Management and leadership in nursing

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Personal Review of Management and Leadership in Nursing

Using your textbook (ATTACHED BELOW) and the results of your personality test, you will answer the questions below in narrative form (no Q & A and no bulleted lists). Please follow all the APA 7th edition rules. Instructions:

  1. Take the Myers-Briggs Type Indicator assessment to examine your individual strengths and experiences in preparation for assuming management and leadership roles. (PERSONALITY RESULTS ATTACHED BELOW)
  2. It should be 5-6 pages of the body (not including the cover and reference page) using the headings and corresponding prompts below.
  3. Your work should be sourced with two (2) scholarly references within the last five years. 
  4. Be APA, 7th edition format and citation style. 


1. Leadership and Management Theory

  • How can you apply a leadership and management theory to achieve high quality nursing care for your patients and collaborate effectively with your health care team? Identify the citation(s) for the leadership or management theory you chose in answering this question.
  • Are you more of a leader or a manager? (LEADER) Please explain why you feel this way. In view of your results of the personality test, how can you strengthen aspects of your personality to grow more in leadership or in management? Which competencies do you need to strengthen to become the leader or manager you want to become?

2. Change Theory

  • How do you deal with change at your practice setting? What personality traits would you utilize to promote change in your facility and how did you decide which traits you would use? Are there traits that you would not agree with and why do you think they appear?

3. Communication Style

  • What did you learn about yourself taking the personality test? Which type of communicator are you? What are areas that you can strengthen to be more effective? To be more therapeutic? What are some barriers to effective communication styles which you have observed in yourself? Note: You may need to read between the lines in the results, as your communication style is not measured directly.

4. Performance Improvement and Quality Improvement

  • How can you manage both performance improvement and quality improvement at the same time? Answer this using your understanding of your results of the personality test and your textbook/lectures about leadership and management.
  • How can you apply the principles of performance improvement and/or quality improvement into your practice? Choose one principle and explain how you can implement it at your workplace.

5. Evidence-based Practice and Improvement

  • Evidence-based practice (EBP) has been emphasized all throughout your BSN program. How does EBP relate to achieving desirable performance outcomes and quality improvement?

6. Supervision Style

  • Compare and contrast effective and ineffective supervision styles which you have observed in your workplace (NURSING FLOOR). When doing so, make sure to apply principles of delegation, authority, responsibility, and accountability.

10/17/22, 10:31 AM Introduction | Architect (INTJ) Personality | 16Personalities 1/7


“Thought constitutes the greatness of man. Man is a reed, the feeblest thing

in nature but he is a thinking reed ”



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in nature, but he is a thinking reed.


It can be lonely at the top. As one of the rarest personality types – and one

of the most capable – Architects (INTJs) know this all too well. Rational and

quick-witted, Architects pride themselves on their ability to think for

themselves, not to mention their uncanny knack for seeing right through

phoniness and hypocrisy. But because their minds are never at rest,

Architects may struggle to �nd people who can keep up with their nonstop

analysis of everything around them.

A Pioneering Spirit

Architects question everything. Many personality types trust the status quo,

relying on conventional wisdom and other people’s expertise to guide their

lives. But ever-skeptical Architects prefer to make their own discoveries. In

their quest to �nd better ways of doing things, they aren’t afraid to break

the rules or risk disapproval – in fact, they rather enjoy it.

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But as anyone with this personality type would tell you, a new idea isn’t

worth anything unless it actually works. Architects want to be successful,

not just inventive. They bring a single-minded drive to their work, applying

the full force of their insight, logic, and willpower. And heaven help anyone

who tries to slow them down by enforcing pointless rules or o�ering poorly

thought-out criticism.

Architects, independent to the core, want to shake o� other

people’s expectations and pursue their own ideas.

This personality type comes with a strong independent streak. Architects

don’t mind acting alone, perhaps because they don’t like waiting around for

others to catch up with them. They also generally prefer making decisions

without asking for anyone else’s input. At times, this lone-wolf behavior can

come across as insensitive, as it fails to take into consideration other

people’s thoughts, desires, and plans.

It would be a mistake, however, to view Architects as uncaring. Whatever

the stereotypes about their stoic intellect, these personalities feel deeply.

When things go wrong or when they hurt others, Architects are personally

a�ected and spend much time and energy trying to �gure out why things

happened the way that they did. They may not always value emotion as a
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decision-making tool, but they are authentically human.

A Thirst for Knowledge

Architects can be both the boldest of dreamers and the bitterest of

pessimists. They believe that, through willpower and intelligence, they can

achieve even the most challenging goals. But these personalities may be

cynical about human nature more generally, assuming that most people are

lazy, unimaginative, or simply doomed to mediocrity.

People with the Architect personality type derive much of their self-esteem

from their knowledge and mental acuity. In school, they may have been

called “bookworms” or “nerds.” But rather than taking these labels as

insults, many Architects embrace them. They recognize their own ability to

teach themselves about – and master – any topic that interests them,

whether that’s coding or capoeira or classical music.

Architects don’t just learn new things for show – they genuinely

enjoy expanding the limits of their knowledge.

Architects can be single-minded, with little patience for frivolity, distractions,

or idle gossip. That said, they’re far from dull or humorless. Many Architects

are known for their irreverent wit, and beneath their serious exteriors, they

often have a sharp, delightfully sarcastic sense of humor.
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Social Frustrations

Architects aren’t known for being warm and fuzzy. They tend to prioritize

rationality and success over politeness and pleasantries – in other words,

they’d rather be right than popular. This may explain why so many �ctional

villains are modeled on this personality type.

Because Architects value truth and depth, many common social practices –

from small talk to white lies – may seem pointless or downright stupid to

them. As a result, they may inadvertently come across as rude or even

o�ensive when they’re only trying to be honest.

At times, Architects may wonder whether dealing with other people

is even worth the frustration.

But like any personality type, Architects do crave social interaction – they’d

just prefer to surround themselves with people who share their values and

priorities. Often, they can achieve this just by being themselves. When

Architects pursue their interests, their natural con�dence can draw people

to them – professionally, socially, and even romantically.

The Chess Game of Life
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Architects are full of contradictions. They are imaginative yet decisive,

ambitious yet private, and curious yet focused. From the outside, these

contradictions may seem ba�ing, but they make perfect sense once you

understand the inner workings of the Architect mind.

For these personalities, life is like a giant game of chess. Relying on strategy

rather than chance, Architects contemplate the strengths and weaknesses

of each move before they make it. And they never lose faith that, with

enough ingenuity and insight, they can �nd a way to win – no matter what

challenges might arise along the way.

How accurate is the introduction?

Architects You May Know

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10th edition
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describe generally accepted practices. However, the author(s), editors, and
publisher are not responsible for errors or omissions or for any consequences from
application of the information in this book and make no warranty, expressed or
implied, with respect to the currency, completeness, or accuracy of the contents of
the publication. Application of this information in a particular situation remains the
professional responsibility of the practitioner; the clinical treatments described and
recommended may not be considered absolute and universal recommendations.

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drug selection and dosage set forth in this text are in accordance with the current
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I dedicate this book to the two most

partnerships in my life: my husband,
Don Marquis,

and my colleague, Carol Huston.
Bessie L. Marquis

I dedicate this book to my
husband Tom.

We have built an
incredible life together and

I thank you for always
being at my side.
Carol J. Huston


Patricia Bishop, PhD, MSN, RN
Dean and Chief Nurse Administrator
Dean of Nursing
Brookline College of Nursing
Phoenix, Arizona

Barbara B. Blozen, EdD, MA, RN-BC, CNL
Associate Professor
New Jersey City University
Jersey City, New Jersey

Linda Cole, DNP, RN, CCNS, CPHQ, CNE
Assistant Professor
Department of Graduate Studies
Cizik School of Nursing
The University of Texas
Houston, Texas

Susan Davis, MSN, RN
Senior Instructor Nursing
Helen and Arthur E. Johnson Beth-El
College of Nursing and Health Sciences
University of Colorado
Colorado Springs, Colorado

Elmer V. Esguerra, MAN, RN
Faculty, Associate Degree Nursing Program
South Texas College Nursing & Allied Health
Weslaco, Texas

Cindy Farris, PhD, MSN, MPH, CNE
Indiana University Fort Wayne
Fort Wayne, Indiana

Teresa Faykus, DNP, MSN, BSN, RN, CNE
Professor Nursing
RN-BSN Coordinator
West Liberty University
West Liberty, West Virginia

Dawn Frambes, PhD, RN, MSA
Assistant Professor
Calvin University
Grand Rapids, Michigan

Kristi Frisbee, DNP, RN
Associate Professor and Master Advisor
Pittsburg State University
Pittsburg, Kansas

Rose A. Harding, MSN, RN
JoAnne Gay Dishman School of Nursing
Lamar University
Beaumont, Texas

Janice Hausauer, DNP, APRN, FNP-BC
Assistant Clinical Professor
Montana State University College of Nursing

Bozeman, Montana

Renee Hoeksel, PhD, RN, MSN, ANEF
College of Nursing
Washington State University Vancouver
Vancouver, Washington

Janine Johnson, RN, MSN
Associate Professor
Clarkson College
Omaha, Nebraska

Judy Kitchin, MS, RN, CNOR
Clinical Lecturer
Decker School of Nursing
Binghamton University
Binghamton, New York

Kathleen M. Lamaute, EdD, FNP-BC, NEA-BC, CNE, MA, MS, RN
Professor of Nursing
Barbara H. Hagan School of Nursing
Molloy College
Rockville Centre, New York

Diana Martinez Dolan, PhD, RN
Assistant Professor
St. David’s School of Nursing
Texas State University Round Rock Campus
Round Rock, Texas

Deborah Merriam, DNS, RN, CNE
Assistant Professor of Nursing
Daemen College

Amherst, New York

Missy Mohler, MS, RN
Assistant Professor
Mount Carmel College of Nursing
Columbus, Ohio

Dona Molyneaux, PhD, RN, CNE
Associate Professor
Frances M. Maguire School of Nursing and Health Professions
Gwynedd Mercy University
Gwynedd Valley, Pennsylvania

Sue Powell, MS, RN, PhN, CNE
Nursing Department
Century College
White Bear Lake, Minnesota

Mark Reynolds, DNP, RN, COI
Clinical Assistant Professor, RN-BSN/MSN Program Director
The University of Alabama in Huntsville
Huntsville, Alabama

Wendy Robb, PhD, RN, MSN, BSN, AND, CNE
School of Nursing
Cedar Crest College
Allentown, Pennsylvania

Joyce A. Shanty, PhD, RN
Coordinator, Allied Health Professions
Indiana University of Pennsylvania

Indiana, Pennsylvania

Cynthia Shartle, MSN, RN
ADN Program Instructor
South Texas College
McAllen, Texas

Ana Stoehr, PhD, RN, Post-MSN, MSN, BSN
Coordinator of the Master’s in Nursing Administration Concentration
George Mason University
Fairfax, Virginia

Diana Tilton, MSN, RN
Assistant Professor
Saint Luke’s College of Health Sciences
Kansas City, Kansas

Debra Wagner, DNP, RN
Associate Professor
Department of Nursing
Saginaw Valley State University
University Center, Michigan

Daryle Wane, PhD, ARNP, FNP-BC
Professor, Nursing BSN
Pasco-Hernando State College
New Port Richey, Florida

Debra White-Jefferson, DNP, MSN, RN
Assistant Professor
University of Louisiana at Lafayette
Lafayette, Louisiana

Mary B. Williams, MS, RN

Professor of Nursing
School of Nursing and Health Sciences
Gordon State College
Barnesville, Georgia


Legacy of Leadership Roles and Management
Functions in Nursing
This book’s philosophy has evolved over 38 years of teaching
leadership and management. We entered academe from the acute
care sector of the health-care industry, where we held nursing
management positions. In our first effort as authors, Management
Decision Making for Nurses: 101 Case Studies, published in 1987,
we used an experiential approach and emphasized management
functions appropriate for first- and middle-level managers. The
primary audience for this text was undergraduate nursing students.

Our second book, Retention and Productivity Strategies for Nurse
Managers, focused on leadership skills necessary for managers to
decrease attrition and increase productivity. This book was directed
at the nurse-manager rather than the student. The experience of
completing research for the second book, coupled with our clinical
observations, compelled us to incorporate more leadership content
in our teaching and to write this book.

Leadership Roles and Management Functions in Nursing was also
influenced by national events in business and finance that led many
to believe that a lack of leadership in management was widespread.
It became apparent that if managers are to function effectively in the
rapidly changing health-care industry, enhanced leadership and
management skills are needed.

What we attempted to do, then, was to combine these two very
necessary elements: leadership and management. We do not see
leadership as merely one role of management or management as
only one role of leadership. We view the two as equally important
and necessarily integrated. We have attempted to show this
interdependence by defining the leadership components and
management functions inherent in all phases of the management
process. Undoubtedly, a few readers will find fault with our divisions
of management functions and leadership roles; however, we felt it
was necessary first to artificially separate the two components for the
reader and then to integrate the roles and functions. We do believe
strongly that adoption of this integrated role is critical for success in

The second concept that shaped this book was our commitment to
developing critical thinking skills with the use of experiential learning
exercises. We propose that integrating leadership and management
can be accomplished using learning exercises. Most academic
instruction continues to be conducted in a teacher-lecturer–student-
listener format, which is one of the least effective teaching strategies.
Few individuals learn best using this style. Instead, most people
learn best by methods that utilize concrete, experiential, self-
initiated, and real-world learning experiences.

In nursing, theoretical teaching is almost always accompanied by
concurrent clinical practice that allows concrete and real-world
learning experience. However, the exploration of leadership and
management theory may have only limited practicum experience, so
learners often have little first-hand opportunity to observe middle-
and top-level managers in nursing practice. As a result, novice
managers frequently have little chance to practice their skills before
assuming their first management position, and their decision making
thus often reflects trial-and-error methodologies. For us, then, there
is little question that vicarious learning, or learning through mock
experience, provides students the opportunity to make significant

leadership and management decisions in a safe environment and to
learn from the decisions they make.

Having moved away from the lecturer–listener format in our
classes, we lecture for only a small portion of class time. A Socratic
approach, case study debate, and small and large group problem
solving are emphasized. Our students, once resistant to the
experiential approach, are now enthusiastic supporters. We also find
this enthusiasm for experiential learning apparent in the workshops
and seminars we provide for registered nurses. Experiential learning
enables management and leadership theory to be fun and exciting,
but most important, it facilitates retention of didactic material. The
research we have completed on this teaching approach supports
these findings.

Although many leadership and management texts are available,
our book meets the need for an emphasis on both leadership and
management and the use of an experiential approach. More than
280 learning exercises, representing various health-care settings
and a wide variety of learning modes, are included to give readers
many opportunities to apply theory, resulting in internalized learning.
In Chapter 1, we provide guidelines for using the experiential
learning exercises. We strongly urge readers to use them to
supplement the text.

New to This Edition
The first edition of Leadership Roles and Management Functions in
Nursing presented the symbiotic elements of leadership and
management, with an emphasis on problem solving and critical
thinking. This tenth edition maintains this precedent with a balanced
presentation of a strong theory component along with a variety of
real-world scenarios in the experiential learning exercises. We have
also maintained the dual focus of leadership development with a
balance of management content.

Responding to reviewer recommendations, we have added and
deleted content. Specifically, we continue to increase the focus on
quality and safety, interprofessional collaboration/team building,
technology in health care, mandates for increased quality and value,
healthy workplaces and civility, change management, and health-
care reform. In addition, there is new content on elastic thinking;
rebel leadership; agile leadership; stakeholder engagement;
interprofessional education; and patient, family, and subordinate
empowerment. We also have increased the use of
outpatient/community settings in our learning exercises.

We believe we have retained the strengths of earlier editions,
reflecting content and application exercises appropriate to the issues
faced by nurse leader-managers as they practice in an era
increasingly characterized by limited resources and emerging
technologies. The tenth edition also includes a continued focus to
include current research and theory to ensure accuracy of the
didactic material.

The Text
Unit I provides a foundation for the decision-making, problem-

solving, and critical-thinking skills as well as management and
leadership skills needed to address the management–leadership
problems presented in the text.

Unit II covers ethics, legal concepts, and advocacy, which we see as
core components of leadership and management decision

Units III to VII are organized using the management processes of
planning, organizing, staffing, directing, and controlling.

Features of the Text
The tenth edition contains many pedagogical features designed to
benefit both the student and the instructor:

• Examining the Evidence, appearing in each chapter, depicts new
research findings, evidence-based practice, and best practices in
leadership and management.

• Learning Exercises interspersed throughout each chapter foster
readers’ critical-thinking skills and promote interactive discussions.
Additional learning exercises are also presented at the end of each
chapter for further study and discussion.

• Breakout Comments are highlighted throughout each chapter,
visually reinforcing key ideas.

• Tables, displays, figures, and illustrations are liberally supplied
throughout the text to reinforce learning as well as to help clarify
complex information.

• Key Concepts summarize important information within every

The Crosswalk
A crosswalk is a table that shows elements from different databases
or criteria that interface. New to the eighth edition was a chapter
crosswalk of content based on the American Association of Colleges
of Nursing (AACN) Essentials of Baccalaureate Education for
Professional Nursing Practice (2008), the AACN Essentials of
Master’s Education in Nursing (2011), the American Organization for
Nursing Leadership (AONL) (formerly American Organization of
Nurse Executives [AONE]) Nurse Executive Competencies (updated
September 2015), and the QSEN Institute Competencies (2019). For
the ninth edition, the newly revised Standards for Professional
Performance from the American Nurses Association (ANA) Nursing:
Scope and Standards of Practice (2015) were included. This edition
continues to show how content in each chapter draws from or
contributes to content identified as essential for baccalaureate and
graduate education, for practice as a nurse administrator, and for
safety and quality in clinical practice.

In health care today, baccalaureate education for nurses is being
emphasized as of increasing importance, and the number of RN-
MSN and BSN-PhD programs is always increasing. Nurses are
being called on to remain lifelong learners and move with more
fluidity than ever before. For these reasons, this textbook includes
mapping to Essentials, Competencies, and Standards not only at the
baccalaureate level but also at the master’s and executive levels so
that nurses may become familiar with the competencies expected as
they continue to grow in their careers.

Without doubt, some readers will disagree with the author’s
determinations of which Essential, Competency, or Standard has
been addressed in each chapter, and certainly, an argument could
be made that most chapters address many, if not all, of the
Essentials, Competencies, or Standards in some way. The
crosswalks in this book then are intended to note the primary content
focus in each chapter, although additional Essentials, Competencies,
or Standards may well be a part of the learning experience.

The American Association of Colleges of Nursing
Essentials of Baccalaureate Education for
Professional Nursing Practice
The AACN Essentials of Baccalaureate Education for Professional
Nursing Practice (commonly called the BSN Essentials) were
released in 2008 and identified the following nine outcomes
expected of graduates of baccalaureate nursing programs (Table 1).
Essential IX describes generalist nursing practice at the completion
of baccalaureate nursing education and includes practice-focused
outcomes that integrate the knowledge, skills, and attitudes
delineated in Essentials I to VIII. Achievement of the outcomes
identified in the BSN Essentials will enable graduates to practice
within complex health-care systems and to assume the roles of

provider of care, designer/manager/coordinator of care, and member
of a profession (AACN, 2008) (Table 1).


Essential I: Liberal education for baccalaureate generalist
nursing practice
● A solid base in liberal education provides the cornerstone for the

practice and education of nurses.
Essential II: Basic organizational and systems leadership for
quality care and patient safety
● Knowledge and skills in leadership, quality improvement, and

patient safety are necessary to provide high-quality health care.
Essential III: Scholarship for evidence-based practice
● Professional nursing practice is grounded in the translation of

current evidence into one’s practice.
Essential IV: Information management and application of
patient-care technology
● Knowledge and skills in information management and patient-

care technology are critical in the delivery of quality patient care.
Essential V: Health-care policy, finance, and regulatory
● Health-care policies, including financial and regulatory, directly

and indirectly influence the nature and functioning of the health-
care system and thereby are important considerations in
professional nursing practice.

Essential VI: Interprofessional communication and
collaboration for improving patient health outcomes
● Communication and collaboration among health-care

professionals are critical to delivering high-quality and safe
patient care.

Essential VII: Clinical prevention and population health

● Health promotion and disease prevention at the individual and
population level are necessary to improve population health and
are important components of baccalaureate generalist nursing

Essential VIII: Professionalism and professional values
● Professionalism and the inherent values of altruism, autonomy,

human dignity, integrity, and social justice are fundamental to the
discipline of nursing.

Essential IX: Baccalaureate generalist nursing practice
● The baccalaureate graduate nurse is prepared to practice with

patients, including individuals, families, groups, communities,
and populations across the life span and across the continuum of
health-care environments.

● The baccalaureate graduate understands and respects the
variations of care, the increased complexity, and the increased
use of health-care resources inherent in caring for patients.

The American Association of Colleges of Nursing
Essentials of Master’s Education in Nursing
The AACN Essentials of Master’s Education in Nursing (commonly
called the MSN Essentials) were published in March 2011 and
identified the following nine outcomes expected of graduates of
master’s nursing programs, regardless of focus, major, or intended
practice setting (Table 2). Achievement of these outcomes will
prepare graduate nurses to lead change to improve quality
outcomes, advance a culture of excellence through lifelong learning,
build and lead collaborative interprofessional care teams, navigate
and integrate care services across the health-care system, design
innovative nursing practices, and translate evidence into practice
(AACN, 2011).


Essential I: Liberal education for baccalaureate generalist
nursing practice
● A solid base in liberal education provides the cornerstone for the

practice and education of nurses.
Essential I: Background for practice from sciences and
● Recognizes that the master’s-prepared nurse integrates scientific

findings from nursing, biopsychosocial fields, genetics, public
health, quality improvement, and organizational sciences for the
continual improvement of nursing care across diverse settings.

Essential II: Organizational and systems leadership
● Recognizes that organizational and systems leadership are

critical to the promotion of high quality and safe patient care.
Leadership skills are needed that emphasize ethical and critical
decision making, effective working relationships, and a systems

Essential III: Quality improvement and safety
● Recognizes that a master’s-prepared nurse must be articulate in

the methods, tools, performance measures, and standards
related to quality as well as prepared to apply quality principles
within an organization.

Essential IV: Translating and integrating scholarship into
● Recognizes that the master’s-prepared nurse applies research

outcomes within the practice setting, resolves practice problems,
works as a change agent, and disseminates results.

Essential V: Informatics and health-care technologies

● Recognizes that the master’s-prepared nurse uses patient-care
technologies to deliver and enhance care and uses
communication technologies to integrate and coordinate care.

Essential VI: Health policy and advocacy
● Recognizes that the master’s-prepared nurse is able to intervene

at the system level through the policy development process and
to employ advocacy strategies to influence health and health

Essential VII: Interprofessional collaboration for improving
patient and population health outcomes
● Recognizes that the master’s-prepared nurse, as a member and

leader of interprofessional teams, communicates, collaborates,
and consults with other health professionals to manage and
coordinate care.

Essential VIII: Clinical prevention and population health for
improving health
● Recognizes that the master’s-prepared nurse applies and

integrates broad, organizational, client-centered, and culturally
appropriate concepts in the planning, delivery, management, and
evaluation of evidence-based clinical prevention and population
care and services to individuals, families, and
aggregates/identified populations.

Essential IX: Master’s-level nursing practice
● Recognizes that nursing practice, at the master’s level, is broadly

defined as any form of nursing intervention that influences
health-care outcomes for individuals, populations, or systems.
Master’s-level nursing graduates must have an advanced level of
understanding of nursing and relevant sciences as well as the
ability to integrate this knowledge into practice. Nursing practice
interventions include both direct and indirect care components.

The American Organization for Nursing
Leadership Nurse Executive Competencies
In 2004 (updated in 2015), the AONL (formerly AONE) published a
paper describing skills common to nurses in executive practice
regardless of their educational level or titles in different
organizations. Although these Nurse Executive Competencies differ
depending on the leader’s specific position in the organization, the
AONL suggested that managers at all levels must be competent in
the five areas noted in Table 3 (AONL, AONE, 2015). These
competencies suggest that nursing leadership/management is as
much a specialty as any other clinical nursing specialty, and as such,
it requires proficiency and competent practice specific to the
executive role.


1. Communication and relationship building
● Communication and relationship building includes effective

communication, relationship management, influencing
behaviors, diversity, community involvement, medical/staff
relationships, and academic relationships.

2. Knowledge of the health-care environment
● Knowledge of the health-care environment includes clinical

practice knowledge, delivery models and work design, health-
care economics and policy, governance, evidence-based
practice/outcome measurement and research, patient safety,
performance improvement/metrics, and risk management.

3. Leadership
● Leadership skills include foundational thinking skills, personal

journey disciplines, systems thinking, succession planning,
and change management.

4. Professionalism
● Professionalism includes personal and professional

accountability, career planning, ethics, and advocacy.
5. Business skills

● Business skills include financial management, human
resource management, strategic management, and
information management and technology.

Nursing Executive Competencies, 2015, 2011 by the American Organization for
Nursing Leadership (AONL). All rights reserved.

