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Problem Solving: part of decision making; systematic process focusing on analyzing a difficult situation
involving higher-order reasoning and evaluation and needs the decision making step.
● It’s possible to make a decision without full understanding in problem solving.
Critical Thinking / Reflective Thinking: the mental process of actively and skillfully conceptualizing,
applying, analyzing, synthesizing, and evaluating information to reach an answer or conclusion
● Broader than decision making and problem solving; involves forming judgments about facts.
While uses knowledge and experience to make sound decisions.
● Characteristics of a Critical Thinker
○ Insight, Intuition, empathy, and willingness to take action.
Clinical Reasoning: integrating and applying different types of knowledge to weigh evidence, critically think
about arguments, and reflect upon the process used to arrive at diagnosis
● Structured approach to problem solving and decision making increases clinical reasoning.
Traditional Problem Solving (bad due to time used for implementation = less effectiveness)
● Identify = identify the problem
● Gather data = establish decision criteria
● Explore alternatives
● Evaluate alternatives
● Select solution = or choose best alternative
● Implement the solution
● Evaluate = evaluate the decision
Feedback Mechanism of the Nursing Process and Nursing Process: A Problem-Solving and Decision-
Making Model
● Assess ● Implement
● Diagnose ● Evaluate
● Plan
● Gender ● Gender
● Values ● Personal individual values
● Life experience ● Life experience
● Individual preference - self-awareness and ● Preferences
honest with oneself (doing unpopular things) ● Willingness to take risks
● Thinking Styles - Right brain …intuitive, ● Brain hemisphere dominance
creative vs. Left Brain ..Analytical ● Predominant thinking style
Decision-Making Tools
● Decision grids ● Consequence tables
● Payoff tables ● Logic models
● Decision trees ● Program evaluation and review technique
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● Management –shapers of structural features of an organization and that goals are being met
○ Process of directing an organization by deployment and manipulation of resources
Leadership Flaws
● A lack of energy ● Not collaborating
● Acceptance of their own mediocre ● Not walking the talk
performance ● Resisting new ideas
● A lack of clear vision ● Not learning from mistakes
● Poor judgement ● Lack of interpersonal skills
● Failing to develop others ● Workers achieving minimum standards doing
● Systematic soldiering the least amount of work possible
Historical Development of Leadership Theory (before this most of the concentration was on management
styles)
● The Great Man Theory
○ Some men born to lead and other born to be led
○ Some believe people are born with traits, characteristics that make for better leaders
○ Contemporary opponents argue that leadership skills can be developed
● Leadership Styles
○ 1951 lewin and Lippit
○ Authoritarian Leaders characterized by:
■ Strong control is maintained
■ Others are motivated by coercion
■ Directed with commands
■ Communication flows downward
■ Decisions do not involve others
■ Status differences
■ Criticism is punitive
○ Ex. US Army, top down
● Democratic leadership
○ Less control
○ Economic and ego are used to motivate
○ Directed through suggestions and guidance
○ Communication up and down
○ Decision making involves others
○ We rather than I and you
○ Criticism is constructive
● Laissez-faire leadership
○ Permissive with little or no control
○ Motivates by support when asked for by the group
○ Provides little or no direction
○ Up and down communication between meers
○ Places emphasis on the group
○ No criticism
Transactional Leadership
● Focus is on management tasks ● No shared values
● Is committed ● Examines causes
● Trade offs to meet goals ● Uses contingency reward
Transformational Leaders
● Identifies common values ● Empowers others
● Is a caretaker ● Traditionally nurses have been over
● Inspires others with visions managed and under led
● Has a long term vision ● Warnings …highly desirable but need to be
● Looks at effects adaptable
MANAGEMENT INVOLVEMENT
● IMPLEMENTING HEALTHCARE REFORM
● ADDRESSING POTENTIAL INTERNATIONAL NURSE SHORTAGE
● HIGH TURNOVER RATES
● ADMINISTRATION SHORTAGE
● UNIONIZATION
● MANDATORY OVERTIME
● MAINTAINING COHESIVE, PRODUCTIVE, INTERPROFESSIONAL TEAMS
LEADERSHIP CRISIS???
