Nursing Leadership And Management

Nursing Leadership And Management

Today, all nurses are managers. Whether you work in a freestanding clinic, an ambulatory 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 assistive 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. Nursing Leadership And Management You need to know what motivates people and how you can help create an environment 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.

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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 medicines, 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)Nursing Leadership And Management . 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 continued 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 government 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 elsewhere, 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 perfect the process. Patient satisfaction surveys are one example of how health care organizations
evaluate their customers’ needs Nursing Leadership And Management . 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 preventable 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 medication 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 million 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)Nursing Leadership And Management .
Evidence-Based Practice
Evidence-based practice has emerged as a strategy to improve quality by using the best available 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 exception, 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 organizations that provide nursing excellence” (ANCC, 2011). To qualify for recognition as a magnet 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).

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Systems involving participatory management and shared governance create organizational
environments that reward decision making, creativity, independence, and autonomy. These organizations 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 magnet 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. Encouraging 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 Nursing Leadership And Management .
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 platforms; 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 manage communication and reduce redundancies, health care was still continuing to rely on voluminous 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 support 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 consultation for specialty care (Zapatochny-Rufo, 2010)Nursing Leadership And Management .
Robotics
Another technological advance is robotics. In the hospital, supplies can be ordered electronically, and then laser-guided robots can fill the order in the pharmacy or central supply and deliver 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 technologies, changing forever the ways people keep informed and interact (Sullivan, 2013). Information (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 encourages 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 organization 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 enhanced 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)Nursing Leadership And Management . 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 workplace. 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 millenials) 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 pandemics challenge health care organizations to prepare for the unthinkable.
Extensive staff training is required (AHRQ, 2011). Techniques include computer simulations, video demonstrations, disaster drills, and a clear understanding of communication systems 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 practice 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 recommendations 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 Nursing Leadership And Management .
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 complex 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 efficient 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 manager 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 collaborative and efficient systems of care. Employees want to be supported in their work with adequate 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 Nursing Leadership And Management .
• 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 readiness 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? Nursing Leadership And Management