The American Nurses Association Standards of
Professional Performance

In 2015, ANA published six Standards of Practice for Nursing
Administration as well as eleven Standards of Professional
Performance. These standards describe a competent level of
nursing practice and professional performance common to all
registered nurses (Table 4). Because the Standards of Practice for
nursing administration describe the nursing process and thus cross
all aspects of nursing care, only the Standards of Professional
Performance have been included in the crosswalk of this book (Table


Standard 7. Ethics
● The registered nurse practices ethically.
Standard 8. Culturally congruent practice
● The registered nurse practices in a manner that is congruent with

cultural diversity and inclusion principles.
Standard 9. Communication
● The registered nurse communicates effectively in all areas of

Standard 10. Collaboration
● The registered nurse collaborates with health-care consumers

and other key stakeholders in the conduct of nursing practice.
Standard 11. Leadership
● The registered nurse leads within the professional practice

setting and the profession.
Standard 12. Education
● The registered nurse seeks knowledge and competence that

reflects current nursing practice and promotes futuristic thinking.
Standard 13. Evidence-based practice and research
● The registered nurse integrates evidence and research findings

into practice.
Standard 14. Quality of practice
● The registered nurse contributes to quality nursing practice.
Standard 15. Professional practice evaluation
● The registered nurse evaluates one’s own and others’ nursing

Standard 16. Resource utilization

● The registered nurse utilizes appropriate resources to plan,
provide, and sustain evidence-based nursing services that are
safe, effective, and fiscally responsible.

Standard 17. Environmental health
● The registered nurse practices in an environmentally safe and

healthy manner.

The Quality and Safety Education for Nurses
Using the Institute of Medicine (2003) competencies for nursing, the
QSEN Institute (2019) defined six prelicensure and graduate quality
and safety competencies for nursing (Table 5) and proposed targets
for the knowledge, skills, and attitudes to be developed in nursing
programs for each of these competencies. Led by a national
advisory board and distinguished faculty, the QSEN Institute pursues
strategies to develop effective teaching approaches to assure that
future graduates develop competencies in patient-centered care,
teamwork and collaboration, evidence-based practice, quality
improvement, safety, and informatics.


Patient-centered care
● Definition: Recognize the patient or designee as the source of

control and full partner in providing compassionate and
coordinated care based on respect for patient’s preferences,
values, and needs.

Teamwork and collaboration
● Definition: Function effectively within nursing and

interprofessional teams, fostering open communication, mutual
respect, and shared decision making to achieve quality patient

Evidence-based practice
● Definition: Integrate best current evidence with clinical expertise

and patient/family preferences and values for delivery of optimal
health care.

Quality improvement
● Definition: Use data to monitor the outcomes of care processes

and use improvement methods to design and test changes to
continuously improve the quality and safety of health-care

● Definition: Minimizes the risk of harm to patients and providers

through both system effectiveness and individual performance.
● Definition: Use information and technology to communicate,

manage knowledge, mitigate error, and support decision making.

Student and Faculty Resources Available

Leadership Roles and Management Functions in Nursing, tenth
edition, has ancillary resources designed with both students and
instructors in mind.

Student Resources Available
• Glossary—Fully updated for the tenth edition, the glossary

contains definitions of important terms in the text.
• Journal Articles—25 full articles from Wolters Kluwer journals are

provided for additional learning opportunities.
• Learning Objectives from the textbook are available in Microsoft

Word for your convenience.
• Nursing Professional Roles and Responsibilities

Instructor’s Resources Available
• Competency Maps pull together the mapping provided in the

crosswalk feature for each chapter, showing how the book content
integrates key competencies for practice.

• An Image Bank lets you use the photographs and illustrations
from this textbook in your PowerPoint slides or as you see fit in
your course.

• An Instructor’s Guide includes information on experiential
learning and guidelines on how to use the text for various types of
learners and in different settings as well as information on how to
use the various types of Learning Exercises included in the text.

• All new PowerPoint Presentations provide an easy way for you
to integrate the textbook with your students’ classroom experience,
either via slide shows or handouts. Audience response questions
are integrated into the presentations to promote class participation
and allow you to use i-clicker technology.

• Sample Syllabi provide guidance for structuring your leadership
and management course and are provided for two different course
lengths: 8 and 15 weeks.

• Strategies for Effective Teaching offer creative approaches for
engaging students.

• A Test Generator lets you put together exclusive new tests from a
bank containing more than 750 questions to help you in assessing
your students’ understanding of the material. Test questions link to
chapter learning objectives.

• Access to all student resources.

Comprehensive, Integrated Digital Learning
We are delighted to introduce an expanded suite of digital solutions
to support instructors and students using Leadership Roles and
Management Functions in Nursing, tenth edition. Now for the first
time, our textbook is embedded into two integrated digital learning
solutions—one specific for prelicensure programs and the other for
postlicensure—that build on the features of the text with proven
instructional design strategies. To learn more about these solutions,
visit or contact your local
Wolters Kluwer representative.

Our prelicensure solution, Lippincott CoursePoint, is a rich
learning environment that drives course and curriculum success to
prepare students for practice. Lippincott CoursePoint is designed for
the way students learn. The solution connects learning to real-life
application by integrating content from Leadership Roles and
Management Functions in Nursing with video cases, interactive
modules, and journal articles. Ideal for active, case-based learning,
this powerful solution helps students develop higher level cognitive

skills and asks them to make decisions related to simple-to-complex

Lippincott CoursePoint for Leadership and Management features
the following:

• Leading content in context: Digital content from Leadership
Roles and Management Functions in Nursing is embedded in our
Powerful Tools, engaging students and encouraging interaction
and learning on a deeper level.
• The complete interactive eBook features annual content updates

with the latest evidence-based practices and provides students
with anytime, anywhere access on multiple devices.

• Full online access to Stedman’s Medical Dictionary for the
Health Professions and Nursing ensures students work with the
best medical dictionary available.

• Powerful tools to maximize class performance: Additional
course-specific tools provide case-based learning for every
• Video Cases help students anticipate what to expect as a

nurse, with detailed scenarios that capture their attention and
integrate clinical knowledge with leadership and management
concepts that are critical to real-world nursing practice. By
watching the videos and completing related activities, students
will flex their problem-solving, prioritizing, analyzing, and
application skills to aid both in NCLEX preparation and in
preparation for practice.

• Interactive Modules help students quickly identify what they do
and do not understand, so they can study smartly. With
exceptional instructional design that prompts students to
discover, reflect, synthesize, and apply, students actively learn.
Remediation links to the digital textbook are integrated

• Curated collections of journal articles are provided via
Lippincott NursingCenter, Wolters Kluwer’s premier destination
for peer-reviewed nursing journals. Through integration of
CoursePoint and NursingCenter, students will engage in how
nursing research influences practice.

• Data to measure students’ progress: Student performance data
provided in an intuitive display lets instructors quickly assess
whether students have viewed interactive modules and video
cases outside of class as well as see students’ performance on
related NCLEX-style quizzes, ensuring students are coming to the
classroom ready and prepared to learn.

To learn more about Lippincott CoursePoint, please visit:

Lippincott RN to BSN Online: Leadership and Management is a
postlicensure solution for online and hybrid courses, marrying
experiential learning with the trusted content in Leadership Roles
and Management Functions in Nursing, tenth edition.

Built around learning objectives that are aligned to the BSN
Essentials and QSEN nursing curriculum standards, every aspect of
Lippincott RN to BSN Online is designed to engage, challenge, and
cultivate postlicensure students.

• Self-paced interactive modules employ key instructional design
strategies—including storytelling, modeling, and case-based and
problem-based scenarios—to actively involve students in learning
new material and focus students’ learning outcomes on real-life

• Pre- and post-module assessments activate students’ existing
knowledge prior to engaging with the module and then assess their
competency after completing the module.

• Discussion board questions create an ongoing dialogue to foster
social learning.

• Writing and group work assignments hone students’
competence in writing and communication, instilling the skills
needed to advance their nursing careers.

• Collated journal articles acquaint students to the body of nursing
research ongoing in recent literature.

• Case study assignments, including unfolding cases that evolve
from cases in the interactive modules, aid students in applying
theory to real-life situations.

• Best Practices in Scholarly Writing Guide covers American
Psychological Association formatting and style guidelines.

Used alone or in conjunction with other instructor-created
resources, Lippincott RN to BSN Online adds interactivity to courses.
It also saves instructors’ time by keeping both textbook and course
resources current and accurate through regular updates to the

To learn more about Lippincott RN to BSN Online, please visit

Closing Note
It is our hope and expectation that the content, style, and
organization of this tenth edition of Leadership Roles and
Management Functions in Nursing will be helpful to those students
who want to become skillful, thoughtful leaders and managers.

Bessie L. Marquis, RN, MSN
Carol J. Huston, RN, MSN, DPA, FAAN


American Association of Colleges of Nursing. (2008). The essentials
of baccalaureate education for professional nursing practice.
Retrieved September 6, 2018, from

American Association of Colleges of Nursing. (2011). The essentials
of master’s education in nursing. Retrieved September 6, 2018,

American Nurses Association. (2015). Nursing: Scope and standards
of practice (3rd ed.). Silver Spring, MD: Author.

American Organization for Nursing Leadership. (AONL, AONE,
2015). AONL nurse executive competencies. Retrieved
September 26, 2019, from

Institute of Medicine. (2003). Health professions education: A bridge
to quality. Washington, DC: The National Academies Press.

QSEN Institute. (2019). Competencies. Retrieved September 6,
2018, from


UNIT I The Critical Triad: Decision Making,
Management, and Leadership

1 Decision Making, Problem Solving, Critical
Thinking, and Clinical Reasoning: Requisites
for Successful Leadership and Management

Decision Making, Problem Solving, Critical Thinking, and Clinical
Vicarious Learning to Increase Problem-Solving and Decision-
Making Skills

Case Studies, Simulation, and Problem-Based Learning
The Marquis-Huston Critical Thinking Teaching Model

Theoretical Approaches to Problem Solving and Decision Making
Traditional Problem-Solving Process
Managerial Decision-Making Models
The Nursing Process
Integrated Ethical Problem-Solving Model
Intuitive Decision-Making Models

Critical Elements in Problem Solving and Decision Making
Define Objectives Clearly
Gather Data Carefully

Take the Time Necessary
Use an Evidence-Based Approach
Generate Numerous Alternatives
Think Logically
Choose and Act Decisively

Individual Variations in Decision Making
Life Experience
Individual Preference
Brain Hemisphere Dominance and Thinking Styles

Overcoming Individual Vulnerability in Decision Making
Life Experience
Individual Preference
Individual Ways of Thinking

Decision Making in Organizations
Effect of Organizational Power
Rational and Administrative Decision Making

Decision-Making Tools
Decision Grids
Payoff Tables
Decision Trees
Consequence Tables
Logic Models
Program Evaluation and Review Technique
Pitfalls in Using Decision-Making Tools

Integrating Leadership Roles and Management Functions in
Decision Making
Key Concepts
Additional Learning Exercises and Applications

2 Classical Views of Leadership and

Historical Development of Management Theory

Scientific Management (1900 to 1930)
Management Functions Identified
Human Relations Management (1930 to 1970)

Historical Development of Leadership Theory (1900 to Present)
The Great Man Theory/Trait Theories (1900 to 1940)
Behavioral Theories (1940 to 1980)
Situational and Contingency Leadership Theories (1950 to
Interactional Leadership Theories (1970 to Present)
Transactional and Transformational Leadership
Full-Range Leadership Model/Theory
Leadership Competencies

Integrating Leadership Roles and Management Functions
Key Concepts
Additional Learning Exercises and Applications

3 Twenty-First-Century Thinking About
Leadership and Management

New Thinking About Leadership and Management

Strengths-Based Leadership and the Positive Psychology
Level 5 Leadership
Servant Leadership
Principal Agent Theory
Human and Social Capital Theory

Emotional Intelligence
Authentic Leadership
Thought Leadership and Rebel Leadership
Agile Leadership
Reflective Thinking and Practice
Quantum Leadership

Transition From Industrial Age Leadership to Relationship Age
Integrating Leadership Roles and Management Functions in the
21st Century
Key Concepts
Additional Learning Exercises and Applications


Foundation for Effective Leadership
and Management: Ethics, Law, and

4 Ethical Issues
Moral Issues Faced by Nurses
Ethical Frameworks for Decision Making
Principles of Ethical Reasoning

Autonomy (Self-Determination)
Beneficence (Doing Good)
Justice (Treating People Fairly)
Veracity (Truth Telling)
Fidelity (Keeping Promises)
Confidentiality (Respecting Privileged Information)

Codes of Ethics and Professional Standards

Ethical Problem Solving and Decision Making
The Traditional Problem-Solving Process
The Nursing Process
The Moral Decision-Making Model

Working Toward Ethical Behavior as the Norm
Separate Legal and Ethical Issues
Collaborate Through Interprofessional Ethics Committees
Use Institutional Review Boards Appropriately
Foster an Ethical Work Environment

Integrating Leadership Roles and Management Functions in
Key Concepts
Additional Learning Exercises and Applications

5 Legal and Legislative Issues
Sources of Law
Types of Laws and Courts
Legal Doctrines and the Practice of Nursing
Professional Negligence (Malpractice)

Elements of Malpractice
Being Sued for Malpractice
Avoiding Malpractice Claims

Extending the Liability
Incident Reports and Adverse Event Forms
Intentional Torts
Other Legal Responsibilities of the Manager

Informed Consent
Informed Consent for Clinical Research

Medical Records
The Patient Self-Determination Act
Good Samaritan Laws

Health Insurance Portability and Accountability Act of 1996
Legal Considerations of Managing a Diverse Workforce
Professional Versus Institutional Licensure
Integrating Leadership Roles and Management Functions in
Legal and Legislative Issues
Key Concepts
Additional Learning Exercises and Applications

6 Patient, Subordinate, Workplace, and
Professional Advocacy

Becoming an Advocate
Patient Advocacy

Patient and Family Engagement
Person- and Family-Centered Care

Patient Rights
The Right to Die Movement and Physician-Assisted Suicide

Subordinate and Workplace Advocacy
Whistleblowing as Advocacy
Professional Advocacy

Nursing’s Advocacy Role in Legislation and Public Policy
Nursing and the Media

Integrating Leadership Roles and Management Functions in
Key Concepts
Additional Learning Exercises and Applications

II I Roles and Functions in Planning

7 Organizational Planning

Visioning: Looking to the Future
Proactive Planning

Strategic Planning at the Organizational Level

SWOT Analysis
Balanced Scorecard
Strategic Planning as a Management Process
Who Should Be Involved in Strategic Planning?

Organizational Planning: The Planning Hierarchy
Vision and Mission Statements
Organizational Philosophy
Societal Philosophies and Values Related to Health Care
Individual Philosophies and Values
Goals and Objectives
Policies and Procedures
Overcoming Barriers to Planning
Integrating Leadership Roles and Management Functions in
Key Concepts
Additional Learning Exercises and Applications

8 Planned Change
Lewin’s Change Theory of Unfreezing, Movement, and


Lewin’s Change Theory of Driving and Restraining Forces
A Contemporary Adaptation of Lewin’s Model

Classic Change Strategies
Resistance: The Expected Response to Change
Planned Change as a Collaborative Process
The Leader-Manager as a Role Model During Planned Change
Organizational Change Associated With Nonlinear Dynamics

Complexity and Complex Adaptive Systems Change Theory
Chaos Theory

Organizational Aging: Change as a Means of Renewal
Integrating Leadership Roles and Management Functions in
Planned Change
Key Concepts
Additional Learning Exercises and Applications

9 Time Management
Three Basic Steps to Time Management

Taking Time to Plan and Establishing Priorities
The Time-Efficient Work Environment
Priority Setting and Procrastination
Making Lists
Dealing With Interruptions
Time Wasters

Personal Time Management
Using a Time Inventory

Integrating Leadership Roles and Management Functions in
Time Management
Key Concepts
Additional Learning Exercises and Applications

10 Fiscal Planning and Health-Care

Balancing Cost and Quality
Responsibility Accounting
Budget Basics

Steps in the Budgetary Process
Types of Budgets

The Personnel Budget
The Operating Budget
The Capital Budget

Budgeting Methods
Incremental Budgeting
Zero-Based Budgeting
Flexible Budgeting
Performance Budgeting

Critical Pathways and Variance Analysis
Health-Care Reimbursement
Medicare and Medicaid
The Prospective Payment System
Managed Care

Types of Managed Care Organizations
Medicare and Medicaid Managed Care
Proponents and Critics of Managed Care Speak Up
The Future of Managed Care

Health-Care Reform Efforts: The Patient Protection and
Affordable Care Act. What Comes Next?

Bundled Payments
Accountable Care Organizations
Hospital Value-Based Purchasing
The Patient-Centered Medical Home
Health Insurance Marketplaces
Outcomes of the Affordable Care Act

Integrating Leadership Roles and Management Functions in
Fiscal Planning

Key Concepts
Additional Learning Exercises and Applications

11 Career Planning and Development in Nursing
Career Stages
Justifications for Career Development
Individual Responsibility for Career Development
The Organization’s Role in Employee Career Development
Career Coaching
Management Development
Promotion: A Career Management Tool
Continued Competency as Part of Career Development

Mandatory Continuing Education to Promote Continued

Professional Specialty Certification
Reflective Practice and the Professional Portfolio
Career Planning and the New Graduate Nurse

Transition-to-Practice Programs/Residencies for New
Graduate Nurses

Resumé Preparation
Resumé Format

Integrating Leadership Roles and Management Functions in
Career Planning and Development
Key Concepts
Additional Learning Exercises and Applications

IV Roles and Functions in Organizing

12 Organizational Structure

Formal and Informal Organizational Structure
Organizational Theory and Bureaucracy
Components of Organizational Structure

Relationships and Chain of Command
Span of Control
Managerial Levels

Limitations of Organization Charts
Types of Organizational Structures

Line Structures
Ad Hoc Design
Matrix Structure
Service Line Organization
Flat Designs

Decision Making Within the Organizational Hierarchy
Organizational Culture
Shared Governance: Organizational Design for the 21st Century
Magnet Designation and Pathway to Excellence
Committee Structure in an Organization

Responsibilities and Opportunities of Committee Work
Integrating Leadership Roles and Management Functions
Associated With Organizational Structure
Key Concepts
Additional Learning Exercises and Applications

13 Organizational, Political, and Personal Power
Understanding Power

Gender and Power
Power and Powerlessness

Types of Power
The Authority–Power Gap

Bridging the Authority–Power Gap
Empowering Subordinates
Mobilizing the Power of the Nursing Profession
An Action Plan for Increasing Professional Power in Nursing
Strategies for Building a Personal Power Base

Maintain Personal Energy
Present a Powerful Picture to Others
Work Hard and Be a Team Player
Determine the Powerful in the Organization
Learn the Language and Symbols of the Organization
Learn How to Use the Organization’s Priorities
Increase Professional Skills and Knowledge
Maintain a Broad Vision
Use Experts and Seek Counsel
Be Flexible
Develop Visibility and a Voice in the Organization
Learn to Accept Compliments
Maintain a Sense of Humor
Empower Others

The Politics of Power
Integrating Leadership Roles and Management Functions When
Using Authority and Power in Organizations
Key Concepts
Additional Learning Exercises and Applications

14 Organizing Patient Care
Traditional Models of Patient Care Organization

Total Patient Care Nursing or Case Method Nursing
Functional Method

Team Nursing
Modular Nursing
Primary Nursing

Primary Nursing in the Inpatient Setting
Interprofessional/Multidisciplinary Health-Care Teams

Registered Nurse Primary Care Coordinators in Patient-
Centered Medical Homes

Case Management
Case Management of Disease Management Programs

Selecting the Optimum Mode of Organizing Patient Care
New Roles in the Changing Health-Care Arena: Nurse
Navigators and Clinical Nurse-Leaders

Nurse Navigators
The Clinical Nurse-Leader

Integrating Leadership Roles and Management Functions in
Organizing Patient Care
Key Concepts
Additional Learning Exercises and Applications

V Roles and Functions in Staffing

15 Employee Recruitment, Selection, Placement,
and Indoctrination

Predicting Staffing Needs
Is a Nursing Shortage Looming?
Supply and Demand Factors Leading to a Potential Nursing



The Nurse-Recruiter
The Relationship Between Recruitment and Retention

Interviewing as a Selection Tool
Limitations of Interviews
Overcoming Interview Limitations

Use a Team Approach
Develop a Structured Interview Format for Each Job
Use Scenarios to Determine Decision-Making Ability
Conduct Multiple Interviews
Provide Training in Effective Interviewing Techniques

Planning, Conducting, and Controlling the Interview
Evaluation of the Interview
Legal Aspects of Interviewing

Tips for the Interviewee

Educational and Credential Requirements
Reference Checks and Background Screening
Preemployment Testing
Physical Examination as a Selection Tool
Making the Selection
Finalizing the Selection



Integrating Leadership Roles and Management Functions in
Employee Recruitment, Selection, Placement, and Indoctrination
Key Concepts
Additional Learning Exercises and Applications

16 Educating and Socializing Staff in a Learning

The Learning Organization
Staff Development

Training Versus Education
Responsibilities of the Education Department

Learning Theories
Adult Learning Theory
Social Learning Theory
Other Learning Concepts

Assessing Staff Development Needs
Evaluation of Staff Development Activities
Shared Responsibility for Implementing Evidence-Based Practice
Socialization and Resocialization

Socialization of the New Nurse: Overcoming Reality Shock
Resocialization of the Experienced Nurse
The Socialization and Orientation of New Managers
Socializing International Nurses
Clarifying Role Expectations Through Role Models,
Preceptors, and Mentors

Role Models

Overcoming Motivational Deficiencies
Positive Sanctions
Negative Sanctions

Coaching as a Teaching Strategy
Meeting the Educational Needs of a Culturally Diverse Staff
Integrating Leadership and Management in Team Building
Through Socializing and Educating Staff in a Learning

Key Concepts
Additional Learning Exercises and Applications

17 Staffing Needs and Scheduling Policies
Management’s Responsibilities in Meeting Staffing Needs
Centralized and Decentralized Staffing
Staffing and Scheduling Options
Workload Measurement Tools
The Relationship Between Nursing Care Hours, Staffing Mix, and
Quality of Care
Should Minimum Registered Nurse to Patient Staffing Ratios Be
Establishing and Maintaining Effective Staffing Policies
Generational Considerations for Staffing
The Impact of Nursing Staff Shortages on Staffing
Fiscal and Ethical Accountability for Staffing
Developing Staffing and Scheduling Policies
Integrating Leadership Roles and Management Functions in
Staffing and Scheduling
Key Concepts
Additional Learning Exercises and Applications

VI Roles and Functions in Directing

18 Creating a Motivating Climate
Intrinsic Versus Extrinsic Motivation
Motivational Theory



Strategies for Creating a Motivating Climate
Worker Engagement
Worker Empowerment
Positive Reinforcement
Incentives and Rewards
The Relationship Between the Employee and His or Her

Integrating Leadership Roles and Management Functions in
Creating a Motivating Climate at Work
Key Concepts
Additional Learning Exercises and Applications

19 Organizational, Interpersonal, and Group
Communication in Team Building

The Communication Process
Variables Affecting Organizational Communication
Organizational Communication Strategies

Channels of Communication
Communication Modes
Elements of Nonverbal Communication


Eye Contact
Facial Expression and Timing
Vocal Expression

Verbal Communication Skills
SBAR, ISBAR, ANTICipate, and I-PASS as Verbal
Communication Tools

Listening Skills
Written Communication Within the Organization
Technology as a Tool in Contemporary Organizational

The Internet
Hospital Information Systems and Intranets
Wireless Local Area Networking
Social Media and Organizational Communication
Balancing Technology and the Human Element

Communication, Confidentiality, and Health Insurance Portability
and Accountability Act
Electronic Health Records
Group Communication
Group Dynamics

Group Task Roles
Group Building and Maintenance Roles
Individual Roles of Group Members

Communication and Team Building
Integrating Leadership and Management in Organizational,
Interpersonal, and Group Communication in Team Building
Key Concepts
Additional Learning Exercises and Applications

20 Delegation

Delegating Effectively

Identify Necessary Skills and Education Levels
Plan Ahead
Select and Empower Capable Personnel
Communicate Goals Clearly
Set Deadlines and Monitor Progress
Be a Role Model and Provide Guidance
Evaluate Performance
Reward Accomplishment

Common Delegation Errors
Improper Delegating

Delegation as a Function of Professional Nursing
Delegating to Unlicensed Assistive Personnel
Unlicensed Assistive Personnel Scope of Practice

Subordinate Resistance to Delegation
Delegating to a Multicultural Work Team
Integrating Leadership Roles and Management Functions in
Key Concepts
Additional Learning Exercises and Applications

21 Conflict, Workplace Violence, and Negotiation
The History of Conflict Management
Intergroup, Intrapersonal, and Interpersonal Conflict
The Conflict Process
Conflict Management



Managing Unit Conflict
Bullying, Incivility, Mobbing, and Workplace Violence

Workplace Violence: Scope of the Problem
Typology of Workplace Violence
Consequences of Workplace Violence
Whose Problem Is It?
Strategies to Address the Problem

Before the Negotiation
During the Negotiation
Destructive Negotiation Tactics
Closure and Follow-Up to Negotiation

Alternative Dispute Resolution
Seeking Consensus
Integrating Leadership Skills and Management Functions in
Managing Conflict
Key Concepts
Additional Learning Exercises and Applications

22 Collective Bargaining, Unionization, and
Employment Laws

Unions and Collective Bargaining
Historical Perspective of Unionization in America

Effective Labor–Management Relations
Union Representation of Nurses
American Nurses Association and Collective Bargaining

Employee Motivation to Join or Reject Unions
Common Reasons Nurses Join Unions
Common Reasons Nurses Do Not Join Unions