● SUGGESTION IS THAT CONTEMPORARY LEADERS HAVE FAILED TO CHANGE WITH THE TIMES
○ WORLD IS CHANGING QUICKLY
○ TRADITIONAL TOP DOWN LEADERSHIP CANT EVOLVE
○ SINGLE DIRECTIVE APPROACHES VS PARTICIPATORY MODELS
SERVANT LEADERSHIP - RECOGNIZED THAT MOST SUCCESSFUL MANAGERS LEAD IN A DIFFERENT WAY
● Put serving others first
○ employees
○ customers
○ community
● Foster an atmospheres
○ collaboration
○ teamwork
○ collective activism
PRINCIPAL AGENT THEORY - SUGGESTS THAT NOT ALL FOLLOWERS ARE INHERENTLY MOTIVATED TO ACT
IN THE BEST INTEREST OF THE PRINCIPAL (LEADER OR EMPLOYER)
● MAY HAVE AN INFORMATIONAL ADVANTAGE OVER THE LEADER
● MAY HAVE THEIR OWN PREFERENCES
EMOTIONAL INTELLIGENCE - THE ABILITY TO PERCEIVE, UNDERSTAND, AND CONTROL ONE'S OWN
EMOTIONS AS WELL AS OTHERS
● INITIALLY DEFINED AS - DEVELOPS WITH AGE
● CONSISTS OF THREE MENTAL PROCESSES
○ APPRAISING AND EXPRESSING EMOTIONS
○ REGULATING EMOTIONS
○ USING EMOTIONS IN ADAPTIVE WAYS
FIVE COMPONENTS OF EI
1. SELF AWARENESS
2. SELF REGULATION
3. MOTIVATION
4. EMPATHY
5. SOCIAL SKILLS
AUTHENTIC LEADERSHIP
● IN ORDER TO LEAD ..LEADERS MUST BE TRUE TO THEMSELVES AND THEIR VALUES AND ACT
ACCORDINGLY
● IT IS THE LEADER'S' PRINCIPLES AND THEIR CONVICTION TO ACT ACCORDINGLY THAT INSPIRE
FOLLOWERS
○ Purpose: understand their own …self aware
○ Values: link purpose and passion
○ Heart: care for themselves and the people they lead
○ Relationships: value building relationships
○ Self-discipline: incorporate balance into personal and professional lives
Thought Leadership
● Applies to a person who is recognized among his or hers peers for innovative ideas and who
demonstrates the confidence to promote those ideas
○ Attract followers with vision and risk taking not empowerment or representation
Industrial Age
● Machine and Capital were primary concern
● People were needed but replaceable
● Focus on controlling workers ..fitting in slots
● Reward and punishment for external motivation
Relationship age leadership and health care
● Leading people who have the power to choose
● Embrace the whole person
● Contemporary health care organizations can not must not focus solely on relationships
● Becoming a better leader manager means knowing what leading-managing mean ..and balance
traditional industrial age management with relationship age leadership
● Self aware regarding personal blocks and ● Prioritizing day to day planning to meet unit
barriers goals
● Function as a role model and resource ● Builds time for planning
● Recognize ones own values on use of time and ● Analyzes how time is managed
the expectation of others ● Eliminates environmental barriers
● Assist followers in working cooperatively ● Handles paperwork promptly and effectively
● Prevents and or filters interruptions ● Breaks down lareger tasks to smaller to make
● Presents calm during high acuity easier to accomplish
● Prioritizes conflicting time requirements ● Utilizes technology and evaluates staffing
SMART Approach
● Set specific, clear goals
● Record your progress ..measurable progress maintains interest
● Identify steps
● Be realistic about time constraints
● Set a time frame
● Examples in day to day nursing
○ Staffing schedules
○ Patient care assignments
○ Coordination of lunch /break schedules
○ Interdiscipinary coordination of patient care
○ Handoff reports
○ Med administration
○ Documentation
Work environment
● Is it poor planning or is it work environment???
● The use of industrial engineering principles
● Gather all supplies
● Group activities that are in the same location
● Use time estimates
● Document activities as soon as possible strive to end the work day on time
Time wasters
● Technology
● Socialization
● How to avoid socialization as a manger
○ Don’t make self overly accessible
○ Innterupt
○ Avoid promoting socialization
○ Be brief
○ Schedule long winded pests
○ Many of these things can also promote team building and trust …so mange them wisely
Self awareness
● Staying focused on things that matter
● Taking care of ones self
● Following through in a timely and consistent manner
● Self awareness regarding completing tasks in an isolated setting vs. group
● Beware of ones own work style and how it influences others
● How and when are we most productive
Formal Organization
● Departmentalization, work division …provides a framework for defining managerial authority,
responisibility, and accountability
○ Roles and functions are defined, differing roles, and rank and hierarchy are evident
Informal Structure
● Natural forming social network
● Fills in the gap with connections and relationships
● Based on camaraderie
● Result in more immediate responses from individuals
● People rely on informal structure if formal structure has stopped being effective
● Informal has it’s own communication network-THE GRAPEVINE !!!
