 8, 1–2.

Brown, D. S., Aydin, C. E., Donaldson, N., Fridman, M., & Sandhu, M. (2010). Benchmarking for small hospitals: Size didn’t mat- ter! Journal of Healthcare Quality, 32(4), 50–60.

Centers for Medicare and Medic- aid Services (CMS) (2011). National health expenditure data. Retrieved April 25, 2011 from https://www. cms.gov/NationalHealth- ExpendData/25_NHE_Fact_ Sheet.asp

Chambers, P. D. (2010). Tap the unique strengths of the mil- lennial generation. Nursing

Management, 41(3), 37–39.

Christianson, J. B., Volmar, K. M., Alexander, J., & Scanlon, D. P. (2010). A report card on provider report cards: Current status of the health care transpar- ency movement. Journal of General Internal Medicine, 25(11), 1235–1241.

Clancy, T. R. (2010). Technology and complexity: Trouble brewing? Journal of Nurs- ing Administration, 40(6), 247–249.

Dunton, N., Gonnerman, D., Montalvo, I., & Schumann, M. J. (2011). Incorporating nursing quality indicators in public reporting and value- based purchasing initiatives. American Nurse Today, 6(1), 14–18.

Encinosa, W. E., & Hellinger, F. J. (2008). The impact of medical errors on ninety- day costs and outcomes: An examination of sur- gical patients. Health Services Research, 43(6), 2067–2085.

Hader, R. (2010). The evident that isn’t . . . interpreting research. Nursing Manage- ment, 41(9), 23–26.

Health Resources and Services Administration (HRSA) (2011). The registered nurse population: Findings from the 2008 national sample survey of registered nurses. Retrieved April 26, 2011

from http://bhpr.hrsa.gov/ healthworkforce/ rnsurvey2008.html

Houser, J., & Oman, K. S. (2010). Evidence-based practice: An implementa- tion guide for healthcare organizations. Sudbury, MA: Jones & Bartlett.

Gomez, R. (2010). Automation: HER upgrade consider- ations. Nursing Manage- ment, 41(2), 35–37.

Institute of Medicine (1999). To err is human: Build- ing a safer health system. Washington, DC: National Academy Press.

Institute of Medicine (2010). The future of nursing: Leading change, advancing health. Retrieved April 26, 2011 from http://www. thefutureofnursing.org/ IOM-Report

Kaplan, A. M., & Haenlein, M. (2010). Users of the world, unite! The challenges and opportunities of social media. Business Horizons, 53(1), 59–68.

Keepnews, D. M., Brewer, C. S., Kovner, C. T., & Shin, J. H. (2010). Genera- tional differences among newly licensed registered nurses. Nursing Outlook, 58(3), 155–163.

Lake, E. T., Shang, J., Klaus, S., & Dunton, N. E. (2010). Patient falls: Association with hospi- tal magnet status and nursing unit staffing. Research in

References

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10 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

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