Averting the Union
Union-Organizing Strategies
Steps to Establish a Union
The Managers’ Role During Union Organizing
The Nurse as Supervisor: Eligibility for Protection Under the
National Labor Relations Act
Employment Legislation

Labor Standards
Minimum Wages and Maximum Hours
The Equal Pay Act of 1963
Equal Employment Opportunity Laws
Civil Rights Act of 1964
Age Discrimination and Employment Act
Sexual Harassment
Legislation Affecting Americans With Disabilities
Veterans Readjustment Assistance Act
The Occupational Safety and Health Act

State Health Facilities Licensing Boards
Integrating Leadership Skills and Management Functions When
Working With Collective Bargaining, Unionization, and
Employment Laws
Key Concepts
Additional Learning Exercises and Applications

VII Roles and Functions in Controlling

23 Quality Control in Creating a Culture of
Patient Safety

Defining Quality Health Care
Quality Control as a Systematic Process/FOCUS PDCA
The Development of Standards
Audits as a Quality Control Tool

Outcome Audit
Process Audit
Structure Audit

Standardized Nursing Languages
Quality Improvement Models

Total Quality Management
Who Should Be Involved in Quality Control?
Quality Measurement as an Organizational Mandate
Professional Standards Review Organizations
The Prospective Payment System
The Joint Commission

Sentinel Event Reporting
Core Measures
National Patient Safety Goals
Medication Reconciliation

Centers for Medicare & Medicaid Services
Hospital Consumer Assessment of Healthcare Providers and
Systems Survey
Multistate Nursing Home Case Mix and Quality Demonstration

National Committee for Quality Assurance
National Database of Nursing Quality Indicators
Report Cards
Medical Errors: An Ongoing Threat to Quality of Care

Reporting and Analyzing Errors in a Just Culture
The Leapfrog Group
Six Sigma Approach and Lean Manufacturing
Reforming the Medical Liability System

Are We Making Progress?
Integrating Leadership Roles and Management Functions With
Quality Control
Key Concepts
Additional Learning Exercises and Applications

24 Performance Appraisal
Using the Performance Appraisal to Motivate Employees
Strategies to Ensure Accuracy and Fairness in the Performance
Performance Appraisal Tools

Trait Rating Scales
Job Dimension Scales
Behaviorally Anchored Rating Scales
Management by Objectives
Peer Review
The 360-Degree Evaluation

Planning the Performance Appraisal Interview
Overcoming Appraisal Interview Difficulties

Before the Interview
During the Interview
After the Interview

Performance Management
Coaching: A Mechanism for Informal Performance Appraisal

Becoming an Effective Coach
When Employees Appraise Their Manager’s Performance
Leadership Skills and Management Functions in Conducting
Performance Appraisals

Key Concepts
Additional Learning Exercises and Applications

25 Problem Employees: Rule Breakers, Marginal
Employees, and the Chemically or
Psychologically Impaired

Constructive Versus Destructive Discipline
Self-Discipline and Group Norms
Fair and Effective Rules
Discipline as a Progressive Process
Disciplinary Strategies for the Manager

Performance Deficiency Coaching
Disciplining the Unionized Employee
The Disciplinary Conference

Reason for Disciplinary Action
Employee’s Response to Disciplinary Action
Rationale for Disciplinary Action
Clarification of Expectations for Change
Agreement and Acceptance of Action Plan
The Environment for Discipline
Timing and Conference Length

The Termination Conference
Grievance Procedures

Formal Process
Rights and Responsibilities in Grievance Resolution

Transferring Employees
The Marginal Employee
The Chemically Impaired Employee

Prevalence of Chemical Dependency in Nursing

Commonly Misused or Abused Drugs
Recognizing the Chemically Impaired Employee

Confronting the Chemically Impaired Employee
The Manager’s Role in Assisting the Chemically Impaired
The Recovery Process
State Board of Nursing Treatment Programs
The Chemically Impaired Employee’s Reentry to the

Integrating Leadership Roles and Management Functions When
Dealing With Problem Employees
Key Concepts
Additional Learning Exercises and Applications

Appendix Solutions to Selected Learning Exercises


The Critical Triad:
Decision Making,
Management, and


Decision Making, Problem
Solving, Critical Thinking, and
Clinical Reasoning:
Requisites for Successful
Leadership and Management

. . . again and again, the impossible problem is solved
when we see that the problem is only a tough decision
waiting to be made.—Robert H. Schuller

. . . in any moment of decision, the best thing you can
do is the right thing, the next best thing is the wrong
thing, and the worst thing you can do is nothing.—
Theodore Roosevelt

. . . If we start with the attitude that different viewpoints
are additive rather than competitive, we become more
effective because our ideas or decisions are honed and
tempered by that discourse.—Edwin Catmull,
President of Pixar and Walt Disney Animation


This chapter addresses:

BSN Essential I: Liberal education for baccalaureate generalist
nursing practice

BSN Essential III: Scholarship for evidence-based practice
BSN Essential IV: Information management and application of
patient-care technology

BSN Essential VI: Interprofessional communication and
collaboration for improving patient health outcomes

MSN Essential I: Background for practice from sciences and

MSN Essential IV: Translating and integrating scholarship into

AONL Nurse Executive Competency I: Communication and
relationship building

AONL Nurse Executive Competency III: Leadership
ANA Standard of Professional Performance 13: Evidence-
based practice and research

ANA Standard of Professional Performance 16: Resource

QSEN Competency: Informatics
QSEN Competency: Evidence-based practice


The learner will:

differentiate between problem solving, decision making, critical
thinking, and clinical reasoning

describe how case studies, simulation, and problem-based
learning can be used to improve the quality of decision making

explore strengths and limitations of using intuition and heuristics
as adjuncts to problem solving and decision making

identify characteristics of successful decision makers

use a PICO (patient or population, intervention, comparison, and
outcome) format to search for current best evidence or practices
to address a problem

identify strategies the new nurse might use to promote
evidence-based practice

select appropriate models for decision making in specific

describe the importance of individual variations in the decision-
making process

identify critical elements of decision making
identify strategies that help decrease individual subjectivity and
increase objectivity in decision making

explore his or her personal propensity for risk taking in decision

discuss the effect of organizational power and values on
individual decision making

differentiate between the economic man and the administrative
man in decision making

select appropriate management decision-making tools that
would be helpful in making specific decisions

differentiate between autocratic, democratic, and laissez-faire
decision styles and identify situation variables that might
suggest using one decision style over another

Decision making is often thought to be synonymous with
management and is one of the criteria on which management
expertise is judged. Much of any manager’s time is spent critically
examining issues, solving problems, and making decisions. The
quality of the decisions that leader-managers make is the factor that
often weighs most heavily in their success or failure.

Decision making, then, is both an innermost leadership activity
and the core of management. This chapter explores the primary
requisites for successful management and leadership: decision
making, problem solving, and critical thinking. Also, because it is the
authors’ belief that decision making, problem solving, and critical
thinking are learned skills that improve with practice and consistency,
an introduction to established tools, techniques, and strategies for
effective decision making is included. This chapter also introduces
the learning exercise as an approach for vicariously gaining skill in
management and leadership decision making. Finally, evidence-
based decision making is introduced as an imperative for both
personal and professional problem solving.

Decision Making, Problem Solving, Critical
Thinking, and Clinical Reasoning
Decision making is a complex, cognitive process often defined as
choosing a particular course of action.
(2018) defines decision making as “the thought process of selecting
a logical choice from the available options” (para. 1). This implies
that doubt exists about several courses of action and that a choice is
made to eliminate uncertainty.

Problem solving is part of decision making and is a systematic
process that focuses on analyzing a difficult situation. Problem
solving always includes a decision-making step. Many educators use
the terms problem solving and decision making synonymously, but
there is a small, yet important, difference between the two. Although
decision making is the last step in the problem-solving process, it is
possible for decision making to occur without the full analysis
required in problem solving. Because problem solving attempts to
identify the root problem in situations, much time and energy are
spent on identifying the real problem.

Decision making, on the other hand, is usually triggered by a
problem but is often handled in a way that does not focus on
eliminating the underlying problem. For example, if a person decided
to handle a conflict when it occurred but did not attempt to identify
the real problem causing the conflict, only decision-making skills
would be used. The decision maker might later choose to address
the real cause of the conflict or might decide to do nothing at all
about the problem. The decision has been made not to problem

This alternative may be selected because of a lack of energy, time,
or resources to solve the real problem. In some situations, this is an
appropriate decision. For example, assume that a nursing supervisor
has a staff nurse who has been absent a great deal over the last 3
months. Normally, the supervisor would feel compelled to intervene.
However, the supervisor has reliable information that the nurse will
be resigning soon to return to school in another state. Because the
problem will soon no longer exist, the supervisor decides that the
time and energy needed to correct the problem are not warranted.

Critical thinking, sometimes referred to as reflective thinking, is
related to evaluation and has a broader scope than decision making
and problem solving. (2018) defines critical thinking
as “disciplined thinking that is clear, rational, open-minded, and
informed by evidence” (para. 1). Critical thinking also involves
reflecting on the meaning of statements, examining the offered
evidence and reasoning, and forming judgments about facts.

Insight, intuition, empathy, and the willingness to take
action are components of critical thinking.

Whatever definition of critical thinking is used, most agree that it is
more complex than problem solving or decision making, involves
higher order reasoning and evaluation, and has both cognitive and

affective components. The authors believe that insight, intuition,
empathy, and the willingness to take action are additional
components of critical thinking. These same skills are necessary to
some degree in decision making and problem solving. See Display
1.1 for additional characteristics of a critical thinker.


Open to new ideas

Risk taker


Willing to take

Outcome directed
Willing to change
Circular thinker

Nurses today must have higher order thinking skills to identify
patient problems and to direct clinical judgments and actions that
result in positive patient outcomes. When nurses integrate and apply
different types of knowledge to weigh evidence, critically think about
arguments, and reflect on the process used to arrive at a diagnosis,
this is known as clinical reasoning. Thus, clinical reasoning uses
both knowledge and experience to make decisions at the point of

Finally, Mlodinow (2018) argues there is elastic thinking. Elastic
thinking arises from what scientists call “bottom-up” processes. In
this mode, individual neurons fire in complex fashion, with valuable
input from the brain’s emotional centers rather than the brain’s high-
level executive structures. This kind of processing is nonlinear and
can produce creative ideas that would not have arisen in the step-by-
step progression of analytical thinking. This allows decision makers

to solve novel problems and overcome the neural and psychological
barriers that can impede us from looking beyond the existing order.

Vicarious Learning to Increase Problem-Solving
and Decision-Making Skills
Decision making, one step in the problem-solving process, is an
important task that relies heavily on critical thinking and clinical
reasoning skills. How do people become successful problem solvers
and decision makers? Although successful decision making can be
learned through life experience, not everyone learns to solve
problems and judge wisely by this trial-and-error method because
much is left to chance. Some educators feel that people are not
successful in problem solving and decision making because
individuals are not taught how to reason insightfully from multiple

Moreover, information and new learning may not be presented
within the context of real-life situations, although this is changing. For
example, in teaching clinical reasoning, nurse educators strive to see
that the elements of clinical reasoning, such as noticing crucial
changes in patient status, analyzing these changes to decide on a
course of action, and evaluating responses to modify care, are
embedded at every opportunity throughout the nursing curricula
(Rischer, 2017). In addition, time is included for meaningful reflection
on the decisions that are made and the outcomes that result. Such
learning can occur in both real-world settings and through vicarious
learning, where students’ problem solve and make decisions based
on simulated situations that are made real to the learner.

Case Studies, Simulation, and Problem-Based

Case studies, simulation, and problem-based learning (PBL) are
some of the strategies that have been developed to vicariously
improve problem solving and decision making. Case studies may be
thought of as stories that impart learning. They may be fictional or
include real persons and events, be relatively short and self-
contained for use in a limited amount of time, or be longer with
significant detail and complexity for use over extended periods of
time. Case studies, particularly those that unfold or progress over
time, are becoming much more common in nursing education
because they provide a more interactive learning experience for
students than the traditional didactic approach.

Similarly, simulation provides learners opportunities for problem
solving that have little or no risk to patients or to organizational
performance. For example, some organizations are now using
computer simulation (known as discrete event simulation) to imitate
the operation of a real-life system such as a hospital. The learner’s
actions in the simulation provide insight to the quality of the learner’s
decision making based on priority setting, timeliness of action, and
patient outcomes.

PBL also provides opportunities for individuals to address and
learn from authentic problems vicariously. Typically, in PBL, learners
meet in small groups to discuss and analyze real-life problems.
Thus, they learn by problem solving. The learning itself is
collaborative as the teacher guides the students to be self-directed in
their learning, and many experts suggest that this type of active
learning helps to develop critical thinking skills.

The Marquis-Huston Critical Thinking Teaching
The desired outcome for teaching and learning decision making and
critical thinking in management is an interaction between learners
and others that results in the ability to critically examine

management and leadership issues. This is a learning of appropriate
social/professional behaviors rather than a mere acquisition of
knowledge. This type of learning occurs best in groups, using a PBL

In addition, learners retain didactic material more readily when it is
personalized or when they can relate to the material being
presented. The use of case studies that learners can identify with
assists in retention of didactic materials.

Also, although formal instruction in critical thinking is important,
using a formal decision-making process improves both the quality
and consistency of decision making. Many new leaders and
managers struggle to make quality decisions because their
opportunity to practice making management and leadership
decisions is very limited until they are appointed to a management
position. These limitations can be overcome by creating
opportunities for vicariously experiencing the problems that
individuals would encounter in the real world of leadership and

The Marquis-Huston Model for Teaching Critical Thinking assists
in achieving desired learner outcomes (Fig. 1.1). Basically, the model
comprises four overlapping spheres, each being an essential
component for teaching leadership and management. The first is a
didactic theory component, such as the material that is presented in
each chapter; second, a formalized approach to problem solving and
decision making must be used. Third, there must be some use of the
group process, which can be accomplished through large and small
groups and classroom discussion. Final, the material must be made
real for the learner so that the learning is internalized. This can be
accomplished through writing exercises, personal exploration, and
values clarification, along with risk taking, as case studies are

FIGURE 1.1 The Marquis-Huston Critical Thinking Teaching Model.

This book was developed with the perspective that experiential
learning provides mock experiences that have tremendous value in
applying leadership and management theory. The text includes
numerous opportunities for readers to experience the real world of
leadership and management. Some of these learning situations,
called learning exercises, include case studies, writing exercises,
specific management or leadership problems, staffing and budgeting
calculations, group discussion or problem-solving situations, and
assessment of personal attitudes and values. Some exercises
include opinions, speculations, and value judgments. All of the

learning exercises, however, require some degree of critical thinking,
problem solving, decision making, or clinical reasoning.

Experiential learning provides mock experiences that
have tremendous value in applying leadership and
management theory.

Some of the case studies have been solved (solutions are found at
the back of the book) so that readers can observe how a systematic
problem-solving or decision-making model can be applied in solving
problems common to nurse-managers. The authors feel strongly,
however, that the problem solving suggested in the solved cases
should not be considered the only plausible solution or “the right
solution” to that learning exercise. Most of the learning exercises in
the book have multiple solutions that could be implemented
successfully to solve the problem.

Theoretical Approaches to Problem Solving and
Decision Making
Parrish (2018) notes that most people don’t actually stop to think.
They just take their first thought and run with it. That’s because most
individuals rely on discrete, often unconscious, processes known as
heuristics to make decisions. Heuristics use trial-and-error methods
or a rule-of-thumb approach to problem solving rather than set rules.
As such, they are practical mental shortcuts and are not expected to
provide perfect or optimal problem solving. They do, however,
provide a more immediate solution to the decision at hand. This is
particularly true for uncertain or emergent situations where
knowledge, time, and resources are limited.

Monteiro, Norman, and Sherbino (2018) agree, noting that
heuristics are often used in medicine and clinical practice given the

ambiguity surrounding clinical decision making. Clinicians then turn
to heuristics to look for general guiding principles to alleviate this

Typically, formal process and structure can benefit the decision-
making process, as they force decision makers to be specific about
options and to separate probabilities from values. A structured
approach to problem solving and decision making increases clinical
reasoning and is the best way to learn how to make quality decisions
because it eliminates trial and error and focuses the learning on a
proven process. A structured or professional approach involves
applying a theoretical model in problem solving and decision making.
Many acceptable problem-solving models exist, and most include a
decision-making step; only four are reviewed here.

A structured approach to problem solving and decision
making increases clinical reasoning.

Traditional Problem-Solving Process
One of the most well-known and widely used problem-solving
models is the traditional problem-solving model. The seven steps are
shown in Display 1.2. (Decision making occurs at step 5.)


1. Identify the problem.
2. Gather data to analyze the causes and consequences of the

3. Explore alternative solutions.
4. Evaluate the alternatives.
5. Select the appropriate solution.
6. Implement the solution.
7. Evaluate the results.

Although the traditional problem-solving process is an effective
model, its weakness lies in the amount of time needed for proper
implementation. This process, therefore, is less effective when time
constraints are a consideration. Another weakness is lack of an initial
objective-setting step. Setting a decision goal helps to prevent the
decision maker from becoming sidetracked.

Managerial Decision-Making Models
To address the weaknesses of the traditional problem-solving
process, many contemporary models for management decision
making have added an objective-setting step. These models are
known as managerial decision-making models or rational decision-
making models. One such model suggested by Decision-making- (2006–2019) includes the six steps shown in Display


1. Determine the decision and the desired outcome (set

2. Research and identify options.
3. Compare and contrast these options and their consequences.
4. Make a decision.
5. Implement an action plan.
6. Evaluate results.

In the first step, problem solvers must identify the decision to be
made, who needs to be involved in the decision process, the timeline
for the decision, and the goals or outcomes that should be achieved.
Identifying objectives to guide the decision making helps the problem
solver determine which criteria should be weighted most heavily in
making his or her decision. Most important decisions require this
careful consideration of context.

In step 2, problem solvers must attempt to identify as many
alternatives as possible. Alternatives are then analyzed in step 3,
often using some type of SWOT (strengths, weaknesses,
opportunities, and threats) analysis. Decision makers may choose to
apply quantitative decision-making tools, such as decision-making
grids and payoff tables (discussed further later in this chapter), to
objectively review the desirability of alternatives.

In step 4, alternatives are rank ordered on the basis of the analysis
done in step 3 so that problem solvers can make a choice. In step 5,
a plan is created to implement desirable alternatives or combinations
of alternatives. In the final step, challenges to successful
implementation of chosen alternatives are identified and strategies
are developed to manage those risks. An evaluation is then
conducted of both process and outcome criteria, with outcome
criteria typically reflecting the objectives that were set in step 1.

The Nursing Process
The nursing process, developed by Ida Jean Orlando in the late
1950s, provides another theoretical system for solving problems and
making decisions. Originally a four-step model (assess, plan,
implement, and evaluate), diagnosis was delineated as a separate
step, and most contemporary depictions of this model now include at
least five steps (Display 1.4).


1. Assess
2. Diagnose
3. Plan
4. Implement
5. Evaluate

As a decision-making model, the greatest strength of the nursing
process may be its multiple venues for feedback. The arrows in
Figure 1.2 show constant input into the process. When the decision
point has been identified, initial decision making occurs and
continues throughout the process via a feedback mechanism.

FIGURE 1.2 Feedback mechanism of the nursing process.

Although the process was designed for nursing practice with
regard to patient care and nursing accountability, it can easily be
adapted as a theoretical model for solving leadership and
management problems. Table 1.1 shows how closely the nursing
process parallels the decision-making process.


Decision-Making Process Simplified Nursing Process

Identify the decision. Assess
Collect data.
Identify criteria for decision. Plan
Identify alternatives.
Choose alternative. Implement
Implement alternative.
Evaluate steps in decision. Evaluate

The weakness of the nursing process, like the traditional problem-
solving model, is in not requiring clearly stated objectives. Goals
should be clearly stated in the planning phase of the process, but
this step is frequently omitted or obscured. However, because
nurses are familiar with this process and its proven effectiveness, it
continues to be recommended as an adapted theoretical process for
leadership and managerial decision making.

Integrated Ethical Problem-Solving Model
Another model for effective thinking and problem solving was
developed by the National Association of Social Workers (2017;
Display 1.5). Although developed primarily for use in solving ethical
problems, the model also works well as a general problem-solving
model. Like the three models already discussed, this model provides
a structured approach to problem solving that includes an
assessment of the problem, problem identification, the analysis and
selection of the best alternative, and reflection as a means for


1. DETERMINE whether there is an ethical issue or/and dilemma.
2. IDENTIFY the key values and principles involved.
3. RANK the values or ethical principles which—in your

professional judgment—are most relevant to the issue or

4. DEVELOP an action plan that is consistent with the ethical
priorities that have been determined as central to the dilemma.

5. IMPLEMENT your plan, utilizing the most appropriate practice
skills and competencies.

6. REFLECT on the outcome of this ethical decision-making

Source: Adapted from National Association of Social Workers. (2017). Essential
steps for ethical problem-solving. Retrieved September 12, 2018, from

Many other excellent problem analysis and decision models exist.
The model selected should be one with which the decision maker is
familiar and one appropriate for the problem to be solved. Using
models or processes consistently will increase the likelihood that
critical analysis will occur. Moreover, the quality of
management/leadership problem solving and decision making will
improve tremendously via a scientific approach.

Intuitive Decision-Making Models
There are theorists who suggest that intuition should always be used
as an adjunct to empirical or rational decision-making models.
Experienced (expert) nurses often report that gut-level feelings
(intuition) encourage them to take appropriate strategic action that

impacts patient outcomes, although intuition generally serves as an
adjunct to decision making founded on a nurse’s scientific
knowledge base. Intuition then can and should be used in
conjunction with evidence-based practice.

Krishnan (2018) agrees, noting that as nurses work in ever-
changing health-care environments, neither logical thinking nor
intuition are adequate to describe the dynamic processes nurses use
in clinical decision making. Thus, the cognitive processes used in
decision making are neither completely analytical nor completely
intuitive (see Examining the Evidence 1.1).

Source: Krishnan, P. (2018). A philosophical analysis
of clinical decision making in nursing. Journal of
Nursing Education, 57(2), 73–78.

Clinical Decision Making: A Combination of
Systematic and Intuitive Decision Making
The purpose of this study was to compare the
use of systematic decision making and intuition
in clinical decision making. The origin, aim,
value, ontology and epistemology,
assumptions, communicability, and context
specificity of both models were examined.

The researcher found little evidence to
suggest that either systematic decision-making
models or intuitive models should be used
solely to account for the breadth of processes
used in clinical decision making in nursing. The
pattern of knowing links information processing
and intuition together in clinical decision
making. The researchers concluded that the
combination of scientific evidence-based
knowledge in conjunction with intuition and
contextual factors is what enables nurses to
achieve excellent clinical decision making.

This recognition of familiar problems and the use of intuition to
identify solutions is a focus of contemporary research on intuitive
decision-making research. Klein (2008) developed the recognition-
primed decision (RPD) model for intuitive decision making in the
mid-1980s to explain how people can make effective decisions under

time pressure and uncertainty. Considered a part of naturalistic
decision making, the RPD model attempts to understand how
humans make relatively quick decisions in complex, real-world
settings such as firefighting and critical care nursing without having
to compare options.

Klein’s (2008) work suggests that instead of using classical
rational or systematic decision-making processes, many individuals
act on their first impulse if the “imagined future” looks acceptable. If
this turns out not to be the case, another idea or concept can
emerge from their subconscious and is examined for probable
successful implementation. Thus, the RPD model blends intuition
and analysis, but pattern recognition and experience guide decision
makers when time is limited or systematic rational decision making is
not possible.

Critical Elements in Problem Solving and
Decision Making
Because decisions may have far-reaching consequences, some
problem solving and decision making must be of high quality. Using
a scientific approach alone for problem solving and decision making
does not, however, ensure a quality decision. Special attention must
be paid to other critical elements. The elements in Display 1.6,
considered crucial in problem solving, must occur if a high-quality
decision is to be made.


1. Define objectives clearly.
2. Gather data carefully.
3. Take the time necessary.
4. Generate many alternatives.
5. Think logically.
6. Choose and act decisively.

Define Objectives Clearly
Decision makers often forge ahead in their problem-solving process
without first determining their goals or objectives. However, it is
especially important to determine goals and objectives when
problems are complex. Even when decisions must be made quickly,
there is time to pause and reflect on the purpose of the decision. A
decision that is made without a clear objective in mind or a decision
that is inconsistent with one’s philosophy is likely to be a poor-quality
decision. Sometimes, the problem has been identified, but the wrong
objectives are set.

If a decision lacks a clear objective or if an objective is
not consistent with the individual’s or organization’s
stated philosophy, a poor-quality decision is likely.

For example, it would be important for the decision maker in
Learning Exercise 1.1 to determine whether the most important
objective is career advancement, having more time with family, or
meeting the needs of her spouse. None of these goals is more “right”
than the others, but not having clarity about which objective is
paramount makes decision making very difficult.


Applying Scientific Models to Decision

You are a registered nurse. Since your graduation 3
years ago, you have worked as a full-time industrial
health nurse for a large manufacturing plant. Although
you love your family (spouse and one preschool-aged
child), you love your job as well because career is very
important to you. Recently, you and your spouse decided
to have another baby. At that time, you and your spouse
reached a joint decision that if you had another baby, you
would reduce your work time and spend more time at
home with the children.

Last week, however, the director of human resources
told you that the full-time director of health-care services
for the plant is leaving and that the organization wants to
appoint you to the position. You were initially thrilled and
excited; however, you found out several days later that
you and your spouse are expecting a baby.