● Communication is fast and easily facilitated in all directions
● Difficult to slow or stop and source of rumor or gossip
Leadership roles and Management Functions
Characteristics of Bureaucracy
● There must be a clear division of labor
● A well defined hierarchy of authority must exist in which superiors are seperated from subordinates
● There must be impersonal rules –people are not free to act as they please
● A system of procedures for dealing with work situations must exist
● A system of rules covering the rights of each position must exist
● Selection for employment and promotion are based on technical competence
Advisory Positions
● Clinical specialists and in-service directors (educators)
● Staff
● Lack Authority
● Descriptions and responsibilities need to be spelled out to maximize productivity
Unity of Command - Employees have one manager to whom they report ..simplifies relationships and
communication
Span of Control
● The number of people directly reporting to any one manager
● The narrower the span the greater number of levels in the organization..
● Ideal span depends on various factors
● Nature of the job
● The manager's abilities
● The employees' maturity
● The task complexity
● The level of the organization in which the work occurs
● Increased financial pressures
● Electronic communication
● Technology advances
● All have had an impact on reducing the number of adminsitrators ---flattinging the organization
Managerial Levels
➢ Effectiveness of these first level managers tremendously affect the organization
➢ Leadership skills influence productivity and satisfaction
● Top Level Managers ---CEO, CNO, COO etc..
○ Coordinate internal and external influences
○ Make decisions with few guidelines or structures
○ Setting policy, creating goals, organization philosophy
○ Greater need for leadership skills
○ Not as involved in daily opperations
● Middle Level Managers –nursing supervisors, unit managers
○ Coordinate efforts of the lower levels of hierarchy and serve as go between between lower
and top level managers
○ Handels Day to day opperations
○ Involved in some long term planning
○ Unit policies
○ Some institutions have changed titles of nurse managers to directors, while other smaller
facilities use director in indicate CNO
● First-Level mangers –RNs
○ Concerned with their units work flow
○ Immediate problems
○ Personal needs of the employees
● Ad Hoc
○ Used on a temporary basis
○ Facilitate the completion of a project
○ Project team / task approach
○ BUT: Decreases the strength of the Chain of Command
○ Decreases loyalty to the organization
● Matrix
○ Focus on product and function
○ Function is all the tasks needed to produce the product
○ Formal horizonal and vertical chain of command
○ Less formal rules
○ Fewer levels of hierarchy
○ Centralizing expertise
○ BUT: Slow because of the need for information sharing
○ Confusion and frustration due to dual-authority
Stakeholders
★ Are those entites that play a role in the organizations health and performance or that are
affected by the organization
○ Internal – RN, RT, dietitian
○ External – nursing schools, Home health agency
★ May have an interest in the organization but not the power to change it
★ Organizations usually do not choose their stakeholders
★ Supportive or threatening influence
★ Organization must analyze stakeholders to clarify the consquences of a decision
Organizational Culture
● Organizations values, language, traditions, customs, and sacred cows—things not open for
discussion or change
○ Expectations
○ Philosophy
○ Self image
○ Interactions with the outside world
○ Not to be confused with organizational climate
○ How employees perceive an organization
○ Climate and culture may differ
○ Assessing the culture is a manager role while developing and building the culture is a
leadership role
○ Building a new culture might require new leadership
○ Conflicits between management and leadership in establishing or changing the culture?
