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Effective Leadership and Management in Nursing
Eleanor J. Sullivan, PhD, RN, FAAN
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
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
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:
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
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
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
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
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
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