Last night, you spoke with your spouse about your
career future. Your spouse is an attorney whose practice
has suddenly gained momentum. Although the two of you
have shared child rearing equally until this point, your
spouse is not sure how much longer this can be done if
the law practice continues to expand. If you take the
position, which you would like to do, it would mean full-
time work and more management responsibilities. You
want the decision you and your spouse reach to be well-

thought-out, as it has far-reaching consequences and
concerns many people.


Determine what you should do. Examine both the
individual aspects of decision making and the
critical elements in making decisions. Make a plan
including a goal, a list of information, and data that
you need to gather and areas where you may be
vulnerable to poor decision making. Examine the
consequences of each alternative available to you.

After you have made your decision, get together
in a group (four to six people) and share your
decisions. Were they the same? How did you
approach the problem solving differently from
others in your group? Was a rational systematic
problem-solving process used, or was the chosen
solution based more on intuition? How many
alternatives were generated? Did some of the group
members identify alternatives that you had not
considered? Was a goal or objective identified?
How did your personal values influence your

Gather Data Carefully
Because decisions are based on knowledge and information
available to the problem solver at the time the decision must be
made, one must learn how to process and obtain accurate
information. The acquisition of information begins with identifying the
problem or the occasion for the decision and continues throughout
the problem-solving process. Often, the information is unsolicited,
but most information is sought actively.

Clear (2018) warns, however, that many people experience
confirmation bias in their data gathering. Confirmation bias refers to
our tendency to search for and favor information that confirms our

beliefs while simultaneously ignoring or devaluing information that
contradicts our beliefs (Clear, 2018). The more someone believes he
or she knows something, the more he or she filters and ignores
information to the contrary. Thus, people negate new information if it
does not validate their perceptions or ideas.

In addition, acquiring information always involves people, and no
tool or mechanism is infallible to human error. Questions that should
be asked in data gathering are shown in Display 1.7.


1. What is the setting?
2. What is the problem?
3. Where is it a problem?
4. When is it a problem?
5. Who is affected by the problem?
6. What is happening?
7. Why is it happening? What are the causes of the problem?

Can the causes be prioritized?
8. What are the basic underlying issues? What are the areas of

9. What are the consequences of the problem? Which is the most


In addition, human values tremendously influence our perceptions.
Therefore, as problem solvers gather information, they must be
vigilant that their own preferences and those of others are not
mistaken for facts.

Facts can be misleading if they are presented in a
seductive manner, if they are taken out of context, or if
they are past oriented.

How many parents have been misled by the factual statement
“Johnny hit me”? In this case, the information seeker needs to do
more fact finding. What was the accuser doing before Johnny hit
him? Was he defending himself? What was he hit with? Where was
he hit? When was he hit? Like the parent, the manager who
becomes expert at acquiring adequate, appropriate, and accurate
information will have a head start in becoming an expert decision
maker and problem solver.

Take the Time Necessary
Most current problem-solving and decision-making theories argue
that human decision making is largely based on quick, automatic,
and intuitive processes. Although trivial decisions can be made fairly
quickly, slower, more controlled deliberation is needed when
outcomes may have significant consequences.

In fact, Parrish (2018) argues that most people need to actually
schedule time to think. Although some people might think more than
a few minutes is a waste of time, this viewpoint is shortsighted and
flawed. Parrish suggests that although it might take 30 minutes to
come to the same conclusion that you might come to in 5 minutes,
you’ll have a better idea of the nuances of the situation, including
which variables matter the most, and you’ll make less mistakes if you
take the time to really think about it.

Use an Evidence-Based Approach
To gain knowledge and insight into managerial and leadership
decision making, individuals must reach outside their current sphere

of knowledge in solving the problems presented in this text. Some
data-gathering sources include textbooks, periodicals, experts in the
field, colleagues, and current research. Indeed, most experts agree
that the best practices in nursing care and decision making are also
evidence-based practices (Prevost & Ford, 2020).

Although there is no one universally accepted definition for an
evidence-based approach, most definitions suggest the term
evidence based can be used synonymously with research based or
science based. Others suggest that evidence based means that the
approach has been reviewed by experts in the field using accepted
standards of empirical research and that reliable evidence exists that
the approach or practice works to achieve the desired outcomes.
Typically, a PICO (patient or population, intervention, comparison,
and outcome) format is used in evidence-based practice to guide the
search for the current best evidence to address a problem.

Given that human lives are often at risk, nurses, then, should feel
compelled to use an evidence-based approach in gathering data to
make decisions regarding their nursing practice. Yet, Prevost and
Ford (2020) suggest that many practicing nurses feel they do not
have the time, access, or expertise needed to search and analyze
the research literature to answer clinical questions. In addition, many
staff nurses practicing in clinical settings have less than a
baccalaureate degree and therefore may not have been exposed to
a formal research course. Findings from research studies may also
be technical, difficult to understand, and even more difficult to
translate into practice. Strategies the new nurse might use to
promote evidence-based practice are shown in Display 1.8.


1. Keep abreast of the evidence—subscribe to professional
journals and read widely.

2. Use and encourage use of multiple sources of evidence.
3. Use evidence not only to support clinical interventions but also

to support teaching strategies.
4. Find established sources of evidence in your specialty—do not

reinvent the wheel.
5. Implement and evaluate nationally sanctioned clinical practice

6. Question and challenge nursing traditions and promote a spirit

of risk taking.
7. Dispel myths and traditions not supported by evidence.
8. Collaborate with other nurses locally and globally.
9. Interact with other disciplines to bring nursing evidence to the


Source: Reprinted from Prevost, S., & Ford, C. D. (2019). Evidence-based
practice. In C. J. Huston (Ed.), Professional issues in nursing: Challenges and
opportunities (5th ed., pp. 69–80). Philadelphia, PA: Wolters Kluwer.

Evidence-based decision making and evidence-based
practice should be viewed as imperatives for all nurses
today as well as for the profession in general.

It is important to recognize that the implementation of evidence-
based best practices is not just an individual, staff nurse–level
pursuit (Prevost & Ford, 2020). Too few nurses understand what best
practices and evidence-based practice are about, and many
organizational cultures do not support nurses who seek out and use

research to change long-standing practices rooted in tradition rather
than in science. Administrative support is needed to access the
resources; provide the support personnel; and sanction the
necessary changes in policies, procedures, and practices for
evidence-based data gathering to be a part of every nurse’s practice
(Prevost & Ford, 2020). This approach to care is even being
recognized as a standard expectation of accrediting bodies such as
The Joint Commission as well as an expectation for Magnet hospital

Generate Numerous Alternatives
The definition of decision making implies that there are at least two
choices in every decision. Unfortunately, many problem solvers limit
their choices to two when many more options usually are available.
Remember that one alternative in each decision should be the
choice not to do anything. When examining decisions to be made by
using a formal process, it is often found that the status quo is the
right alternative.

The greater the number of alternatives that can be
generated, the greater the chance that the final decision
will be sound.

Several techniques can help to generate more alternatives.
Involving others in the process confirms the adage that two heads
are better than one. Because everyone thinks uniquely, increasing
the number of people working on a problem increases the number of
alternatives that can be generated.

Brainstorming is another frequently used technique. The goal in
brainstorming is to think of all possible alternatives, even those that
may seem “off target.” By not limiting the possible alternatives to only
apparently appropriate ones, people can break through habitual or

repressive thinking patterns and allow new ideas to surface.
Although most often used by groups, people who make decisions
alone also may use brainstorming.


Possible Alternatives in Problem Solving

In the personal-choice scenario presented in Learning
Exercise 1.1, some of the following alternatives could
have been generated:

Do not take the new position.
Hire a full-time housekeeper and take the position.
Ask your spouse to quit working.
Have an abortion.
Ask one of the parents to help.
Take the position and do not hire childcare.
Take the position and hire childcare.
Have your spouse reduce the law practice and

continue helping with childcare.
Ask the director of human resources if you can work 4

days a week and still have the position.
Take the position and wait and see what happens after

the baby is born.


How many of these alternatives did you or your
group generate? What alternatives did you identify
that are not included in this list?

Think Logically
During the problem-solving process, one must draw inferences from
information. An inference is part of deductive reasoning. People
must carefully think through the information and the alternatives.
Faulty logic at this point may lead to poor-quality decisions. Primarily,
people think illogically in three ways.

1. Overgeneralizing: This type of “crooked” thinking occurs when
one believes that because A has a particular characteristic,
every other A also has the same characteristic. This kind of
thinking is exemplified when stereotypical statements are used
to justify arguments and decisions.

2. Affirming the consequences: In this type of illogical thinking,
one decides that if B is good and he or she is doing A, then A
must not be good. For example, if a new method is heralded as
the best way to perform a nursing procedure and the nurses on
your unit are not using that technique, it is illogical to assume
that the technique currently used in your unit is wrong or bad.

3. Arguing from analogy: This thinking applies a component that is
present in two separate concepts and then states that because
A is present in B, then A and B are alike in all respects. An
example of this would be to argue that because intuition plays a
part in clinical and managerial nursing, then any characteristic
present in a good clinical nurse also should be present in a
good nurse-manager. However, this is not necessarily true; a
skilled nurse-manager does not necessarily possess all the
same skills as a skilled nurse-clinician.

Various tools have been designed to assist managers with the
important task of analysis. Several of these tools are discussed in
this chapter. In analyzing possible solutions, individuals may want to
look at the following questions:

1. What factors can you influence? How can you make the
positive factors more important and minimize the negative

2. What are the financial implications in each alternative? What
are the political implications? Who else will be affected by the
decision, and what support is available?

3. What are the weighting factors?
4. What is the best solution?
5. What are the means of evaluation?
6. What are the consequences of each alternative?

Choose and Act Decisively
It is not enough to gather adequate information, think logically, select
from among many alternatives, and be aware of the influence of
one’s values. In the final analysis, one must act. Many individuals
delay acting because they do not want to face the consequences of
their choices (e.g., if managers granted all employees’ requests for
days off, they would have to accept the consequences of dealing
with short staffing).

Many individuals choose to delay acting because they
lack the courage to face the consequences of their

It may help the reluctant decision maker to remember that even
though decisions often have long-term consequences and far-
reaching effects, they are not usually cast in stone. Often, judgments

found to be ineffective or inappropriate can be changed. By later
evaluating decisions, managers can learn more about their abilities
and where the problem solving was faulty. However, decisions must
continue to be made, although some are of poor quality, because
through continued decision making, people develop improved
decision-making skills.

Individual Variations in Decision Making
If each person receives the same information and uses the same
scientific approach to solve problems, an assumption could be made
that identical decisions would result. However, in practice, this is not
true. Because decision making involves perceiving and evaluating,
and people perceive by sensation and intuition and evaluate their
perception by thinking and feeling, it is inevitable that individuality
plays a part in decision making. Because everyone has different
values and life experiences, and each person perceives and thinks
differently, different decisions may be made given the same set of
circumstances. No discussion of decision making would, therefore,
be complete without a careful examination of the role of the
individual in decision making.

New research suggests that gender may play a role in how
individuals make decisions, although some debate continues as to
whether these differences are more gender role based than gender
based. Research does suggest, however, that men and women do
have different structures and wiring in the brain and that men and
women may use their brains differently (Edmonds, 2018). For
example, Harvard researchers have found that parts of the frontal
lobe, responsible for problem solving and decision making, and the
limbic cortex, responsible for regulating emotions, are larger in
women (Hoag as cited in Edmonds, 2018). Men also have

approximately 6.5 times more gray matter in the brain than women,
but women have about 10 times more white matter than men (Carey
as cited in Edmonds, 2018). Researchers believe that men may think
more with their gray matter, whereas women think more with the
white matter. This use of white matter may allow a woman’s brain to
work faster than a man’s (Hotz as cited in Edmonds, 2018).

Individual decisions are based on each person’s value system. No
matter how objective the criteria, value judgments will always play a
part in a person’s decision making, either consciously or
subconsciously. The alternatives are generated, and the final
choices are limited by each person’s value system. For some,
certain choices are not possible because of a person’s beliefs.
Because values also influence perceptions, they invariably influence
information gathering, information processing, and outcomes. Values
also determine which problems in one’s personal or professional life
will be addressed or ignored.

No matter how objective the criteria, value judgments will
always play a part in a person’s decision making, either
consciously or subconsciously.

Life Experience
Each person brings to the decision-making task past experiences
that include education and decision-making experience. The more
mature the person and the broader his or her background, the more
alternatives he or she can identify. Each time a new behavior or
decision is observed, that possibility is added to the person’s
repertoire of choices.

In addition, people vary in their desire for autonomy, so some
nurses may want more autonomy than others. It is likely that people
seeking autonomy may have much more experience at making
decisions than those who fear autonomy. Likewise, having made
good or poor decisions in the past will influence a person’s decision

Individual Preference
With all the alternatives a person considers in decision making, one
alternative may be preferred over another. The decision maker, for
example, may see certain choices as involving greater personal risk
than others and therefore may choose the safer alternative. Physical,
economic, and emotional risks and time and energy expenditures
are types of personal risks and costs involved in decision making.
For example, people with limited finances or a reduced energy level
may decide to select an alternative solution to a problem that would
not have been their first choice had they been able to overcome
limited resources.

Brain Hemisphere Dominance and Thinking
Our way of evaluating information and alternatives on which we base
our final decision constitutes a thinking skill. Individuals think
differently. Some think systematically—and are often called analytical
thinkers—whereas others think more intuitively. About 30 years ago,
researchers first began arguing that most people have either right- or
left-brain hemisphere dominance. They suggested that analytical,
linear, left-brain thinkers process information differently from
creative, intuitive, right-brain thinkers. Left-brain thinkers were
supposed to be better at processing language, logic, and numbers,

whereas right-brain thinkers excelled at nonverbal ideation and

Some researchers, including Nobel Prize winner Roger Sperry,
suggested that there were actually four different thinking styles
based on brain dominance. Ned Herrmann, a researcher in critical
thinking and whole-brain methods, also suggested that there are four
brain hemispheres and that decision making varies with brain
dominance (12 Manage: The Executive Fast Track, 2018). For
example, Herrmann suggested that individuals with upper-left-brain
dominance truly are analytical thinkers who like working with factual
data and numbers. These individuals deal with problems in a logical
and rational way. Individuals with lower-left-brain dominance are
highly organized and detail oriented. They prefer a stable work
environment and value safety and security over risk taking.

In addition, researchers suggested that individuals with upper-
right-brain dominance were big picture thinkers who looked for
hidden possibilities and were futuristic in their thinking. They were
thought to frequently rely on intuition to solve problems and are
willing to take risks to seek new solutions to problems. Individuals
with lower-right-brain dominance experienced facts and problem
solved in a more emotional way than the other three types. They
were sympathetic, kinesthetic, and empathetic and focused more on
interpersonal aspects of decision making (12 Manage: The
Executive Fast Track, 2018).

Nauert (2018) suggests, however, that the existence of left or right
brain dominance is too simplistic. He suggests that newer studies
have failed to find evidence that individuals tend to have stronger
left- or right-sided brain networks. Cherry (2019) agrees, suggesting
that recent research has shown that the brain is not nearly as
dichotomous as once thought. For example, abilities in subjects such
as math are strongest when both halves of the brain work together.
Indeed, both sides of the brain collaborate to perform a broad variety
of tasks, and the two hemispheres communicate through the corpus

callosum (Cherry, 2019). Cherry notes that it is true that some brain
functions occur in one or the other side of the brain (language tends
to be on the left and attention more on the right), but people don’t
tend to have a stronger left- or right-sided brain network.

New evidence suggests the existence of left or right brain
dominance may be an oversimplification.


Thinking Styles

In small groups, discuss individual variations in thinking.
Did some individuals identify themselves as more intuitive
thinkers or more linear thinkers? Did group members self-
identify with one or more of the four thinking styles noted
by Herrmann (12 Manage: The Executive Fast Track,
2018)? Did gender seem to influence thinking style or
brain hemisphere dominance? What types of thinkers
were represented in group members’ families? Did most
group members view variances in a positive way?

Overcoming Individual Vulnerability in Decision
How do people overcome subjectivity in making decisions? This can
never be completely overcome or should it. After all, life would be
boring if everyone thought alike. However, managers and leaders
must become aware of their own vulnerability and recognize how it

influences and limits the quality of their decision making. Using the
following suggestions will help decrease individual subjectivity and
increase objectivity in decision making.

Being confused and unclear about one’s values may affect decision-
making ability. Overcoming a lack of self-awareness through values
clarification decreases confusion. People who understand their
personal beliefs and feelings will have a conscious awareness of the
values on which their decisions are based. This awareness is an
essential component of decision making and critical thinking.
Therefore, to be successful problem solvers, managers must
periodically examine their values. Values clarification exercises are
included in Chapter 7.

Life Experience
It is difficult to overcome inexperience when making decisions.
However, a person can do some things to decrease this area of
vulnerability. First, use available resources, including current
research and literature, to gain a fuller understanding of the issues
involved. Second, involve other people, such as experienced
colleagues, mentors, trusted friends, and experts, to act as sounding
boards and advisors. Third, analyze decisions later to assess their
success. By evaluating decisions, people learn from mistakes and
are able to overcome inexperience.

In addition, novice nurse-leaders of the future may increasingly
choose to improve the quality of their decision making by the use of
commercially purchased expert networks—communities of top
thinkers, managers, and scientists—to help them make decisions.
Such network panels are typically made up of researchers, health-
care professionals, attorneys, and industry executives.

Individual Preference
Overcoming this area of vulnerability involves self-awareness,
honesty, and risk taking. The need for self-awareness was discussed
previously, but it is not enough to be self-aware; people also must be
honest with themselves about their choices and their preferences for
those choices. In addition, the successful decision maker must take
some risks. Nearly every decision has some element of risk, and
most decisions involve consequences and accountability.

Those who can do the right but unpopular thing and who
dare to stand alone will emerge as leaders.

Individual Ways of Thinking
People making decisions alone are frequently handicapped because
they are not able to understand problems fully or make decisions
from both analytical and intuitive perspectives. However, most
organizations include both types of thinkers. Using group process,
talking management problems over with others, and developing
whole-brain thinking also are methods for ensuring that both intuitive
and analytical approaches will be used in solving problems and
making decisions. Use of heterogeneous rather than homogeneous
groups will usually result in better quality decision making. Indeed,
learning to think “outside the box” is often accomplished by including
a diverse group of thinkers when solving problems and making

Although not all experts agree, many consider the following to be
qualities of a successful decision maker:

Courage: Courage is particularly important and involves the
willingness to take risks.

Sensitivity: Good decision makers seem to have some sort of
antenna that makes them particularly sensitive to situations and

Energy: People must have the energy and desire to make things

Creativity: Successful decision makers tend to be creative

thinkers. They develop new ways to solve problems.

Decision Making in Organizations
In the beginning of this chapter, the need for managers and leaders
to make quality decisions was emphasized. The effect of the
individual’s values and preferences on decision making was
discussed, but it is important for leaders and managers to also
understand how the organization influences the decision-making
process. Because organizations are made up of people with differing
values and preferences, there is often conflict in organizational
decision dynamics.

Effect of Organizational Power
Powerful people in organizations are more likely to have decisions
made (by themselves or their subordinates) that are congruent with
their own preferences and values. On the other hand, people
wielding little power in organizations must always consider the
preference of the powerful when they make management decisions.
In organizations, choice is constructed and constrained by many
factors, and therefore, choice is not equally available to all people.

In addition, not only do the preferences of the powerful influence
decisions of the less powerful but the powerful also can inhibit the
preferences of the less powerful. This occurs because individuals
who remain and advance in organizations are those who feel and
express values and beliefs congruent with the organization.
Therefore, a balance must be found between the limitations of
choice posed by the power structure within the organization and

totally independent decision making that could lead to organizational

The ability of the powerful to influence individual
decision making in an organization often requires
adopting a private personality and an organizational

For example, some might believe they would have made a
different decision had they been acting on their own, but they went
along with the organizational decision. This “going along” constitutes
a decision. People choose to accept an organizational decision that
differs from their own preferences and values. The concept of power
in organizations is discussed in more detail in Chapter 13.

Rational and Administrative Decision Making
For many years, it was widely believed that most managerial
decisions were based on a careful, scientific, and objective thought
process and that managers made decisions in a rational manner. In
the late 1940s, Herbert A. Simon’s work revealed that most
managers made many decisions that did not fit the objective
rationality theory. Simon (1965) delineated two types of management
decision makers: the economic man and the administrative man.

Managers who are successful decision makers often attempt to
make rational decisions, much like the economic man described in
Table 1.2. Because they realize that restricted knowledge and limited
alternatives directly affect a decision’s quality, these managers
gather as much information as possible and generate many
alternatives. Simon (1965) believed that the economic model of man,
however, was an unrealistic description of organizational decision
making. The complexity of information acquisition makes it
impossible for the human brain to store and retain the amount of

information that is available for each decision. Because of time
constraints and the difficulty of assimilating large amounts of
information, most management decisions are made using the
administrative man model of decision making.


Economic Administrative

Makes decisions in a very
rational manner

Makes decisions that are good

Has complete knowledge of the
problem or decision situation

Because complete knowledge is
not possible, knowledge is
always fragmented.

Has a complete list of possible

Because consequences of
alternatives occur in the future,
they are impossible to predict

Has a rational system of ordering
preference of alternatives

Usually chooses from among a
few alternatives, not all possible

Selects the decision that will
maximize utility

The final choice is satisficing
rather than maximizing.

Source: Based on Simon, H. A. (1965). The shape of automation for man and
management. New York, NY: Harper & Row.

Most management decisions are made by using the
administrative man model of decision making.

The administrative man never has complete knowledge and
generates fewer alternatives. Simon (1965) argued that the

administrative man carries out decisions that are only satisficing, a
term used to describe decisions that may not be ideal but result in
solutions that have adequate outcomes. These managers want
decisions to be “good enough” so that they “work,” but they are less
concerned that the alternative selected is the optimal choice. The
“best” choice for many decisions is often found to be too costly in
terms of time or resources, so another less costly but workable
solution is found.

Clear (2018) agrees, suggesting that although researchers and
economists believed for some time that humans always made
logical, well-considered decisions, more current research suggests
that a wide range of mental errors often derail our thinking.
Sometimes, we make logical decisions, but there are many times
when we make emotional, irrational, and confusing choices.

Annie Duke (2018), a famous poker player, suggests this occurs
because we often must make quick decisions with limited
information. This means that mistakes, emotions, and poor choices
are common. Judging the quality of our decision making on outcome
alone then can be short sighted and counterproductive. Duke notes
that sometimes, we make the best choice based on the information
available, but other information is hidden. Other times, we choose a
path with a high likelihood of success, but it fails. Still, other times,
we make a decision that works, but other choices would have been
better. So, decision making becomes less about being good or bad
and more about “calibrating among all the shades of gray” (Duke,
2018, p. 34).

Decision-Making Tools
There is always some uncertainty in making decisions. However,
management analysts have developed tools that provide some order
and direction in obtaining and using information or that are helpful in
selecting who should be involved in making the decision. Because

there are so many decision aids, this chapter presents selected
technology that would be most helpful to beginning- or middle-level
managers, including decision grids, payoff tables, decision trees,
consequence tables, logic models, and program evaluation and
review technique (PERT). It is important to remember, though, that
any decision-making tool always results in the need for the person to
make a final decision and that all such tools are subject to human

Decision Grids
A decision grid allows one to visually examine the alternatives and
compare each against the same criteria. Although any criterion may
be selected, the same criteria are used to analyze each alternative.
An example of a decision grid is depicted in Figure 1.3. When many
alternatives have been generated or a group or committee is
collaborating on the decision, these grids are particularly helpful to
the process. This tool, for instance, would be useful when changing
the method of managing care on a unit or when selecting a
candidate to hire from a large interview pool. The unit manager or
the committee would evaluate all of the alternatives available using a
decision grid. In this manner, every alternative is evaluated using the
same criteria. It is possible to weigh some of the criteria more heavily
than others if some are more important. To do this, it is usually
necessary to assign a number value to each criterion. The result
would be a numeric value for each alternative considered.

FIGURE 1.3 A decision grid.

Payoff Tables
The decision aids known as payoff tables have a cost–profit–volume
relationship and are very helpful when some quantitative information
is available, such as an item’s cost or predicted use. To use payoff
tables, one must determine probabilities and use historical data,
such as a hospital census and a report on the number of operating
procedures performed. To illustrate, a payoff table might be
appropriately used in determining how many participants it would
take to make an in-service program break even in terms of costs.

If the instructor for the class costs $500, the in-service director
would need to charge each of the 20 participants $25 for the class,
but for 40 participants, the class would cost only $12.50 each. The
in-service director would use attendance data from past classes and
the number of nurses potentially available to attend to determine
probable class size and thus how much to charge for the class.
Payoff tables do not guarantee that a correct decision will be made,
but they assist in visualizing data.

Decision Trees
Because decisions are often tied to the outcome of other events,
management analysts have developed decision trees.

The decision tree in Figure 1.4 compares the cost of hiring regular
staff with the cost of hiring temporary employees. Here, the decision
is whether to hire extra nurses at regular salary to perform outpatient
procedures on an oncology unit or to have nurses available to the
unit on an on-call basis and pay them on-call and overtime wages.
The possible consequences of a decreased volume of procedures
and an increased volume must be considered. Initially, costs would
increase in hiring a regular staff, but, over a longer time, this move
would mean greater savings if the volume of procedures does not
dramatically decrease.

FIGURE 1.4 A decision tree.