○ Organizations may have subcultures
■ Nurse leader must recognize subcultures and do what is needed to create shared
norms and priorities
■ Assist individuals with different values to understand the organizations culture
Committee Structure
● Managers are responsible for creating appropriate committee structures
● Committees used to facilitate good upward communication
● Can pool expertise and skills to reduce resistance to change
● If committees are not organized or led well
○ Becomes liability
○ Wastes energy, time, money, and can defer or slow decision making
Managers responsibilities
● Managers should do what they can to see that employees feel they have some control over
scheduling, shift options, and staffing policies
● The use of staffing clerks and computers can help with staffing
● But staffing is an important function for first and middle managers
Centralized Staffing
● Centralized Staffings when decisions are made by personnel in a central office or staffing center
○ Good Points
■ Manager has limited roles
■ Minor adjustments
■ Ultimate responsibility for meeting organizations needs
■ Illness or acuity changes
■ Generally fairer
■ Policies are consistent and impartial
■ Frees manager to do other priorities
○ Bad Points
■ Less flexibility
■ Less responsive to budget issues
Decentralized Staffing
● Decentralized Staffing is when the manager is responsible for:
○ covering all absences,
○ reducing staffing in periods of low census
○ preparing monthly schedule
○ Preparing holiday and vacation schedules
● Good Points
○ Manager understands the units needs
○ Feels more in control
○ Increased autonomy and flexibility
● Bad Points
○ Risk of unfair or inconsistent scheduling
○ Time consuming
○ Staffing is unequal or higher quality in certain areas
Staffing Diversity
● Managers must be aware to have ethnically and culturally diverse staff to meet the needs of
increasingly diverse patient populations
● 2013 US department of health and human services put 15 standards into effect
● Several of these directly addressed cultural and linguistic diversity
○ Language assistive services
○ Competency of the interpreters
○ Verbal and written notice be given that services exist
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Chapter 20 Delegation
Delegation - getting work done through others or directing the performance of one or more people to
accomplish organizational goals.
● Giving someone the authority to complete a task or action on your behalf - but you're still
responsible
● Joint Statement of Delegation –ANA and NCSBN
● States that delegation ts a skill that must be taught, practiced and developed.
● Delegation is also used for learning opportunities - without them subordinates become bored and
non-productive.
Delegating Effectively by the following
● Plan ahead to prevent crisis situation or become overwhelmed
● Identify necessary skill and education level to complete the task
● Select capable personnel
● Communicate goals clearly
● Empower the delegate
● Set deadline and monitor progress
● Monitor the role, be a role model, and provide guidance
● Evaluate performance
● Reward accomplishment
Before Delegation you must Identify Necessary skills and education levels
● Scope of practice for RN is typically defined by the Board of Nursing in each state
● Challenge for RN is to understand the scope of practice for others on the team
● Nurse must be aware of the essential elements of delegation in their states NPA
○ Items that can not be delegated
○ Items that can be routinely delegated
○ Guidelines about delegated tasks
○ Description of professional nursing practice
○ Description of LVN/LPN and unlicensed roles
○ Degree of supervision required
○ Guidelines for lowering delegation risks
○ Warnings about inappropriate delegation
○ Restricted use of the word nurse to licensed staff
Select Capable Personnel
● Leadership role is to stretch new and capable employees who want opportunities to learn and grow
● Look for employees who are innovative and willing to take risks
● Important that the person whom the task is being delegated considers the task to be important
● Ask the individual if they are capable of completing the task (if they have enough resources), then
validate it by observation
Communicate Goals Clearly
● Identify limitations or qualifications that are being imposed on the task
● Communicate specifically WHAT, HOW, and by WHEN
● Should also provide the purpose, limitations, and expectations for reporting
Empower the delegate
● Delegate the authority and the responsibility to complete the task
● Frustrating to the employee not to have the resources available to carry out the plan
Set deadlines and monitor progress
● Informal but regularly scheduled meetings
● Encourages ongoing communication to clarify any questions or misconceptions
● Leader/manager must be ready to intervene on patients behalf at any moment, and if so provide
feedback
Model the role and provide guidance
● Convey a feeling of confidence and encouragement
● Be available to identify alternative solutions
● Encourage employee to solve problems first but be available to answer questions
● Reassuming the task should be manages last resort for it fosters a sense of failure in the employee
Evaluate performance and Reward Accomplishment
● Evaluate the experience
● Include positive and negative aspects
● Shared reflections on what could have been done differently
● The more recognition team members receive, the more recognition will be given to their leader
Common Delegation Errors
● Under Delegation
○ Can be seen as a lack of ability by leader where in fact delegation can be empowering
○ Lack of trust
■ Communicate frequently to decrease fears and increase sense of control
○ Not enough time to delegate due to not having enough time to teach
○ Lack of experience in delegating
Over Delegating
● Poor managers of time
● Insure about their ability to perform a task
● Over Delegate to exceptional employees that can become overworked and tired thus less
productive
Improper delegating
● Wrong time, wrong person, or for wrong reason
● Beyond the capabilities of the individual
Five Rights of Delegation
● Right task ● Right direction/communication
● Right circumstances ● Right level of supervision
● Right person