Consequence Tables
Consequence tables demonstrate how various alternatives create
different consequences. A consequence table lists the objectives for

solving a problem down one side of a table and rates how each
alternative would meet the desired objective.

For example, consider this problem: “The number of patient falls
has exceeded the benchmark rate for two consecutive quarters.”
After a period of analysis, the following alternatives were selected as

1. Provide a new educational program to instruct staff on how to
prevent falls.

2. Implement a night check to ensure that patients have side rails
up and beds in low position.

3. Implement a policy requiring direct patient observation by
sitters on all confused patients.

The decision maker then lists each alternative opposite the
objectives for solving the problem, which for this problem might be
(a) reduces the number of falls, (b) meets regulatory standards, (c) is
cost-effective, and (d) fits present policy guidelines. The decision
maker then ranks each desired objective and examines each of the
alternatives through a standardized key, which allows a fair
comparison between alternatives and assists in eliminating
undesirable choices. It is important to examine long-term effects of
each alternative as well as how the decision will affect others. See
Table 1.3 for an example of a consequence table.


Objectives for
Problem Solving Alternative 1 Alternative 2 Alternative 3

1. Reduces the
number of falls


2. Meets regulatory


3. Is cost-effective X X X
4. Fits present policy


Decision Score

Logic Models
Logic models are schematics or pictures of how programs are
intended to operate. The schematic typically includes resources,
processes, and desired outcomes and depicts exactly what the
relationships are between the three components.

Program Evaluation and Review Technique
PERT is a popular tool to determine the timing of decisions.
Developed by the Booz-Allen-Hamilton organization and the U.S.
Navy in connection with the Polaris missile program, PERT is
essentially a flowchart that predicts when events and activities must
take place if a final event is to occur. Figure 1.5 shows a PERT chart
for developing a new outpatient treatment room for oncology
procedures. The number of weeks to complete tasks is listed in
optimistic time, most likely time, and pessimistic time. The critical
path shows something that must occur in the sequence before one
may proceed. PERT is especially helpful when a group of people is
working on a project. The flowchart keeps everyone up-to-date, and

problems are easily identified when they first occur. Flowcharts are
popular, and many people use them in their personal lives.

FIGURE 1.5 Example of a program evaluation and review technique flow

Pitfalls in Using Decision-Making Tools
A common flaw in making decisions is to base decisions on first
impressions. This then typically leads to confirmation biases. A
confirmation bias is a tendency to affirm one’s initial impression and
preferences as other alternatives are evaluated. So, even the use of
consequence tables, decision trees, and other quantitative decision
tools will not guarantee a successful decision.

It is also human nature to focus on an event that leaves a strong
impression, so individuals may have preconceived notions or biases
that influence decisions. Too often, managers allow the past to
unduly influence current decisions.

Many of the pitfalls associated with management
decision-making tools can be reduced by choosing the
correct decision-making style and involving others when

Although there are times when others should be involved, it is not
always necessary to involve others in decision making, and
frequently, a manager does not have time to involve a large group.
However, it is important to separate out those decisions that need
input from others and those that a manager can make alone.

Integrating Leadership Roles and Management
Functions in Decision Making
This chapter has discussed effective decision making, problem
solving, critical thinking, and clinical reasoning as requisites for being
a successful leader and manager. The effective leader-manager is
aware of the need for sensitivity in decision making. The successful
decision maker possesses courage, energy, and creativity. It is a
leadership skill to recognize the appropriate people to include in
decision making and to use a suitable theoretical model for the
decision situation.

Managers who make quality decisions are effective administrators.
The manager should develop a systematic, scientific approach to
problem solving that begins with a fixed goal and ends with an
evaluation step. Decision tools exist to help make more effective
decisions; however, leader-managers must remember that they are

not foolproof and that they often do not adequately allow for the
human element in management. In addition, managers should strive
to make decisions that reflect research-based best practices and
nursing’s scientific knowledge base. Yet, the role of intuition as an
adjunct to quality decision making should not be overlooked.

The integrated leader-manager understands the significance that
gender, personal values, life experience, preferences, willingness to
take risks, brain hemisphere dominance, and thinking styles have on
selected alternatives in making the decision. The critical thinker
pondering a decision is aware of the areas of vulnerability that hinder
successful decision making and will expend his or her efforts to
avoid the pitfalls of faulty logic and data gathering.

Both managers and leaders understand the impact that the
organization has on decision making and that some of the decisions
that will be made in the organization will be only satisficing. However,
leaders will strive to problem solve adequately in order to reach
optimal decisions as often as possible.

Key Concepts

■ Successful decision makers are self-aware, courageous,
sensitive, energetic, and creative.

■ The rational approach to problem solving begins with a fixed
goal and ends with an evaluation process.

■ Naturalistic decision making blends intuition and analysis, but
pattern recognition and experience guide decision makers
when time is limited or systematic rational decision making is
not possible.

■ Evidence-based nursing practice integrates the best
evidence available to achieve desirable outcomes.

■ Typically, a PICO format is used in evidence-based practice
to guide the search for the current best evidence to address a

■ The successful decision maker understands the significance
that gender, personal, individual values, life experience,
preferences, willingness to take risks, brain hemisphere
dominance, and predominant thinking style have on
alternative identification and selection.

■ Left- and right-brain dominance may be an oversimplification
in terms of how individuals think.

■ The critical thinker is aware of areas of vulnerability that
hinder successful decision making and makes efforts to avoid
the pitfalls of faulty logic in his or her data gathering.

■ The act of making and evaluating decisions increases the
expertise of the decision maker.

■ There are many models for improving decision making. Using
a systematic decision-making or problem-solving model
reduces heuristic trial-and-error or rule-of-thumb methods
and increases the probability that appropriate decisions will
be made.

■ Two major considerations in organizational decision making
are how power affects decision making and whether
management decision making needs to be only satisficing.

■ Management science has produced many tools to help
decision makers make better and more objective decisions,
but all are subject to human error, and many do not
adequately consider the human element.

Additional Learning Exercises and Applications


Assessing Personal Decision Making

Write a two- to three-page response to one of the
following prompts:
A. Identify a poor decision that you recently made

because of faulty data gathering. Have you ever
made a poor decision because necessary
information was intentionally or unintentionally
withheld from you?

B. Describe the two best decisions that you have
made in your life and the two worst. What factors
assisted you in making the wise decisions? What
elements of critical thinking went awry in your
poor decision making? How would you evaluate
your decision-making ability?

C. Examine the process that you used in your
decision to become a nurse. Would you describe
it as fitting a profile of the economic man or the
administrative man?

D. Do you typically use a problem-solving or
decision-making model to solve problems? Have
you ever used an intuitive model? Think of a
critical decision that you have made in the last
year. Describe what theoretical model, if any, you
used to assist you in the process. Did you enlist
the help of other experts in solving the problem?


Sharing Workload

You are a staff nurse on a small telemetry unit. The unit
is staffed at a ratio of one nurse for every four patients,
and the charge nurse is counted in this staffing because
there is a full-time unit secretary and monitor technician
to assist at the desk. The charge nurse is responsible for
making the daily staffing assignments. Although you
recognize that the charge nurse needs to reduce her
patient care assignment to have time to perform the
charge nurse duties, you have grown increasingly
frustrated that she normally assigns herself only one
patient, if any, and these patients always have the lowest
acuity level on the floor. This has placed a
disproportionate burden on the other nurses, who often
feel the assignment they are being given may be unsafe.
The charge nurse is your immediate supervisor. She has
not generally been responsive to concerns expressed by
the staff to her about this problem.


Decide what the problem is in this scenario and
who owns it. Identify at least five alternatives for
action and select which one you believe will have
the greatest likelihood of successful
implementation. How did differences in power and
status influence the alternatives you identified?
What outcomes must be achieved for you to feel
that the choice you made was a good one?


Considering Critical Elements in
Decision Making

You are a college senior and president of your student
nursing organization. You are on the committee to select
a slate of officers for the next academic year. Several of
the current officers will be graduating, and you want the
new slate of officers to be committed to the organization.
Some of the brightest members of the junior class
involved in the organization are not well liked by some of
your friends in the organization.


Looking at the critical elements in decision making,
compile a list of the most important points to
consider in making the decision for selecting a slate
of officers. What must you guard against, and how
should you approach the data gathering to solve
this problem?


Decision Making and Risk Taking

You are a new graduate nurse just finishing your 3-
month probation period at your first job in acute care
nursing. You have been working closely with a preceptor;
however, he has been gradually transitioning you to more
independent practice. You now have your own patient
care assignment and have been giving medications
independently for several weeks. Today, your assignment
included an elderly confused patient with severe coronary
disease. Her medications include antihypertensives,
antiarrhythmics, and beta-blockers. It was a very busy
morning, and you have barely had a moment to
reorganize and collect your thoughts.

It is now 2:30 PM, and you are preparing your handoff
report. When you review the patient’s 2:00 PM vital signs,
you note a significant rise in this patient’s blood pressure
and heart rate. The patient, however, reports no distress.
You remember that when you passed the morning
medications, the patient was in the middle of her bath

and asked that you just set the medications on the
bedside table and that she would take them in a few
minutes. You meant to return to see that she did but were
sidetracked by a problem with another patient.

You now go to the patient’s room to see if she, indeed,
did take the pills. The pill cup and pills are not where you
left them, and a search of the wastebasket, patient bed,
and bedside table yields nothing. The patient is too
confused to be an accurate historian regarding whether
she took the pills. No one on your patient care team
noticed the pills.

At this point, you are not sure what you should do next.
You are upset that you did not wait to give the
medications in person but cannot change this now. You
charted the medications as being given this morning
when you left them at the bedside. You are reluctant to
report this as a medication error because you are still on
probation, and you are not sure that the patient did not
take the pills as she said she would. Your probation
period has not gone as smoothly as you would have liked
anyway, and you are aware that reporting this incident
will likely prolong your probation, and that a copy of the
error report will be placed in your personnel file. The
patient’s physician is also frequently short-tempered and
will likely be agitated when you report your uncertainty
about whether the patient received her prescribed
medications. The reality is that if you do nothing, it is
likely that no one will ever know about the problem.

You do feel responsible, however, for the patient’s
welfare. The physician might want to give additional
doses of the medication if indeed the patient did not take
the pills. In addition, the rise in heart rate and blood
pressure has only just become apparent, and you realize

that her heart rate and blood pressure could continue to
deteriorate over the next shift. The patient is not due to
receive the medications again until 9:00 PM tonight (b.i.d.
every 12 hours).


Decide how you will proceed. Determine whether
you will use a systematic problem-solving model,
intuition, or both in making your choices. How did
your values, preferences, life experiences,
willingness to take risks, and individual ways of
thinking influence your decision?


Determining a Need to Know

You are a nursing student. You are also HIV positive
because of some high-risk behaviors you engaged in a

decade ago. (It seems like a lifetime ago.) You are now in
a committed, monogamous relationship, and your partner
is aware of your HIV status. You have experienced
relatively few side effects from the antiretroviral drugs you
take, and you appear to be healthy. You have not shared
your sexual preferences, past sexual history, or HIV
status with any of your classmates, primarily because you
do not feel that it is their business and because you fear
being ostracized in the local community, which is fairly

Today, in the clinical setting, one of the students
accidentally stuck herself with a needle right before she
injected it into a patient. Laboratory follow-up was
ordered to ensure that the patient was not exposed to
any blood-borne disease from the student. Tonight, for
the first time, you recognize that no matter how careful
you are, there is at least a small risk that you could
inadvertently expose patients to your bodily fluids and
thus to some risk.


Decide what you will do. Is there a need to share
your HIV status with the school? With future
employers? With patients? What determines
whether there is “a need to tell” and a “need to
know”? What objective weighted most heavily in
your decision?


Using a Flowchart for Project

Think of a project that you are working on; it could be a
dance, a picnic, remodeling your bathroom, or a
semester schedule of activities in a class.


Draw a flowchart, inserting at the bottom the date
that activities for the event are to be completed.
Working backward, insert critical tasks and their
completion dates. Refer to your flowchart
throughout the project to see if you are staying on


Addressing a Communication Gap
(Marquis & Huston, 2012)

You are a new graduate nurse just finishing your 3-
month probation period at your first job in acute care
nursing. Your usual assignment is to be a team leader for
eight patients, with one licensed practical nurse/licensed
vocational nurse and one nursing assistant on your team.
Today, your assignment included an elderly confused
patient. You requested, during work assignments with

your team, that the nursing assistant pay attention to this
patient’s intake and output (I & O) as you feel he may
need some intravenous fluids if his I & O remain poor.
You asked the nursing assistant to notify you if there was
significant change, so you could notify the physician. It
was a very busy day, and you have barely had a moment
to reorganize and collect your thoughts.

It is now 2:30 PM, and you are preparing your end-of-
shift report. When you review the patient’s 2:00 PM I & O
sheet, you note a significant drop in intake and the total
output for the shift is only 90 mL. You meant to check the
I & O sheet during the day but kept getting sidetracked by
problems with other patients. However, you are also
upset that the nursing assistant did not keep you
informed of this condition.

You now go to the patient’s room and assess the
patient and find his vital signs and other findings similar
to this morning’s assessment. You check with the nursing
assistant to make sure the I & O recorded for the day is
accurate, and you call the physician to obtain an order to
begin intravenous fluids. When you ask the nursing
assistant why she did not report the significant drop in
output to you, she said, “I forgot.”

At this point, you are not sure what you should do next.
You feel you should handle this yourself and not go to the
charge nurse. You are a new nurse and do want to get
started on the wrong foot by speaking too harshly to the
nursing assistant, yet you feel this lack of following
instructions cannot go unanswered. The reality is that if
you do nothing, it is likely that no one else will ever know
about the problem.

The doctor did not seem upset when you called him
about the drop in output, he just ordered the fluids, but

the need to start the intravenous line and give report
caused you to work overtime. By the time you finished
your shift, the nursing assistant had gone home and you
are left to spend your evening at home pondering what, if
anything, you should do to follow up on this tomorrow.


Decide how you will proceed. Determine whether
you will use a systematic problem-solving model,
intuition, or both in making your choices. How did
your values, preferences, life experiences,
willingness to take risks, and individual ways of
thinking influence your decision?


Returning to School for a Bachelor of
Science in Nursing Degree (Marquis &
Huston, 2012)

You have been a registered nurse (RN) for 5 years.
Right after high school, you became a licensed vocational
nurse (LVN) and after 6 years decided to attend a local
LVN to associate degree in nursing program at a local
community college. You have become increasingly
interested in attending a baccalaureate university to
complete requirements for your Bachelor of Science in
Nursing (BSN) degree. You are still undecided; some of
your friends are urging you to do this, and others ask why
you need the degree.

Not only must you make up your mind about pursuing
this option but you also have two different local
opportunities. The regional university is 60 miles away

and would require significant amounts of driving if you did
the on-campus program; however, the university’s school
of nursing also offers an online course that would require
only four full Saturdays of attendance each semester.
Both options have pros and cons.

After making a payoff table, calculating chances for
advancement and salary increase weighed against cost
of your new degree, you decided that it made economic
sense to get a BSN degree.

Now that you have decided to get your baccalaureate
degree, you must decide between three alternatives: (a)
attending a distant university 60 miles away, (b) attending
your local university and enrolling in their on-campus
program, or (c) enrolling as an online student.


Create a decision grid for the three alternatives,
weighting the same criteria for each, using such
things as cost, travel, quality of campus life,
reputation and quality of the university, and so on.
Assign each of your criteria a weighted score for the
value that you personally view it. What did your final
grid look like and what was your final decision?


How Good Are Your Decision-Making
Skills? Quiz and Key

For each statement, mark the box in the column that best
describes you. Please answer questions as you actually
are (rather than how you think you should be).


all Rarely

times Often


1 I evaluate the risks
associated with
each alternative
before making a

2 After I make a
decision, it is final—
because I know my
process is strong.

3 I try to determine
the real issue
before starting a

4 I rely on my own
experience to find
potential solutions
to a problem.

5 I tend to have a
strong “gut instinct”
about problems,
and I rely on it in

6 I am sometimes
surprised by the

consequences of
my decisions.

7 I use a well-defined
process to structure
my decisions.

8 I think that involving
many stakeholders
to generate
solutions can make
the process more
complicated than it
needs to be.

9 If I have doubts
about my decision,
I go back and
recheck my
assumptions and
my process.

10 I take the time
needed to choose
the best decision-
making tool for
each specific

11 I consider a variety
of potential
solutions before I
make my decision.

12 Before I
communicate my
decision, I create

an implementation

13 In a group decision-
making process, I
tend to support my
friends’ proposals
and try to find ways
to make them work.

14 When
communicating my
decision, I include
my rationale and

15 Some of the
options I’ve chosen
have been much
more difficult to
implement than I
had expected.

16 I prefer to make
decisions on my
own, and then let
other people know
what I’ve decided.

17 I determine the
factors most
important to the
decision, and then
use those factors to
evaluate my

18 I emphasize how
confident I am in




my decision as a
way to gain support
for my plans.

Total = 0

As you answered the questions, did you see some
common themes? We based our quiz on six essential
steps in the decision-making process:

1. Establishing a positive decision-making environment.
2. Generating potential solutions.
3. Evaluating the solutions.
4. Deciding.
5. Checking the decision.
6. Communicating and implementing.

If you are aware of these six basic elements and
improve the way you structure them, this will help you
develop a better overall decision-making system. Let us
look at the six elements individually.

Establishing a Positive Decision-Making Environment
(Statements 3, 7, 13, and 16)
If you have ever been in a meeting where people seem to
be discussing different issues, then you have seen what
happens when the decision-making environment has not
been established. It is so important for everyone to
understand the issue before preparing to make a
decision. This includes agreeing on an objective, making
sure the right issue is being discussed, and agreeing on a
process to move the decision forward.

You also must address key interpersonal
considerations at the very beginning. Have you included
all the stakeholders? And do the people involved in the
decision agree to respect one another and engage in an

open and honest discussion? After all, if only the
strongest opinions are heard, you risk not considering
some of the best solutions available.

Generating Potential Solutions (Statements 4, 8, and
Another important part of a good decision process is
generating as many good alternatives as sensibly
possible to consider. If you simply adopt the first solution
you encounter, then you are probably missing a great
many even better alternatives.

Evaluating Alternatives (Statements 1, 6, and 15)
The stage of exploring alternatives is often the most time-
consuming part of the decision-making process. This
stage sometimes takes so long that a decision is never
made! To make this step efficient, be clear about the
factors you want to include in your analysis. There are
three key factors to consider:

1. Risk—Most decisions involve some risk. However,
you need to uncover and understand the risks to make
the best choice possible.

2. Consequences—You cannot predict the implications
of a decision with 100% accuracy. But you can be
careful and systematic in the way that you identify and
evaluate possible consequences.

3. Feasibility—Is the choice realistic and
implementable? This factor is often ignored. You
usually have to consider certain constraints when
making a decision. As part of this evaluation stage,
ensure that the alternative you have selected is
significantly better than the status quo.

Deciding (Statements 5, 10, and 17)

Making the decision itself can be exciting and stressful.
To help you deal with these emotions as objectively as
possible, use a structured approach to the decision. This
means taking a look at what is most important in a good

Take the time to think ahead and determine exactly
what will make the decision “right.” This will significantly
improve your decision accuracy.

Checking the Decision (Statements 2 and 9)
Remember that some things about a decision are not
objective. The decision has to make sense on an
intuitive, instinctive level as well. The entire process we
have discussed so far has been based on the
perspectives and experiences of all the people involved.
Now, it is time to check the alternative you have chosen
for validity and “making sense.”

If the decision is a significant one, it is also worth
auditing it to make sure that your assumptions are
correct, and that the logical structure you have used to
make the decision is sound.

Communicating and Implementing (Statements 12,
14, and 18)
The last stage in the decision-making process involves
communicating your choice and preparing to implement
it. You can try to force your decision on others by
demanding their acceptance. Or you can gain their
acceptance by explaining how and why you reached your
decision. For most decisions—particularly those that
need participant buy-in before implementation—it is more
effective to gather support by explaining your decision.

Have a plan for implementing your decision. People
usually respond positively to a clear plan—one that tells

them what to expect and what they need to do.
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good is your decision making? Retrieved October 11,
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Classical Views of Leadership
and Management

. . . management is efficiency in climbing the ladder of
success; leadership determines whether the ladder is
leaning against the right wall.—Stephen R. Covey

. . . no executive has ever suffered because his
subordinates were strong and effective.—Peter

. . . leadership is a choice, not a position.—Stephen R.


This chapter addresses:

BSN Essential II: Basic organizational and systems leadership
for quality care and patient safety

BSN Essential VI: Interprofessional communication and
collaboration for improving patient health outcomes

BSN Essential IX: Baccalaureate generalist nursing practice
MSN Essential II: Organizational and systems leadership
MSN Essential VII: Interprofessional collaboration for improving
patient and population health outcomes

MSN Essential IX: Master’s level nursing practice

AONL Nurse Executive Competency I: Communication and
relationship building

AONL Nurse Executive Competency II: A knowledge of the
health-care environment

AONL Nurse Executive Competency III: Leadership
ANA Standard of Professional Performance 11: Leadership
QSEN Competency: Teamwork and collaboration


The learner will:

identify similarities and differences between leadership and

differentiate between leadership roles and management

discuss the historical evolution of management theory
correlate management theorists with their appropriate
theoretical contributions

define the components of the management process
discuss the historical evolution of leadership theory
correlate leadership theorists with their appropriate theoretical

identify common leadership styles and describe situations in
which each leadership style could be used appropriately

differentiate between authoritative, democratic, and laissez-faire
leadership styles

describe the differences between interactional and
transformational leadership theories

identify contextual factors impacting the relationship between
leaders and followers based on full-range leadership theory

analyze why full-range leadership models suggest leaders must
have skills in transformational leadership, transactional
leadership, and laissez-faire leadership

delineate variables suggested in situational and contingency

recognize that the integration of both leadership and
management skills is critical to the long-term viability of today’s
health-care organizations

The relationship between leadership and management continues to
prompt some debate, although there clearly is a need for both.
Leadership is viewed by some as one of management’s many
functions; others maintain that leadership requires more complex
skills than management and that management is only one role of
leadership. Still, others suggest that management emphasizes
control—control of hours, costs, salaries, overtime, use of sick leave,
inventory, and supplies—whereas leadership increases productivity
by maximizing workforce effectiveness.

Kerr (2015) suggests,

There’s a difference between leadership and management.
Leaders look forward and imagine the possibilities that the
future may bring to set direction. Managers monitor and adjust
today’s work, regularly looking backward to ensure that current
goals and objectives are being met. The best leaders lead and
let their management teams manage the work at hand. (para. 3)

In fact, Kerr (2015) suggests there are 10 important distinctions
between leaders and managers and these differences must be
understood and recognized so that an organization can leverage
each to the fullest (Display 2.1).


1. Leadership inspires change; management manages

2. Leadership requires vision; management requires tenacity.
3. Leadership requires imagination; management requires

4. Leadership requires abstract thinking; management requires

concrete data.
5. Leadership requires ability to articulate; management requires

ability to interpret.
6. Leadership requires an aptitude to sell; management requires

an aptitude to teach.
7. Leadership requires understanding of the external

environment; management requires understanding of how
work gets done inside the organization.

8. Leadership requires risk taking; management requires self-

9. Leadership requires confidence in the face of uncertainty;
management requires blind commitment to completing the
task at hand.

10. Leadership is accountable to the entire organization;
management is accountable to the team.

So which is more important—good leadership or good
management? The answer varies depending on the situation
(situational leadership). We are all aware of individuals in leadership
positions who cannot manage and individuals in management roles
who cannot lead.

If a manager guides, directs, and motivates and a leader
empowers others, however, then it could be said that every manager

should be a leader. Fowler (2015) agrees, suggesting that not only
are the differences between leadership and management difficult to
verbalize, but for the clinical nurse, it is even more difficult to work
out what particular “hat” you are wearing or should be wearing when
trying to lead and manage a team through a busy shift. Clinicians
often act as both leaders and managers in the clinical setting, even if
not officially recognized as doing so, and that their success in these
roles is critical to high-level unit functioning and the attainment of
patient goals. Indeed, Fowler suggests that good clinical leaders
must continually find an intersection between good leadership and
management skills to be successful.

Unfortunately, a 2016 Gallup poll found that only 18% of managers
demonstrated a high level of talent for managing others—meaning a
shocking 82% of managers weren’t very good at leading people
(Hougaard, 2018). This may be occurring because the processes
that help determine and shape leaders often produce people who
behave differently from what many employees desire. In addition,
managers are often promoted into their roles based on tenure or
previous manager roles—with little account for whether they possess
the humanistic skills and qualities of good leadership. Hougaard
(2018) also notes that in many cases, the qualities that organizations
actually select for and reward in most workplaces—ambition,
perfectionism, competitiveness—are precisely the ones that are
unlikely to produce leaders who are good for employees or for long-
term organizational performance.

Paradoxically, many leaders are guilty of self-deception. In a 2016
McKinsey & Company study of more than 52,000 managers and
employees, leaders rated themselves as better and more engaging
than their employees did. This included 86% of leaders who believed
they modeled the improvements they wanted employees to make,
whereas another 77% of leaders believed they “inspired action.”
These figures differ dramatically from the 2016 Gallup poll,

suggesting that a surprising number of leaders may suffer from
inflated views of their abilities (Hougaard, 2018).

In the end, both leadership and management skills are needed for
organizational success. The other reality is that leadership without
management results in chaos and failure for both the organization
and the individual executive. Boss (2018) agrees, noting that most
organizations are in a perpetual state of flux—and always will be.
Managers are needed to fund, allocate, or reallocate resources for
the changes that continually occur. Leaders are needed, however, to
strategize how best the organization can adapt. This need to
envision, create, sustain, and adapt are imperative to organizational
success (Boss, 2018). Thus, in the face of significant change, both
sound management and strong leadership skills are essential to the
long-term viability of today’s health-care organizations. Kerr (2015)
agrees, suggesting that most organizations need both kinds of skills
and aptitudes to secure enduring success.

This chapter first artificially differentiates between management
and leadership, focusing on theory development in each field of
study. A chronological view of the development of management and
leadership theory is provided, although the authors recognize that
boundaries are blurred between the two areas of theoretical
development and that much of the work done by later management
theorists and early leadership theorists overlaps. This chapter
concludes with a discussion of how closely integrated leadership and
management must actually be for individuals in contemporary
leadership or management roles.


Leadership Roles and Management

In small or large groups, discuss your views of
management and leadership. Do you believe they are the
same or different? If you believe that they are different,
do you think that they have the same importance for the
future of nursing? Do you feel that one is more important
than the other? How can novice nurse-managers learn
important management functions and develop leadership

Managers (n.d.) defines management as “the
organization and coordination of the activities of a business in order
to achieve defined objectives” (para. 1). This definition implies that
management is the process of leading and directing all or part of an
organization through the deployment and manipulation of resources.

Management is the process of leading and directing all or
part of an organization through the deployment and
manipulation of resources.

Although the term leader has been in use since the 1300s, the word
leadership was not known in the English language until the first half
of the 19th century. Despite its relatively new addition to the English
language, leadership has many meanings and there is no single
definition broad enough to encompass the total leadership process.

To examine the word leader, however, is to note that leaders lead.
Leaders are those individuals who take risks, attempt to achieve
shared goals, and inspire others to action. Those individuals who
choose to follow a leader do so by choice, not because they have to.
Stoner (2018) notes then that leadership impact depends on the
ability to influence people, not the ability to command, coerce, or

It is important to remember, though, that a job title alone does not
make a person a leader. Only a person’s behavior determines if he
or she holds a leadership role. The manager is the person who
brings things about—the one who accomplishes, has the
responsibility, and conducts. A leader is the person who influences
and guides direction, opinion, and course of action.

How do you recognize a leader? It’s not by their location.
A leader can be out in front, in the middle or following
behind. You recognize a leader by the response of their
followers (Stoner, 2018).

Other characteristics of leaders include the following:

Leaders often do not have delegated authority but obtain their
power through other means, such as influence.

Leaders have a wider variety of roles than do managers.
Leaders may or may not be part of the formal organization.
Leaders focus on group process, information gathering,

feedback, and empowering others.
Leaders emphasize interpersonal relationships.
Leaders direct willing followers.
Leaders have goals that may or may not reflect those of the


Trojani (2018) notes that leadership requires a constant exchange
between leaders and followers that is both verbal and nonverbal.

The strength of the relationship depends on each party’s capacity to
support the other. Trojani argues then that leadership is not about
individuals; it is a shared responsibility between leaders and

It is important also to remember that all it takes to stop being a
leader is to have others stop following you. Leadership then is more
dynamic than management, and leaders do make mistakes that can
result in the loss of their followers. For example, Zenger and
Folkman (2009), using 360-degree feedback data from more than
450 Fortune 500 executives, identified 10 fatal flaws that derail
leaders (Display 2.2). Although these flaws seem obvious, many
ineffective leaders are unaware that they exhibit these behaviors.


1. Lack of energy and enthusiasm
2. Acceptance of their own mediocre performance
3. Lack of a clear vision and direction
4. Having poor judgment
5. Not collaborating
6. Not walking the talk
7. Resisting new ideas
8. Not learning from mistakes
9. A lack of interpersonal skills
10. Failing to develop others

Source: Zenger, J., & Folkman, J. (2009). Ten fatal flaws that derail leaders.
Harvard Business Review, 87(6), 18. Retrieved July 9, 2018, from

Display 2.3 includes a partial list of common leadership roles, and
Display 2.4 contrasts traditional components of leadership and


Decision maker
Risk taker
Priority setter

Critical thinker

Creative problem

Change agent
Role model


Are assigned a position by the organization
Have a legitimate source of power due to delegated authority

that accompanies their position
Have specific duties and responsibilities they are expected to

carry out
Emphasize control, decision making, decision analysis, and

Manipulate people, the environment, money, time, and other

resources to achieve the goals of the organization
Have a greater formal responsibility and accountability for

rationality and control than leaders
Direct willing and unwilling subordinates

Often do not have delegated authority but obtain power through

other means, such as influence
Have a wider variety of roles than managers
Focus on group process, information gathering, feedback, and

empowering others
May or may not be part of the formal hierarchy of the

Emphasize interpersonal relationships
Direct willing followers
Have goals that may or may not reflect those of the organization

Historical Development of Management Theory

Management science, like nursing, develops a theory base from
many disciplines, such as business, psychology, sociology, and
anthropology. Because organizations are complex and varied,
theorists’ views of what successful management is and what it
should be have changed repeatedly in the last 100 years.

Theorists’ views of what successful management is and
what it should be have changed repeatedly in the last 100

Scientific Management (1900 to 1930)
Frederick W. Taylor, the “father of scientific management,” was a
mechanical engineer in the Midvale and Bethlehem Steel plants in
Pennsylvania in the late 1800s. Frustrated with what he called
“systematic soldiering,” where workers achieved minimum standards
doing the least amount of work possible, Taylor postulated that if
workers could be taught the “one best way to accomplish a task,”
productivity would increase. Borrowing a term coined by Louis
Brandeis, a colleague of Taylor’s, Taylor called these principles
scientific management. The four overriding principles of scientific
management as identified by Taylor (1911) are the following:

1. Traditional “rule of thumb” means of organizing work must be
replaced with scientific methods. In other words, by using time
and motion studies and the expertise of experienced workers,
work could be scientifically designed to promote greatest
efficiency of time and energy.

2. A scientific personnel system must be established so that
workers can be hired, trained, and promoted based on their
technical competence and abilities. Taylor thought that each
employee’s abilities and limitations could be identified so that
the worker could be best matched to the most appropriate job.

3. Workers should be able to view how they “fit” into the
organization and how they contribute to overall organizational
productivity. This provides common goals and a sharing of the
organizational mission. One way Taylor thought that this could
be accomplished was by the use of financial incentives as a
reward for work accomplished. Because Taylor viewed humans
as “economic animals” motivated solely by money, workers
were reimbursed according to their level of production rather
than by an hourly wage.

4. The relationship between managers and workers should be
cooperative and interdependent, and the work should be
shared equally. Their roles, however, were not the same. The
role of managers, or functional foremen as they were called,
was to plan, prepare, and supervise. The worker was to do the
work (Fig. 2.1).

FIGURE 2.1 Factory workers use an efficient assembly line process. (Courtesy of

What was the result of scientific management? Productivity and
profits rose dramatically. Organizations were provided with a rational
means of harnessing the energy of the industrial revolution. Some
experts have argued that Taylor (1911) lacked humanism and that
his scientific principles were not in the best interest of unions or
workers. However, it is important to remember the era in which
Taylor did his work. During the Industrial Revolution, laissez-faire
economics prevailed, optimism was high, and a Puritan work ethic
prevailed. Taylor maintained that he truly believed managers and
workers would be satisfied if financial rewards were adequate as a
result of increased productivity. As the cost of labor rises in the
United States, many organizations are taking a new look at scientific
management with the implication that we need to think of new ways
to do traditional tasks so that work is more efficient.

About the same time that Taylor (1911) was examining worker
tasks, Max Weber, a well-known German sociologist, began to study
large-scale organizations to determine what made some workers
more efficient than others. Weber saw the need for legalized, formal
authority and consistent rules and regulations for personnel in
different positions; he thus proposed bureaucracy as an
organizational design. His essay “Bureaucracy” was written in 1922
in response to what he perceived as a need to provide more rules,
regulations, and structure within organizations to increase efficiency.
Much of Weber’s work and bureaucratic organizational design are
still evident today in many health-care institutions. His work is
discussed further in Chapter 12.


Strategies for Efficiency

In small groups, discuss some work routines carried out
in health-care organizations that seem to be inefficient.
Could such routines or the time and motion involved to
carry out a task be altered to improve efficiency without
jeopardizing quality of care? Make a list of ways that
nurses could work more efficiently. Do not limit your
examination to only nursing procedures and routines but
examine the impact that other departments or the
arrangement of the nurse’s work area may have on
preventing nurses from working more efficiently. Share
your ideas with your peers.

Management Functions Identified
Henri Fayol (1925) first identified the management functions of
planning, organization, command, coordination, and control. Luther
Gulick (1937) expanded on Fayol’s management functions in his
introduction of the “seven activities of management”—planning,
organizing, staffing, directing, coordinating, reporting, and budgeting
—as denoted by the mnemonic POSDCORB. Although often
modified (either by including staffing as a management function or
renaming elements), these functions or activities have changed little
over time. Eventually, theorists began to refer to these functions as
the management process.

The management process, shown in Figure 2.2, is this book’s
organizing framework. Brief descriptions of the five functions for
each phase of the management process follow:

1. Planning encompasses determining philosophy, goals,
objectives, policies, procedures, and rules; carrying out long-
and short-range projections; determining a fiscal course of
action; and managing planned change.

2. Organizing includes establishing the structure to carry out
plans, determining the most appropriate type of patient care
delivery, and grouping activities to meet unit goals. Other
functions involve working within the structure of the
organization and understanding and using power and authority

3. Staffing functions consist of recruiting, interviewing, hiring, and
orienting staff. Scheduling, staff development, employee
socialization, and team building are also often included as
staffing functions.

4. Directing sometimes includes several staffing functions.
However, this phase’s functions usually entail human resource
management responsibilities, such as motivating, managing
conflict, delegating, communicating, and facilitating

5. Controlling functions include performance appraisals, fiscal
accountability, quality control, legal and ethical control, and
professional and collegial control.

FIGURE 2.2 The management process.

Human Relations Management (1930 to 1970)
During the 1920s, worker unrest developed. The Industrial
Revolution had resulted in great numbers of relatively unskilled
laborers working in large factories on specialized tasks. Thus,
management scientists and organizational theorists began to look at
the role of worker satisfaction in production. This human relations
era developed the concepts of participatory and humanistic
management, emphasizing people rather than machines.

Mary Parker Follett (1926) was one of the first theorists to suggest
basic principles of what today would be called participative decision
making or participative management. In her essay “The Giving of
Orders,” Follett espoused her belief that managers should have
authority with, rather than over, employees. Thus, solutions could be
found that satisfied both sides without having one side dominate the

The human relations era also attempted to correct what was
perceived as the major shortcoming of the bureaucratic system—a
failure to include the “human element.” Studies done at the
Hawthorne Works of the Western Electric Company near Chicago
between 1927 and 1932 played a major role in this shifting focus.
The studies, conducted by Elton Mayo and his Harvard associates,
began as an attempt to look at the relationship between light
illumination in the factory and productivity.

Mayo and his colleagues discovered that when management paid
special attention to workers, productivity was likely to increase,
regardless of the environmental working conditions. This Hawthorne
effect indicated that people respond to the fact that they are being
studied, attempting to increase whatever behavior they feel will
continue to warrant the attention. Mayo (1953) also found that
informal work groups and a socially informal work environment were
factors in determining productivity, and Mayo recommended more
employee participation in decision making.

Douglas McGregor (1960) reinforced these ideas by theorizing
that managerial attitudes about employees (and, hence, how
managers treat those employees) can be directly correlated with
employee satisfaction. He labeled this Theory X and Theory Y.
Theory X managers believe that their employees are basically lazy,
need constant supervision and direction, and are indifferent to
organizational needs. Theory Y managers believe that their workers
enjoy their work, are self-motivated, and are willing to work hard to
meet personal and organizational goals.

Chris Argyris (1964) supported McGregor (1960) and Mayo (1953)
by saying that managerial domination causes workers to become
discouraged and passive. He believed that if self-esteem and
independence needs are not met, employees will become
discouraged and troublesome or may leave the organization. Argyris
stressed the need for flexibility within the organization and employee
participation in decision making.

The human relations era of management science brought about a
great interest in the study of workers. Many sociologists and
psychologists took up this challenge, and their work in management
theory contributed to our understanding about worker motivation,
which is discussed in Chapter 18. Table 2.1 summarizes the
development of management theory up to 1970. By the late 1960s,
however, there was growing concern that the human relations
approach to management was not without its problems. Most people
continued to work in a bureaucratic environment, making it difficult to
always apply a participatory approach to management. The human
relations approach was time consuming and often resulted in unmet
organizational goals. In addition, not every employee liked working in
a less structured environment. This resulted in a greater recognition
of the need to intertwine management and leadership than ever

1900 TO 1970

Theorist Theory

Taylor Scientific management
Weber Bureaucratic organizations
Fayol Management functions
Gulick Activities of management
Follett Participative management
Mayo Hawthorne effect
McGregor Theories X and Y
Argyris Employee participation


Management Skills Assessment

Recall times when you have been a manager. This
does not only mean a nursing manager. Perhaps you
were a head lifeguard or an evening shift manager at a
fast-food restaurant. During those times, do you think you
were a good manager? Did you involve others in your
management decision making appropriately? How would
you evaluate your decision-making ability? Make a list of
your management strengths and a list of management
skills that you felt you were lacking.

Historical Development of Leadership Theory
(1900 to Present)
Because strong management skills were historically valued more
than strong leadership skills, the scientific study of leadership did not
begin until the 20th century. Early works focused on broad
conceptualizations of leadership, such as the traits or behaviors of
the leader. Contemporary research focuses more on leadership as a
process of influencing others within an organizational culture and the
interactive relationship of the leader and follower. To better
understand newer views about leadership, it is necessary to look at
how leadership theory has evolved over the last century.

Like management theory, leadership theory has been
dynamic; that is, what is “known” and believed about
leadership continues to change over time.

The Great Man Theory/Trait Theories (1900 to
The Great Man theory and trait theories were the basis for most
leadership research until the mid-1940s. The Great Man theory, from
Aristotelian philosophy, asserts that some people are born to lead,
whereas others are born to be led. It also suggests that great leaders
will arise when the situation demands it.

Trait theories assume that some people have certain
characteristics or personality traits that make them better leaders
than others. To determine the traits that distinguish great leaders,
researchers studied the lives of prominent people throughout history.
The effect of followers and the impact of the situation were ignored.
Although trait theories have obvious shortcomings (e.g., they neglect
the impact of others or the situation on the leadership role), they are

worth examining. Many of the characteristics identified in trait
theories (Display 2.5) are still used to describe successful leaders


Oral fluency



Personal integrity
Emotional balance

and control
Risk taking
Critical thinking
Able to enlist


Interpersonal skills
Social participation

priority setting

Contemporary opponents of trait theories argue, however, that
leadership skills can be developed, not just inherited. That is not to
say that some people don’t have certain characteristics or
personality traits that may make it easier for them to lead. For
example, Huston (2018) notes that some people, even at very young
ages, are more fearless. Others are just naturally more outgoing;
they’re more curious; they take more risks. But not all leaders need
to be gregarious by nature. There’s lots of room for quiet leadership.
In fact, some of the most effective leaders are individuals who didn’t
seek out that role—they simply grew into it because they stepped
forth to do what had to be done when no one else would (Huston,

Perhaps leaders are both born and made that way.

Behavioral Theories (1940 to 1980)
During the human relations era, many behavioral and social
scientists studying management also studied leadership. For
example, McGregor’s (1960) theories had as much influence on
leadership research as they did on management science. As
leadership theory developed, researchers moved away from
studying what traits the leader had and placed emphasis on what he
or she did—the leader’s style of leadership.

A breakthrough occurred when Lewin (1951) and White and Lippitt
(1960) isolated common leadership styles. Later, these styles came
to be called authoritarian, democratic, and laissez-faire.

The authoritarian leader is characterized by the following

Strong control is maintained over the work group.
Others are motivated by coercion.
Others are directed with commands.
Communication flows downward.
Decision making does not involve others.
Emphasis is on difference in status (“I” and “you”).
Criticism is punitive.

Authoritarian leadership results in well-defined group actions that
are usually predictable, reducing frustration in the work group and
giving members a feeling of security. Productivity is usually high, but
creativity, self-motivation, and autonomy are reduced. Authoritarian
leadership is frequently found in very large bureaucracies such as
the armed forces.

The democratic leader exhibits the following behaviors:

Less control is maintained.

Economic and ego awards are used to motivate.
Others are directed through suggestions and guidance.
Communication flows up and down.
Decision making involves others.
Emphasis is on “we” rather than I and you.
Criticism is constructive.

In other words, democratic leaders seek input from their followers
and include them in decision making whenever possible. Stoker
(2018) suggests that when you ask a person for his or her ideas or to
help you solve a problem, you are sending the message that you
value the person’s ideas and experience and you are also creating a
learning opportunity to hear something you need to know.

Democratic leadership, appropriate for groups who work together
for extended periods, promotes autonomy and growth in individual
workers. Democratic leadership is particularly effective when
cooperation and coordination between groups are necessary.
Studies have shown, however, that democratic leadership may be
less efficient quantitatively than authoritative leadership.

Because many people must be consulted, democratic
leadership takes more time and, therefore, may be
frustrating for those who want decisions made rapidly.

The laissez-faire leader is characterized by the following

Takes a hands-off approach.
Is permissive, with little or no control.
Motivates by support when requested by the group or

Provides little or no direction.
Uses upward and downward communication between members

of the group.

Disperses decision making throughout the group.
Places emphasis on the group.
Does not criticize.

Because it is nondirected leadership, the laissez-faire style can be
frustrating; group apathy and disinterest can occur. However, when
all group members are highly motivated and self-directed, this
leadership style can result in much creativity and productivity.
Laissez-faire leadership is appropriate when problems are poorly
defined, and brainstorming is needed to generate alternative

For some time, theorists believed that leaders had a predominant
leadership style and used it consistently. During the late 1940s and
early 1950s, however, theorists began to believe that most leaders
did not fit a textbook picture of any one style but rather fell
somewhere on a continuum between authoritarian and laissez-faire.
They also came to believe that leaders moved dynamically along the
continuum in response to each new situation. This recognition was a
forerunner to what is known as situational or contingency leadership

Situational and Contingency Leadership Theories
(1950 to 1980)
The idea that leadership style should vary according to the situation
or the individuals involved was first suggested almost 100 years ago
by Mary Parker Follett, one of the earliest management consultants
and among the first to view an organization as a social system of
contingencies. Her ideas, published in a series of books between
1896 and 1933, were so far ahead of their time that they did not gain
appropriate recognition in the literature until the 1970s. Her law of
the situation, which said that the situation should determine the

directives given after allowing everyone to know the problem, was
contingency leadership in its humble origins.


Leadership Skills Assessment

In groups or individually, list additional characteristics
that you believe an effective leader possesses. Which
leadership characteristics do you have? Do you believe
that you were born with leadership skills, or have you
consciously developed them during your lifetime? If so,
how did you develop them?

Define your predominant leadership style
(authoritarian, democratic, or laissez-faire). Ask those
who work with you if in their honest opinion this is indeed
the leadership style that you use most often. What style
of leadership do you work best under? What leadership
style best describes your present or former managers?

Fiedler’s (1967) contingency approach reinforced these findings,
suggesting that no one leadership style is ideal for every situation.
Fiedler felt that the interrelationships between the group’s leader and
its members were most influenced by the manager’s ability to be a
good leader. The task to be accomplished and the power associated
with the leader’s position also were cited as key variables.

In contrast to the continuum from autocratic to democratic, Blake
and Mouton’s (1964) grid showed various combinations of concern
or focus that managers had for or on productivity, tasks, people, and
relationships. In each of these areas, the leader-manager may rank

high or low, resulting in numerous combinations of leadership
behaviors. Various formations can be effective depending on the
situation and the needs of the worker.

Hersey and Blanchard (1977) also developed a situational
approach to leadership. Their tridimensional leadership effectiveness
model predicts which leadership style is most appropriate in each
situation on the basis of the level of the followers’ maturity. As people
mature, leadership style becomes less task focused and more
relationship oriented.

Tannenbaum and Schmidt (1958) built on the work of Lewin (1951)
as well as White and Lippitt (1960), suggesting that managers need
varying mixtures of autocratic and democratic leadership behavior.
They believed that the primary determinants of leadership style
should include the nature of the situation, the skills of the manager,
and the abilities of the group members.

Although situational and contingency theories added necessary
complexity to leadership theory and continue to be applied effectively
by managers, by the late 1970s, theorists began arguing that
effective leadership depended on an even greater number of
variables, including organizational culture, the values of the leader
and the followers, the work, the environment, the influence of the
leader-manager, and the complexities of the situation. Efforts to
integrate these variables are apparent in more contemporary
interactional and transformational leadership theories.

This complexity of variables suggests there is likely no “one-size-
fits-all” answer to the question of what leadership style is most
effective. In the face of ambiguity and complexity, it seems that good
leadership is nuanced and requires careful consideration (see
Examining the Evidence 2.1).

Not all leadership is virtuous leadership (Haden, 2017).

Source: Maxwell, E. (2017). Good leadership in
nursing: What is the most effective approach?
Nursing Times, 113(8), 18–21. Retrieved July 16,
2018, from

What Makes Good Leadership in Nursing?
Despite overwhelming interest in leadership
within the nursing profession, there is
surprisingly little evidence about what approach
to leadership actually works best in nursing.
Maxwell notes there is evidence to suggest that
nurse leadership has a significant impact in two
main areas: patient experience and outcomes
and nurse satisfaction and retention. There is
some suggestion that the latter then influences
the former.

There is also a body of evidence indicating
that nurse leadership styles have a strong
influence on nurse morale and retention.
Finally, Maxwell notes that some evidence
exists that good leadership can have a positive
impact on patient outcomes through creating
the conditions, which allow nurses to reach
their full potential and build both personal and
organizational resilience in the face of
unexpected or increased workload.

The author concludes that determining what
makes good nurse leadership is challenging,
and this complexity means there is likely no
“one-size-fits-all” answer to the question. In the

face of ambiguity and complexity, it seems that
good leadership is nuanced and requires
careful consideration.

Interactional Leadership Theories (1970 to
The basic premise of interactional theory is that leadership behavior
is generally determined by the relationship between the leader’s
personality and the specific situation. Schein (1970), an interactional
theorist, was the first to propose a model of humans as complex
beings whose working environment was an open system to which
they responded. A system may be defined as a set of objects, with
relationships between the objects and between their attributes. A
system is considered open if it exchanges matter, energy, or
information with its environment. Schein’s model, based on systems
theory, had the following assumptions:

People are very complex and highly variable. They have multiple
motives for doing things. For example, a pay raise might mean
status to one person, security to another, and both to a third.

People’s motives do not stay constant; instead, they change
over time.

Goals can differ in various situations. For example, an informal
group’s goals may be quite distinct from a formal group’s goals.

A person’s performance and productivity are affected by the
nature of the task and by his or her ability, experience, and

No single leadership strategy is effective in every situation.

To be successful, the leader must diagnose the situation and
select appropriate strategies from a large repertoire of skills.
Hollander (1978) was among the first to recognize that both leaders

and followers have roles outside of the leadership situation and that
both may be influenced by events occurring in their other roles.

With leader and follower contributing to the working relationship
and both receiving something from it, Hollander (1978) saw
leadership as a dynamic two-way process. According to Hollander, a
leadership exchange involves three basic elements:

The leader, including his or her personality, perceptions, and

The followers, with their personalities, perceptions, and abilities
The situation within which the leader and the followers function,

including formal and informal group norms, size, and density

Leadership effectiveness, according to Hollander (1978), requires
the ability to use the problem-solving process; maintain group
effectiveness; communicate well; demonstrate leader fairness,
competence, dependability, and creativity; and develop group

Ouchi (1981) was a pioneer in introducing interactional leadership
theory in his application of Japanese style management to corporate
America. Theory Z, the term Ouchi used for this type of
management, is an expansion of McGregor’s Theory Y and supports
democratic leadership. Characteristics of Theory Z include
consensus decision making, fitting employees to their jobs, job
security, slower promotions, examining the long-term consequences
of management decision making, quality circles, guarantee of
lifetime employment, establishment of strong bonds of responsibility
between superiors and subordinates, and a holistic concern for the
workers (Ouchi, 1981). Ouchi was able to find components of
Japanese style management in many successful American

In the 1990s, Theory Z lost its favor with many management
theorists. American managers seemed unable to put these same
ideas into practice in the United States. Instead, many continued to

boss-manage workers in an attempt to make them do what they do
not want to do. Although Theory Z is more comprehensive than
many of the earlier theories, it too neglects some of the variables
that influence leadership effectiveness. It has the same
shortcomings as situational theories in inadequately recognizing the
dynamics of the interaction between the worker and the leader.

One of the pioneering leadership theorists of this time was Kanter
(1977), who developed the theory that the structural aspects of the
job shape a leader’s effectiveness. She postulated that the leader
becomes empowered through both formal and informal systems of
the organization. A leader must develop relationships with a variety
of people and groups within the organization in order to maximize job
empowerment and be successful. The three major work
empowerment structures within the organization are opportunity,
power, and proportion. Kanter asserts that these work structures
have the potential to explain differences in leader responses,
behaviors, and attitudes in the work environment.

Nelson and Burns (1984) suggested that organizations and their
leaders have four developmental levels and that these levels
influence productivity and worker satisfaction. The first of these
levels is reactive. The reactive leader focuses on the past, is crisis
driven, and is frequently abusive to subordinates. In the next level,
responsive, the leader is able to mold subordinates to work together
as a team, although the leader maintains most decision-making
responsibility. At the proactive level, the leader and followers
become more future oriented and hold common driving values.
Management and decision making are more participative. At the last
level, high-performance teams, maximum productivity and worker
satisfaction are apparent.

Kanter (1989) perhaps best summarized the work of the
interactive theorists by her assertion that title and position authority
were no longer sufficient to mold a workforce where subordinates

are encouraged to think for themselves, and instead, managers must
learn to work synergistically with others.

Transactional and Transformational Leadership
Similarly, Burns (2003), a noted scholar in the area of leader–
follower interactions, was among the first to suggest that both
leaders and followers have the ability to raise each other to higher
levels of motivation and morality. Identifying this concept as
transformational leadership, Burns maintained that there are two
primary types of leaders in management. The traditional manager,
concerned with the day-to-day operations, was termed a
transactional leader. The manager who is committed, has a vision,
and can empower others with this vision was termed a
transformational leader. A composite of the two different types of
leaders is shown in Table 2.2.


Transactional Leader Transformational Leader

Focuses on management tasks Identifies common values
Is directive and results oriented Is a caretaker
Uses trade-offs to meet goals Inspires others with vision
Does not identify shared values Has long-term vision
Examines causes Looks at effects
Uses contingency reward Empowers others

Transactional leaders focus on tasks and getting the
work done. Transformational leaders focus on vision and

Similarly, Bass and Avolio (1994) suggested that transformational
leadership leads followers to levels of higher morals because such
leaders do the right thing for the right reason, treat people with care
and compassion, encourage followers to be more creative and
innovative, and inspire others with their vision. This new shared
vision provides the energy required to move toward the future.
Similarly, the American Nurses Association California (2019)
suggests that leaders do more than delegate, dictate, and direct;
they help others achieve their highest potential.

Kouzes and Posner (2017) are perhaps the best known authors to
further the work on transformational leadership in the past decade.
Kouzes and Posner suggest that exemplary leaders foster a culture
in which relationships between aspiring leaders and willing followers
can thrive. This requires the development of the five practices shown
in Display 2.6. Kouzes and Posner suggest that when these five
practices are employed, anyone can further their ability to lead
others to get extraordinary things done.


1. Modeling the way: requires value clarification and self-
awareness so that behavior is congruent with values

2. Inspiring a shared vision: entails visioning that inspires
followers to want to participate in goal attainment

3. Challenging the process: identifies opportunities and taking

4. Enabling others to act: fosters collaboration, trust, and the
sharing of power

5. Encouraging the heart: recognizes, appreciates, and
celebrates followers and the achievement of shared goals

Source: Kouzes, J., & Posner, B. (2017). The leadership challenge (6th ed.). San
Francisco, CA: Jossey-Bass.

Although the transformational leader is held as the current ideal,
many management theorists sound a warning about transformational
leadership. Although transformational qualities are highly desirable,
they must be coupled with the more traditional transactional qualities
of the day-to-day managerial role. In addition, both sets of
characteristics need to be present in the same person in varying
degrees. The transformational leader will fail without traditional
management skills. Indeed, some leaders are not very visionary or
inspiring. Still, others are inspiring and passionate, but their vision
and desired outcomes are flawed.

Although transformational qualities are highly desirable,
they must be coupled with the more traditional
transactional qualities of the day-to-day managerial role
or the leader will fail.

Full-Range Leadership Model/Theory
It is this idea that context is an important mediator of
transformational leadership that led to the creation of a full-range
leadership model (FRLM) late in the 20th century. Bass and Avolio
(1993) first described a full-range leader as a leader who could apply
principles of three specific styles of leadership at any given time:
transformational, transactional, and laissez-faire.

MacKie (2014) suggests the FRLM “encompasses both the
transformational elements of leadership (that is building trust, acting
with principle and integrity, inspiring others, innovating, and
developing others), transactional elements (that includes both
constructive elements, e.g., contingent reward and corrective
elements and management-by-exception) and avoidant or laissez-
faire leadership behaviors” (pp. 120–121). Thus, transformational
leadership was thought to add to the benefits of transactional
leadership through an augmentation effect where the
transformational engagement of followers encouraged their
enhanced performance through increased discretionary effort. Thus,
the more transactional elements of leadership such as goal setting
can be enhanced with the addition of transformational elements of
leadership where followers are inspired to give more of their time
and effort by the vision and charisma of the leader (MacKie, 2014).

Thus, the transformational leadership helps the full-range leader
motivate his or her team and allows the leader to be viewed as an
example of what they can become. Transactional leadership,
however, is still needed to reinforce or modify behavior respectively,
and laissez-faire leadership is included because there will be times
when the full-range leader needs to step back and do nothing
because the team is fully capable of doing the work on its own. Thus,
full-range leaders evolve and adapt their leadership style based on
which leadership styles are needed for a given situation.

Further work by Antonakis, Avolio, and Sivasubramaniam (2003)
suggested there are nine factors impacting leadership style and its
impact on followers in the FRLM; five are transformational, three are
transactional, and one is a nonleadership or laissez-faire leadership
factor (Display 2.7; Rowold & Schlotz, 2009).


Factor 1 Inspirational motivation Transformational
Factor 2 Idealized influence (attributed) Transformational
Factor 3 Idealized influence (behavior) Transformational
Factor 4 Intellectual stimulation Transformational
Factor 5 Individualized consideration Transformational
Factor 6 Contingent reward Transactional
Factor 7 Active management-by-exception Transactional
Factor 8 Management-by-exception


Factor 9 Nonleadership Laissez-faire

In describing these factors, Rowold and Schlotz (2009) suggest
that the first factor, inspirational motivation, is characterized by the
leader’s articulation and representation of vision. Idealized influence
(attributed), the second factor, relies on the charisma of the leader to
create emotional ties with followers that build trust and confidence.
The third factor, idealized influence (behavior), results in the leader
creating a collective sense of mission and values and prompting
followers to act on these values. With the fourth factor, intellectual
stimulation, leaders challenge the assumptions of followers’ beliefs
as well as analyze subordinates’ problems and possible solutions.
The final transformational factor, individualized consideration, occurs
when the leader is able to individualize his or her followers,

recognizing and appreciating their unique needs, strengths, and

The first transactional factor, as described by Rowold and Schlotz
(2009), is contingent reward. Here, the leader is task oriented in
providing followers with meaningful rewards based on successful
task completion. Active management-by-exception, the second
transactional factor, suggests that the leader watches and searches
actively for deviations from rules and standards and takes corrective
actions when necessary. In contrast, the third transactional factor,
management-by-exception passive, describes a leader who
intervenes only after errors have been detected or standards have
been violated. Finally, the ninth factor of full-range leadership theory
is the absence of leadership. Thus, laissez-faire is a contrast to the
active leadership styles of transformational and transactional
leadership exemplified in the first eight factors.

Leadership Competencies
Just as Fayol (1925) and Gulick (1937) identified management
functions, contemporary leadership experts suggest that there are
certain competencies (skills, knowledge, and abilities) health-care
leaders need to be successful. The American College of Healthcare
Executives, the American Association for Physician Leadership
(formerly the American College of Physician Executives), the
American Organization of Nurse Executives, the Healthcare
Information and Management Systems Society, the Healthcare
Financial Management Association, and the Medical Group
Management Association have collaborated to identify leadership
competencies, which included leadership skills and behavior,
organizational climate and culture, communicating vision, and
managing change.

Integrating Leadership Roles and Management
Because rapid, dramatic change will continue in nursing and the
health-care industry, it has grown increasingly important for nurses to
develop skill in both leadership roles and management functions. For
managers and leaders to function at their greatest potential, the two
must be integrated.

Gardner (1990) asserted that integrated leader-managers possess
six distinguishing traits:

1. They think longer term: They are visionary and futuristic. They
consider the effect that their decisions will have years from now
as well as their immediate consequences.

2. They look outward, toward the larger organization: They do not
become narrowly focused. They are able to understand how
their unit or department fits into the bigger picture.

3. They influence others beyond their own group: Effective leader-
managers rise above an organization’s bureaucratic

4. They emphasize vision, values, and motivation: They
understand intuitively the unconscious and often nonrational
aspects that are present in interactions with others. They are
very sensitive to others and to differences in each situation.

5. They are politically astute: They are capable of coping with
conflicting requirements and expectations from their many

6. They think in terms of change and renewal: The traditional
manager accepts the structure and processes of the
organization, but the leader-manager examines the ever-
changing reality of the world and seeks to revise the
organization to keep pace.

Leadership and management skills can and should be integrated
as they are learned. Table 2.3 summarizes the development of
leadership theory through the end of the 20th century. Newer (21st
century) and emerging leadership theories are discussed in Chapter


Theorist Theory

Aristotle Great Man theory
Lewin and White Leadership styles
Follett Law of the situation
Fiedler Contingency leadership
Blake and Mouton Task versus relationship in determining

leadership style
Hersey and

Situational leadership theory

Tannenbaum and

Situational leadership theory

Kanter Organizational structure shapes leader

Burns Transactional and transformational

Bass and Avolio Transformational leadership
Full-range leadership theory

Kouzes and Posner Five practices for exemplary leadership
Gardner The integrated leader-manager

In examining leadership and management, it becomes clear that
these two concepts have a symbiotic or synergistic relationship.
Every nurse is a leader and manager at some level, and the nursing

role requires leadership and management skills. The need for
visionary leaders and effective managers in nursing precludes the
option of stressing one role over the other. Highly developed
management skills are needed to maintain healthy organizations. So
too are the visioning and empowerment of subordinates through an
organization’s leadership team. Because rapid, dramatic change will
continue in nursing and the health-care industry, it continues to be
critically important for nurses to develop skill in both leadership roles
and management functions and to strive for the integration of
leadership characteristics throughout every phase of the
management process.

Key Concepts

■ Management functions include planning, organizing, staffing,
directing, and controlling. These are incorporated into what is
known as the management process.

■ Classical, or traditional, management science focused on
production in the workplace and on delineating organizational
barriers to productivity. Workers were assumed to be
motivated solely by economic rewards, and little attention
was given to worker job satisfaction.

■ The human relations era of management science
emphasized concepts of participatory and humanistic

■ Three primary leadership styles have been identified:
authoritarian, democratic, and laissez-faire.

■ Research has shown that the leader-manager must assume
a variety of leadership styles, depending on the needs of the
worker, the task to be performed, and the situation or

environment. This is known as situational or contingency
leadership theory.

■ Leadership is a process of persuading and influencing others
toward a goal and is composed of a wide variety of roles.

■ Early leadership theories focused on the traits and
characteristics of leaders.

■ Interactional leadership theory focuses more on leadership
as a process of influencing others within an organizational
culture and the interactive relationship of the leader and

■ The manager who is committed, has a vision, and is able to
empower others with this vision is termed a transformational
leader, whereas the traditional manager, concerned with the
day-to-day operations, is called a transactional leader.

■ Full-range leadership theory suggests that context is an
important mediator of transformational leadership.

■ Full-range leaders evolve and adapt their leadership style
based on which leadership styles are needed for a given
situation but need transformational, transactional, and
laissez-faire leadership skills to be successful.

■ Integrating leadership skills with the ability to carry out
management functions is necessary if an individual is to
become an effective leader-manager.

■ The integration of both leadership and management skills is
critical to the long-term viability of today’s health-care

Additional Learning Exercises and Applications


When Culture and Policy Clash

You are the nurse-manager of a medical unit. Recently,
your unit admitted a 16-year-old East Indian boy who has
been newly diagnosed with insulin-dependent diabetes.
The nursing staff has been interested in his case and has
found him to be a delightful young man—very polite and
easygoing. However, his family has been visiting in
increasing numbers and bringing him food that he should
not have.

The nursing staff has come to you on two occasions
and complained about the family’s noncompliance with
visiting hours and unauthorized food. Normally, the
nursing staff on your unit has tried to develop culturally
sensitive nursing care plans, so their complaints have
taken you by surprise.

Yesterday, two of the family members visited you and
complained about hospital visitor policies and what they
took to be rudeness by two different staff members. You
spent time talking to the family, and when they left, they
seemed agreeable and understanding.

Last night, one of the staff nurses told the family that
according to hospital policy, only two members could stay
(this is true) and if the other family members did not
leave, she would call hospital security. This morning, the
boy’s mother and father have suggested that they will
take him home if this matter is not resolved. The patient’s
diabetes is still not controlled, and you feel that it would
be unwise for this to happen.


Leadership is needed to keep this situation from
deteriorating further. Divide into groups. Develop a
plan of action for solving this problem. First, select
three desired objectives for solving the problem and
then proceed to determine what you would do that
would enable you to meet your objectives. Be sure
that you are clear as to who you consider your
followers to be and what you expect from each of

Then, list at least five management functions and
five leadership roles that you could delineate in this
scenario. How would you divide the management
functions and leadership roles? For example, you
might say that having the nurse-manager adhere to
hospital policy was a management function and that
counseling staff was a leadership role.


Leadership Challenges for Health-Care

Mary Starmann Harrison, president and chief executive
officer (CEO) of Hospital Sisters Health System, was
quoted in an article by Smith (2012) that the greatest
challenge for health-care leaders today is the transition
from volume to value, including a determination of how
best to guide the organization through that transition as

well as the timing to do so. Doug Smith, president and
CEO of B.E. Smith, suggests that the greatest challenges
for contemporary health-care leaders are large turnover
numbers and an inability or unwillingness to change.
Carol Dozer, CEO of Ivinson Memorial Hospital, suggests
it is the need to cut costs and preserve resources while
bringing in the resources needed to operate under a
value-based system.


Interview the CEO or top nursing executive at a
local health-care agency. Ask them what they
perceive to be the top five leadership challenges
encountered by health-care leaders today. Then
ask them to identify five management challenges.
Did these health-care leaders differentiate between
leadership and management challenges? Did they
feel that the leadership or management challenges
were greater?


Quiet at Night?

You are the night shift charge nurse on a busy surgical
unit in a large, urban teaching hospital. Surgeries occur
around the clock, and frequently, noise levels are higher
than desired because of the significant number of nurses,

physicians, residents, interns, and other health-care
workers who gather at the nurses’ station or in the halls
outside of patient rooms. Today, the unit manager has
come to you because the hospital’s score on the Centers
for Medicare and Medicaid Services’ Hospital Consumer
Assessment of Healthcare Providers and Systems
(HCAHPS) survey for the category Always Quiet at Night
falls far below the desired benchmark. She has asked
you to devise a plan to address this quality-of-care issue.
The management goal in this situation is to achieve an
HCAHPS score on Always Quiet at Night that meets the
accepted best practices benchmark, thus assuring that
patients get the rest they need to promote their recovery.
The leadership goal is to foster a shared commitment
among all health-care professionals working on the unit
to achieve the Always Quiet at Night goal.


1. Identify five management strategies you might
use to address the problem of excessive noise
on the unit at night. For example, your list might
include structural environmental changes or work

2. Then identify five leadership strategies you
might use to promote buy-in of the Quiet at Night
initiative by all health-care professionals on the
unit. How will you inspire these individuals to
work with you in achieving this critically important
goal? What incentives might you use to reward
behavior conducive to meeting this goal?

3. Discuss whether you feel this goal could be
achieved by employing only the management
strategies you identified. Could it be achieved
only with the implementation of leadership
strategies for team building?


Leadership as a New Nurse (Marquis &
Huston, 2012)

Sally Jones is a 36-year-old new registered nurse (RN)
who graduated 6 months ago from a community college
with an associate degree in nursing. Sally worked her
way through school as a licensed practical nurse in a
pediatric unit of a local hospital. After passing her RN
exams, she moved to a larger city and was hired to work

the evening shift on the pediatric unit as a primary care
nurse. Her patient load is usually six pediatric patients,
and she has a nursing assistant working under her

Sally has been bothered recently by discrepancies
regarding the credits of intravenous (IV) solutions given in
handoff report. For example, she was told at report
yesterday that 150 mL remained in one patient’s bag of
IV solution, but upon making initial patient rounds, she
found the IV machine beeping and had to hurriedly
replace the bag. At the previous hospital where she had
worked, it was a unit policy that all pediatric patients have
their IV solutions observed by both oncoming and
outgoing primary nurse at shift change so such
discrepancies could be discovered and corrected prior to
departure of the outgoing shift. She feels this was a good
policy and would like to see a similar policy implemented
at her new place of employment.


If you were Sally, what would you do in this
situation? Answer the following questions to help
decide what to do.
1. Is it appropriate for a new nurse to take a

leadership role in addressing this problem?
2. What are some possible steps you could take in

correcting this situation?
3. Would a followership role be better suited to

solve this issue?
4. Should you act alone or involve others?


Choosing a Leadership Style (Marquis &
Huston, 2012)

You are a team leader with one licensed practical
nurse/licensed vocational nurse (LPN/LVN) and one
nursing assistant on your team. You also share the unit
clerical person with two other team leaders and the
charge nurse. You have found the LPN/LVN to be a
seasoned team member and very reliable. The nursing
assistant is young and very new and seems a bit
disorganized but is a very willing team member. At
various times, you will be directing these three individuals
during your workday, that is, asking them to do things,
supervising their work, and so on.


What leadership style (authoritative, democratic, or
laissez-faire) should you use with each person or
would it be the same with all three? Would you be
justified in using only one leadership style? If an
emergency occurred, would your leadership style
change or remain the same? Discuss solutions to
this scenario in class.


Prescription Misuse and the Opioid

Kacik (2018) reported that more than half (52%) of
Americans tested by Quest Diagnostics in 2017 misused
prescription drugs, suggesting that medication adherence
is increasingly more difficult as the opioid epidemic

swells. Most of the misuse stemmed from positive results
for nonprescribed or illegal drugs in addition to their

Indeed, about 10% of hospitalizations and 125,000
deaths annually in the United States stem from not taking
medications as prescribed, according to one estimate.
That can translate to as much as $289 billion per year in
excess health-care costs (Kacik, 2018).


Assume you are an office nurse in a small family
practice. The physicians in the practice have
recently attempted to alter their prescribing patterns
to address a clearly mounting national problem.
Sharp restrictions on opioid prescribing alone,
however, will not solve the prescription drug
epidemic. Because you have so much direct
contact with patients in the practice, you want to be
a part of the solution. Identify at least three
leadership roles and three management functions
that might allow you, as a member of the
interprofessional team, to help address the
problem. What interprofessional collaboration might
be needed to help you implement these leadership
roles and management functions?

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Twenty-First-Century Thinking
About Leadership and

. . . No institution can possibly survive if it needs
geniuses or supermen to manage it. It must be
organized in such a way as to be able to get along
under a leadership composed of average human
beings.—Peter Drucker

. . . It is better to lead from behind and to put others in
front, especially when you celebrate victory when nice
things occur. You take the front line when there is
danger. Then people will appreciate your leadership.—
Nelson Mandela

. . . The leaders of tomorrow will face ever-changing
team structures, with more remote workers and more
diverse skill sets than ever before.—Catherine Wong


This chapter addresses:

BSN Essential II: Basic organizational and systems leadership
for quality care and patient safety

BSN Essential VI: Interprofessional communication and
collaboration for improving patient health outcomes

BSN Essential IX: Baccalaureate generalist nursing practice
MSN Essential II: Organizational and systems leadership
MSN Essential VII: Interprofessional collaboration for improving
patient and population health outcomes

MSN Essential IX: Master’s level nursing practice
AONL Nurse Executive Competency I: Communication and
relationship building

AONL Nurse Executive Competency II: A knowledge of the
health-care environment

AONL Nurse Executive Competency III: Leadership
ANA Standard of Professional Performance 9:

ANA Standard of Professional Performance 10:

ANA Standard of Professional Performance 11: Leadership
QSEN Competency: Teamwork and collaboration


The learner will:

analyze how current and future paradigm shifts in health care
affect the leadership skills that will be needed by nurses in the
coming decade

compare strengths-based leadership, which focuses on the
development or empowerment of workers’ strengths, with the
traditional management practices of identifying problems,
improving underperformance, and addressing weaknesses and

identify Level 5 leadership skills (as espoused by Jim Collins),
which differentiate great companies from good companies

identify the characteristics of a servant leader and suggest
strategies for encouraging a service inclination in others

explore elements of human and social capital, which impact
resource allocation in organizations

describe situations where followers (agents) might not be
inherently motivated to act in the best interest of the principal
(leader or employer)

describe components of emotional intelligence, which promote
the development of productive work teams

identify characteristics of authentic leadership and discuss the
consequences to the leader–follower relationship when leaders
are not authentic

identify contemporary nurse-leaders who exemplify thought
leadership and the innovative ideas they have suggested

describe why quantum leaders need flexibility in responding to
the complex relationships that exist between environment and
context in work environments

describe complexities that exist in the relationship between
followers and leaders

provide examples of the 21st-century shift from industrial age
leadership to relationship age leadership

develop insight into his or her individual leadership strengths

Throughout history, nursing has been required to respond to
changing technological and social forces. In the last decade alone, a
growing elderly population, health-care reform, reductions in federal
and state government reimbursement as well as commercial
insurance, and new quality imperatives such as value-based
purchasing and pay for performance have resulted in major
redesigns of most health-care organizations. In addition, the locus of

care continues to shift from acute care hospitals to community and
outpatient settings, innovation and technological advances are
transforming the workplace, and organizational cultures are
increasingly focusing on externally regulated, safety-driven,
customer-focused care. All these changes have brought about a
need for leader-managers to learn new roles and develop new skills.

The new managerial responsibilities placed on organized nursing
services call for nurse administrators who are knowledgeable,
skilled, and competent in all aspects of management. Now more
than ever, there is a greater emphasis on the business of health
care, with managers being involved in the financial and marketing
aspects of their respective departments. Managers are expected to
be skilled communicators, organizers, and team builders and to be
visionary and proactive in preparing for emerging new threats such
as domestic terrorism, biological warfare, and global pandemics.

In addition, the need to develop nursing leadership skills has never
been greater. At the national level, nurse-leaders and nurse-
managers are actively involved in determining how best to
implement health-care reform and in addressing health-care worker
shortages. At the organizational and unit levels, nurse-leaders are
being directed to address turnover rates by staff, an emerging
shortage of qualified top-level nursing administrators, unionization,
and intensified efforts to legislate minimum staffing ratios and
eliminate mandatory overtime while maintaining civil and productive
work environments. Moreover, ensuring successful recruitment,
creating shared governance models, and maintaining high-quality
practice depend on successful interprofessional team building,
another critical leadership skill in contemporary health-care
organizations. This challenging and changing health-care system
requires leader-managers to use their scarce resources
appropriately and to be visionary and proactive in planning for
challenges yet to come.

In addition, Strock (2018) points out that the 21st century has seen
a breakdown of some of the long-standing barriers that defined
leadership. “For example, individuals holding high positions of power
traditionally tended to be distant from the those they served. Today,
anyone can find a way to communicate with almost anyone else
through new technologies. Such individuals no longer have the
zones of privacy that separated their personal and professional lives”
(Prichard, 2018, “21st Century Leadership,” para. 2). The new trends
are part of a transformational change wrought by digital technology.

Prichard (2018) notes that in the 20th century, interactions were
generally transactional but that now, we’re in a web of relationships.
Those relationships can be established or defined by individuals
rather than by large public and private institutions. This ongoing
empowerment of individuals and previously isolated or marginalized
groups through new technology has accelerated leadership exerted
through influence rather than domination or dictation. Thus,
leadership roles are subject to greater accountability, and the tools of
workaday management and service are in transition.

Indeed, a recent survey found that millennials expect and demand
different things from their employer, their job, and, most certainly,
their leaders today than they did 20 years ago (Elliott & Corey,
2018). In this new world of work, leader-managers need to eliminate
the barriers that separate them from their followers, using every tool
they have at their disposal to cut through the hierarchy and bring
themselves closer to their people (Elliott & Corey, 2018). By doing
this, they will significantly improve upward feedback and employee
engagement as well as loyalty (see Examining the Evidence 3.1).

Source: Elliott, G., & Corey, D. (2018). 10 Traits of
great leaders in this new world of work. Retrieved
November 18, 2018, from

Leadership Traits Most Respected and
Valued by Millennials
The world of work has changed dramatically
and continues to change. The workforce, which
now consists of five generations working side
by side, expects and demands different things
from its organization, its job, and, most
certainly, its leaders today than it did 20 years
ago. This study asked 350 millennials to
answer the question: What do you want and
expect from your leaders?

The 10 traits millennials identified as
expecting from their leaders included

1. Own and live the company values
2. Communicate openly and early
3. Inspire people to reach higher
4. Own their mistakes
5. Recognize big wins, small wins, and hard

6. Trust people
7. Make the right decision, not the popular

8. Add value to their teams, helping them to


9. Have the courage to be genuine and

10. Take care of people

In confronting these new and expanding responsibilities and
demands, many leader-managers turn to the experts for tools or
strategies to meet these expanded role dimensions. What they have
found is some new and innovative thinking about how best to
manage organizations and lead people as well as some
reengineered interactive leadership theories from the later 20th
century. This chapter explores this contemporary thinking about
leadership and management, with specific attention given to
emergent 21st-century thinking.

New Thinking About Leadership and
Given current health-care system and organizational complexity,
most 21st-century nurse leader-managers will need to improve and
add to their leadership skill toolbox to meet emerging challenges in
the coming decade. In addition, they will be required to embrace new
roles in new settings. Some leader-managers, however, will
undoubtedly try to use a traditional top-down hierarchical approach
in leading and managing others but will likely find that it no longer
works well, if at all. Instead, they must seek out more participatory,
transdisciplinary, and collaborative models that are not easy to

For example, new research on leadership, including full-range
leadership theory (see Chapter 2), is rediscovering the importance of
organizational context, levels of analysis, and potential boundary
conditions on transformational leadership. Indeed, many recent
leadership and management concepts focus on the complexity of the

relationship between the leader and the follower, and much of the
leadership research emerging in the second decade of the 21st
century builds on the interactive leadership theories developed in the
latter part of the 20th century. As a result, concepts such as
strengths-based leadership, Level 5 Leadership, servant leadership,
principal agent theory, human and social capital theory, emotional
intelligence (EI), authentic leadership, quantum leadership, and
thought leadership have emerged as part of the leader-manager’s
repertoire for the 21st century.

Strengths-Based Leadership and the Positive
Psychology Movement
Strengths-based leadership, which grew out of the positive
psychology movement (which began in the late 1990s), focuses on
the development or empowerment of strengths as opposed to
weaknesses or areas of needed growth. Thus, strengths-based
leadership is part of the development of positive organizational
scholarship, which focuses on successful performance that exceeds
the norm and embodies an orientation toward strengths and
developing collective efficacy.

Research suggests that using a strengths-based approach, even
at a young age, can have a profound impact on the ability of
individuals to self-manage and to regulate their emotions. A study by
Dennison, Daniel, Gruber, Cavanaugh, and Mayfield (2018) of fifth
and seventh graders exposed to a brief strengths-based leadership
training group found significant positive changes in the children
regarding internal areas of functioning and social skills, anger
management skills, and school attitude. Just changing the
framework in which the children were approached from “at risk” to “at
promise” seemed to make a difference (see Examining the Evidence

Source: Dennison, S. T., Daniel, S. S., Gruber, K. J.,
Cavanaugh, A. M., & Mayfield, A. (2018). A leadership
training group for at risk fifth & seventh graders:
Results from a brief strength-based group program.
Social Work With Groups, 41(3), 181–197.

Using Strengths-Based Leadership Training
to Move Students From “At Risk” to “At
An increasing number of school-age youth
exhibit social, emotional, and behavioral
problems that place them at risk for not
meeting the demands of the classroom or
performing at grade level. A total of 225
students from grades 5 and 7 were recruited to
participate in an 8-week school-based group
strengths-based leadership training program,
and an additional 100 fifth and seventh grade
students were enrolled in the matched
comparison group (students who received only
pre- and post-assessments but no training
intervention). A mixed-methodology design was
used; three standardized scales were
administered pre- and post-group intervention,
and a focus group was conducted with each
group after their eighth group session.

Findings from this study suggested that fifth
and seventh grade students were able to make
significant positive changes over 8 weeks
regarding their peer skills, anger management,
and school attitude. Furthermore, these

findings suggest there is value in conducting
early intervention programs where services
often have less stigma attached to them and
they can be delivered to a larger number of
students, particularly minority and poor. The
researchers concluded that it is imperative that
group interventions like strengths-based
leadership training be replicated and further
studied to contribute to our knowledge
regarding evidence-based treatment for K to 12
at risk youth.

The importance of strengths-based leadership in organizations
was noted by Rath and Conchie (2008) who completed a review of
30 years of research by Gallup including over 40,000 personal
interviews with leaders from around the world and 20,000 interviews
with followers to ask why they follow a leader. They found that
effective leaders are always investing in strengths but that they
consciously and consistently work to use their key strengths to their
advantage rather than putting significant effort into being better
rounded (Ambler, 2015).

In addition, Rath and Conchie (2008) found that the most effective
leaders surround themselves with the right people (people who have
different strengths than they do) and that they maximize their team
(Ambler, 2015). This typically requires that leaders create teams that
have a balance of strengths in the following four leadership domains:

1. Strategic thinking: Effective leaders keep everyone focused
on a long-term future.

2. Influence: Effective leaders can sell ideas, develop political
support, and get people to rally behind a project or an initiative.

3. Relationship building: Effective leaders are able to unite a
group of disparate individuals into a team that works toward a

common goal.
4. Execution: Effective leaders know how to get things done by

translating plans into action.

Finally, Rath and Conchie (2008) found that the most effective
leaders understand their follower’s needs (Ambler, 2015). The
researchers asked followers to choose three words that best
describe the contribution that a leader makes to their life. Many of
them used the same words to describe what they seek from their
leaders. The four most common responses follow:

1. Trust: Nothing happens without a sense of trust between
leaders and followers.

2. Compassion: Followers want to know that their leaders care
about them.

3. Stability: Followers want leaders who they can depend on.
4. Hope: Followers want to feel positive about their future


Effective leaders then understand their followers’ needs as well as
strengths and engage them in activities that allow these strengths to
grow and for employees to be empowered and successful. Ambler
(2015) identifies 10 questions emerging leaders can ask to assess
their strengths-based leadership skills (Display 3.1).


1. Do you have a good understanding of your personal strengths
and weaknesses?

2. What are your top three strengths and are you using them on
a daily basis?

3. Are you deliberately investing in your strengths?
4. Are you building a team that compensates for your

5. Do you select team members for their leadership strengths as

opposed to their knowledge and technical expertise?
6. Are you developing your team members’ strengths?
7. What is the level of trust between you and your team?
8. Does your team feel that you care for them on a personal

9. Does your team know what to expect from you?
10. Is your team inspired by a positive future?

Level 5 Leadership
The concept of Level 5 leadership was developed by Jim Collins and
published in his classic book, Good to Great: Why Some Companies
Make the Leap . . . and Others Don’t (Collins, 2001). Collins (2001)
studied 1,435 companies to determine what separates great
companies from good companies. What he found was that five levels
of leadership skill (Display 3.2) may be present in any organization.
Truly great organizations, however, typically have leaders who
possess the qualities found in all five levels. Thus, not only do Level
5 leaders have the knowledge to do the job, but they also have team
building skills and can help groups achieve shared goals. They also,
though, demonstrate humility and seek success for the team, rather
than for self-serving purposes, a core component of another 21st-

century leadership theory known as servant leadership. Level 5
leaders also know when to ask for help, accept responsibility for the
errors they or their team make, and are incredibly disciplined in their


Level 1: Highly Capable Individual
Leader makes high-quality contributions to his or her work,
possesses useful levels of knowledge, and has the talent and
skills needed to do a good job.

Level 2: Contributing Team Member
Leader uses knowledge and skills to help his or her team succeed
and works effectively, productively, and successfully with other
people in his or her group.

Level 3: Competent Manager
Leader is able to organize a group effectively to achieve specific
goals and objectives.

Level 4: Effective Leader
Leader is able to galvanize a department or organization to meet
performance objectives and achieve a vision.

Level 5: Great Leader
Leader has all of the abilities needed for the other four levels, plus
a unique blend of humility and will that is required for true

Source: Collins, J. (2001). Level 5 leadership: The triumph of humility and fierce
resolve. Harvard Business Review, 79(1), 66–76.

Level 5 leaders also possess qualities found in the four other
levels of leadership that Collins (2001) identified. It is not necessary
to pass sequentially through each individual level before becoming a

Level 5 leader, but the leader must have the skills and capabilities
found in each level of the hierarchy to be a top performing leader
(Mind Tools Content Team, n.d.).

Servant Leadership
Although Greenleaf (1977) developed the idea of servant leadership
more than 35 years ago, it continues to greatly influence leadership
thinking in the 21st century. In more than four decades of working as
director of leadership development at AT&T, Greenleaf noticed that
most successful managers lead in a different way from traditional
managers. These managers, which he termed servant leaders, put
serving others, including employees, customers, and the community,
as the number one priority.

This choice between personal advantage and organizational
advantage speaks to the heart of servant leadership. “‘Win-win’ is
challenging when YOU win later and OTHERS win sooner” (When
Servant-Leaders, 2018, para. 3). In addition, servant leaders foster a
service inclination in others that promotes collaboration, teamwork,
and collective activism. Other defining qualities of servant leadership
are shown in Display 3.3.


1. The ability to listen on a deep level and to truly understand
2. The ability to keep an open mind and hear without judgment
3. The ability to deal with ambiguity, paradoxes, and complex

4. The belief that honestly sharing critical challenges with all

parties and asking for their input is more important than
personally providing solutions

5. Being clear on goals and good at pointing the direction toward
goal achievement without giving orders

6. The ability to be a servant, helper, and teacher first and then a

7. Always thinking before reacting
8. Choosing words carefully so as not to damage those being

9. The ability to use foresight and intuition
10. Seeing things whole and sensing relationships and



Creating a Service Inclination

An important part of servant leadership is the servant
leader’s ability to create a service inclination in others. In
doing so, more leaders are created for the organization.


Identify servant leaders who you have worked with.
Did they motivate followers to be service oriented?
If so, what strategies did they use? Does servant
leadership result in a greater number of leaders
within an organization? If so, why do you think that
this happens?

Ken Blanchard, author of Servant Leadership in Action: How You
Can Achieve Great Relationships and Results, notes, however, that
although servant leadership is about leading from the ground up, it
still requires leadership and that aspect is often forgotten (Kruse,
2018). Servant leaders must still create and communicate their
vision, direction, and goals. Followers must be clear about what the
leader is trying to accomplish as well as their values and goals. Once
that is clear, the pyramid can be turned upside down so that the
leader can begin to help followers live according to the vision of
values and goals and be successful.

Values are the pillars that uphold the entire structure of
servant leadership. Honesty, truth, compassion, and
acceptance are some of the intrinsic core values shared
by servant leaders (Eswaran, 2018).

For example, Trojani (2018) shared a story about the first time
President John F. Kennedy visited National Aeronautics and Space
Administration’s headquarters and met a janitor mopping the floor.
When President Kennedy asked him what he was doing, he replied,
“I’m helping to put a man on the moon.” President Kennedy provided
the vision, but the janitor felt empowered to do his part to achieve the


Servant Leadership in Nursing and


Write a one-page essay that addresses the
1. Both nursing and medicine are helping service-

oriented professions. Do you believe there are
inherent differences in service inclination
between individuals who choose nursing for a
profession rather than medicine?

2. Do you believe that nursing education fosters a
greater service inclination than medical

3. Do you believe the female majority (gender) of
the nursing profession influences nursing’s
propensity to be service oriented?

Principal Agent Theory
Principal agent theory, which first emerged in the 1960s and 1970s,
is another interactive leadership theory being actively explored in the
21st century. The principal agent problem occurs when one person
(the agent) can make decisions on behalf of another person (the
principal) (Agarwal, 2019). In this situation, there are issues of moral
hazard and conflicts of interest.

This occurs because not all followers (agents) are inherently
motivated to act in the best interest of the leader or employer

(principal). This is because followers may have an informational
(expertise or knowledge) advantage over the leader as well as their
own preferences, which may deviate from the principal’s
preferences. The risk then is that agents will pursue their own
objectives or interests instead of that of their principal.

Principals then must identify and provide agents with appropriate
incentives to act in the organization’s best interest. For example,
consumers with good health insurance and small out-of-pocket
expenses may have little motivation to act prudently in accessing
health-care resources because payment for services used will come
primarily from the insurer. The insurer then must create incentives for
agents to access only needed services.

Another example might be end-of-shift overtime. Although most
employees do not intentionally seek or want to work overtime after a
long and busy shift, the reality is that doing so typically results in
financial rewards. Employers then must either create incentives that
reward employees who are able to complete their work in the allotted
shift time or create disincentives for those who do not.


The Agent’s Motives

You are a team leader for 10 patients on a busy medical
unit. Your team includes Lori, a licensed vocational nurse,
passing medications and assisting with patient
treatments, and Tom, an experienced certified nursing
assistant, who provides basic care such as monitoring
vital signs, ambulating patients, and assisting with
hygiene. On several occasions in the past, Tom has failed

to report significant changes in patients’ vital signs to you
until significant time had elapsed or you discovered them
yourself. Despite confronting Tom about the need to
report these changes and the specific vital sign
parameters that need to be reported, this behavior has
continued. You have become concerned that patient
harm might occur if this pattern of behavior can continue.


Identify possible motives that Tom (the agent) may
have for failing to share this information with you
(the principal). What incentives might you employ to
modify his behavior?

Human and Social Capital Theory
The traditional view of employees as costs is now obsolete. Instead,
employees are now viewed as assets or capital that can be
developed and nurtured. Human capital refers to the collective skills,
knowledge, or other intangible assets of individuals that can be used
to create economic value for the individuals, their employers, or their
community (, 2018, para. 1). For example, formal
educational attainment generally increases human capital because
the returns are in the form of wage, salary, or other compensation.
Human capital can be viewed, however, from an organizational
perspective as well. In this case, human capital would refer to the
group’s collective knowledge or experience.

Human capital can refer to a group’s collective
knowledge, skills, and abilities.

Human capital theory suggests that individuals and/or
organizations will invest in education and professional development
if they believe that such an investment will have a future payoff. For
example, a health-care organization that provides tuition
reimbursement for nurses to go back to school to earn higher
degrees is likely doing so in anticipation that a more highly educated
nursing staff will result in increased quality of care and higher
retention rates—both of which should translate into higher
productivity and financial return.

Investing in human capital development was identified as a
leadership trend shaping contemporary organizations (Forbes
Coaches Council, 2018a). Leaders and companies who recognize
the long-term benefit of focusing on human capital development and
take a vested interest in helping employees thrive in all areas of their
lives (not just work) will create more engagement, productivity, and
overall happier employees.

Emotional Intelligence
Another leadership theory gaining prominence in the 21st century is
that of EI (also known as EQ). Broadly defined, EI refers to the ability
to perceive, understand, and control one’s own emotions as well as
those of others. Gabriel (2018) suggests that it’s our EI that gives us
the ability to read our instinctive feelings and those of others. It also
allows us to understand and label emotions as well as express and
regulate them.

Gabriel (2018) suggests that many people overestimate their EI
because they think it is the ability or tendency to be nice. It’s not.
Instead, it is about being empathetic, being able to look at situations
from alternative points of view, being open minded, bouncing back
from challenges, and pursuing goals despite challenges. Some
proponents of EI have suggested that having EI may be even more
critical to leadership success than intellectual intelligence (IQ).

In their original work on EI in 1990, Mayer and Salovey (1997)
suggested that EI consists of three mental processes:

Appraising and expressing emotions in the self and others
Regulating emotion in self and others
Using emotions in adaptive ways

In 1997, they further refined EI into four mental abilities:
perceiving/identifying emotions, integrating emotions into thought
processes, understanding emotions, and managing emotions.

Goleman (1998), in his best seller Working With Emotional
Intelligence, built on this work in his identification of five components
of EI: self-awareness, self-regulation, motivation, empathy, and
social skills (Display 3.4).


1. Self-awareness: the ability to recognize and understand one’s
moods, emotions, and drives as well as their effects on others

2. Self-regulation: the ability to control or redirect disruptive
impulses or moods as well as the propensity to suspend

3. Motivation: a passion to work for reasons that go beyond
money or status; a propensity to pursue goals with energy and

4. Empathy: the ability to understand and accept the emotional
makeup of other people

5. Social skills: proficiency in handling relationships and building
networks; an ability to find common ground

Source: Goleman, D. (1998). Working with emotional intelligence. New York, NY:
Bantam Books.

Goleman (1998) argued that all individuals have a rational thinking
mind and an emotional feeling mind and that both influence action.
The goal, then, in EI is emotional literacy—being self-aware about
one’s emotions and recognizing how they influence subsequent
action. Unlike Mayer and Salovey (1997), who suggested that EI
develops with age, Goleman argued that EI could be learned,
although he too felt that it improves with age. Tyler (2015) agrees,
arguing that although EI tends to increase with age, we do not have
to wait until we grow older to improve this skill set. To do so,
however, we must be willing to change, practice changed behaviors,
and receive feedback regarding our progress.

Authentic Leadership
Another emerging leadership theory for the contemporary leader-
manager’s arsenal is that of authentic leadership (also known as
congruent leadership). Authentic leadership suggests that in order to
lead, leaders must be true to themselves and their values and act
accordingly. Integrity is conformance between what leaders profess
and how they actually act (Kador, 2018).

It is important to remember that authentic or congruent leadership
theory differs somewhat from more traditional transformational
leadership theories, which suggest that the leader’s vision or goals
are often influenced by external forces and that there must be at
least some “buy-in” of that vision by followers. In authentic
leadership, it is the leaders’ principles and their conviction to act
accordingly that inspire followers.

In authentic leadership, it is the leaders’ principles and
their conviction to act accordingly that inspire followers.


Emotions and Decision Making

Think back on a recent decision you made that was
more emotionally laden than usual. Were you self-aware
about what emotions were influencing your thinking and
how your emotions might have influenced the course(s)
of action you chose? Were you able to objectively identify
the emotions that others were experiencing and how
these emotions may have influenced their actions?

Sostrin (2017) suggests that sustaining an enduring alignment
between your values and your actions is vital for leadership
success. “It’s what lets you be you and it serves as a bond of
integrity that enables your followers to trust you. Increase the
alignment between your values and behaviors by understanding
what makes you tick—defining the specific values that animate
you—then making them apparent to your clients and teams. This
integrity will produce a more consistent, authentic expression of
who you are in the moments that matter” (para. 7).

Hoff (2018) agrees, noting that authenticity breeds trust, which
is a crucial element in the workplace. Leaders who demonstrate
integrity and character command the support and fidelity of their
followers, who are then much more likely to go the extra mile and
stand by their leader regardless of circumstance. In contrast, the
absence of trust can make it very difficult for leaders to gain
support (Hoff, 2018).

Forbes Coaches Council (2018a) suggests that unfortunately,
“leaders have long gotten away with vocally supporting policies

and procedures, but their actions say otherwise. That tide will turn.
With so much light being shed on unacceptable behavior in all
workplaces, leaders must begin to understand they need to not
only hold their teams accountable for proper behavior but hold
themselves accountable as well” (para. 7).

The reality, though, is that authentic leadership is not easy. It
takes great courage to be true to one’s convictions when external
forces or peer pressure encourages an individual to do something
he or she feels morally would be inappropriate. For example, there
is little doubt that some nurse-leaders experience intrapersonal
value conflicts between what they believe to be morally
appropriate and a need to deliver results in a health-care system
increasingly characterized by pay for performance and rewarded
by cost containment.

The trust that is such an important part of authentic leadership
may also take time to develop. Although Kador (2018) notes that
trust can occur very quickly under the right circumstances,
generally, it takes time as well as a lifelong commitment to self-
reflection. Trust is also easier to experience than to precisely
measure (Kador, 2018). Five questions an individual might use to
assess his or her trustworthiness as an authentic leader are
shown in Display 3.5.


1. Do I act with integrity?
2. Do I welcome ideas and opinions different from my own?
3. Do I appreciate employees who are willing to bring bad news

to my attention?
4. Do I admit my own mistakes?
5. Do I always tell the truth, even if it is inconvenient?
6. Do I publicly encourage suggestions from everyone on the

team, from the top performers to the most junior employees,
and then do I listen to the contributions with equal respect?

Source: Kador, J. (2018). Are you a trusted leader? Retrieved July 15, 2018, from

Finally, one must not be so idealistic as to assume that all leaders
strive to be authentic. Indeed, many are flawed, at least at times.
Leaders may be deceitful and trustworthy, greedy and generous, and
cowardly and brave. To assume that all good leaders are good
people is foolhardy and makes us blind to the human condition.
Future leadership theory may well focus on why leaders behave
badly and why followers continue to follow bad leaders.


Inconsistency in Word and Action

There are many examples of internationally or nationally
recognized leaders who have lost their followers because

of their actions being inconsistent with personally stated
convictions. An example might be a world-class athlete
and advocate for healthy lifestyles who is found to be
using steroids to enhance physical performance. Or it
might be a political figure who preaches morality and
becomes involved in an extramarital affair or a religious
leader who promotes celibacy and then becomes
involved in a sex scandal.


Think of a leader who espoused one message and
then acted in a different manner. How did it affect
the leader’s ability to be an effective leader? How
did it change how you personally felt about that
leader? Do you feel that leaders who have lost their
“authenticity” can ever regain the trust of their

Thought Leadership and Rebel Leadership
Another relatively new leadership theory to emerge in the 21st
century is that of thought leadership, which applies to a person who
is recognized among his or her peers for innovative ideas and who
demonstrates the confidence to promote those ideas. Thus, thought
leadership refers to any situation in which one individual convinces
another to consider a new idea, product, or way of looking at things.

Thought leaders challenge the status quo and attract followers not
by any promise of representation or empowerment but by their risk
taking and vision in terms of being innovative. The ideas put forth by
thought leaders typically are future oriented and make a significant
impact. In addition, they are generally problem oriented, which
increases their value to both individuals and organizations.

For example, in her book, Rebel Talent: Why It Pays to Break the
Rules at Work and in Life, Gino (2018) argues companies should
encourage employees to pursue core strengths of novelty, curiosity,
perspective, diversity, and authenticity because success is often
linked with breaking rules and breaking traditions (Nobel, 2018).
Gino suggests that business leaders should strive for and encourage
rebellion in their workplaces because when people break rules to
explore new ideas and create positive change, everyone benefits
(Nobel, 2018). Gino’s eight principles of rebel leadership are shown
in Display 3.6.


1. Seek out the new.
2. Encourage constructive dissent.
3. Open conversations—don’t close them.
4. Reveal yourself—and reflect.
5. Learn everything—then forget everything.
6. Find freedom in constraints.
7. Lead from the trenches.
8. Foster happy accidents (mistakes may unlock a breakthrough).

Source: Gino, F. (2018). Rebel talent: Why it pays to break the rules at work and in
life. New York, NY: HarperCollins.

Organizations can also be thought leaders. For example, Blue
Cross and Blue Shield were early thought leaders in the
development of private health insurance in the late 1920s. Johnson
& Johnson launched the Discover Nursing campaign earlier this
decade to champion the nursing profession and promote the
recruitment and retention of nurses. Thought leaders in the coming
decade will likely focus on enduring issues that continue to be of

critical importance to nursing and health care and address new,
emerging problems of significance. For example, thought leadership
is still greatly needed in identifying and adopting innovative safety
and quality improvement approaches that actually reduce the risk of
harm to patients and health-care workers. In addition, the threat of
an international nursing shortage continues to loom, and an
inadequate number of innovative solutions have been suggested for
addressing the dire nursing faculty shortage that is expected to occur
in the next 5 to 10 years.


Technological Innovation and Thought

Technological innovations continue to change the face
of health care, and the pace of such innovations
continues to increase exponentially. For example,
wireless communication, computerized charting, and the
barcode scanning of medications have all greatly affected
the practice of nursing.


Choose at least one of the following technological
innovations and write a one-page report on how this
technology is expected to impact nursing and health
care in the coming decade. See if you can identify
the thought leader(s) credited with developing these
technologies and explore the process that they
used to both develop and market their innovations.

Biometrics to ensure patient

Computerized physician order entry
Point-of-care testing
Bluetooth technology
Electronic health records
Artificial intelligence
Robotic surgery
Nursebots (prototype nurse robots)
Genetic and genomic testing

Agile Leadership
Another newer leadership theory is agile leadership, a term
borrowed from the software world. Agile leaders have the ability (and
agility) to think in many ways so that they can be flexible, adaptable,
and fast in their decision making (Forbes Coaches Council, 2018b).
The Center for Agile Leadership (2018) concurs, noting that agile
leaders are inclusive, democratic leaders who exhibit a greater
openness to ideas and innovations. With a passion for learning, a
focus on developing people, and a strong ability to define and
communicate a desired vision, they possess the tools necessary to
inspire others and become an agent for change within any

Agile leaders listen deeply and ask powerful questions to gain
insights and make the right decision to help the organization move
forward through problems. Agile leaders also quickly adapt to
situations as they come along and are flexible and open to change
and growth (Forbes Coaches Council, 2018b).

In addition, agile leaders demonstrate agility with their employees.
Indeed, agile leadership was proposed to meet the needs of the
millennial workforce, which has different needs, different wants, and
different motivators than any generation before them (Center for
Agile Leadership, 2018). People like to be communicated with and
recognized differently. It is never a one-size-fits-all model. When
agile leaders show how much they value their team’s contribution by
understanding and being what they need, productivity and
engagement rise (Forbes Coaches Council, 2018b).

Reflective Thinking and Practice
Other leadership theories that have gained prominence in the past
decade are those of reflective thinking and practice. Sherwood and
Horton-Deutsch (2015) note that today’s chaotic health-care
environment requires nurse-leaders to be nimble, flexible, and
responsive to change. “The need for change arises from the
awareness that current practices or processes aren’t working—that
results are not the desired outcomes” (p. xiii). Thus, the goal for
nurse-leaders must be to become so agile that they are able to
continually adapt, reflect on progress and setbacks, and adjust their
course as needed (Sherwood & Horton-Deutsch, 2015).

Sherwood and Horton-Deutsch (2015) suggest that reflection
provides an opportunity to apply theory from all ways of knowing and
learning as an extension of evidence-based practices and research.
It also allows individuals to learn from experience by considering
what they know, believe, and value within the content of current
situations and then to reframe to develop future responses or

actions. Sherwood and Horton-Deutsch suggest two questions
nurse-leaders can use to increase their reflective practice (Display


1. How can you bring the power of reflection to bear on your day-
to-day work?

2. How could you amplify the effectiveness of your decision
making and empower your teams to step up and participate in
the decision-making process?

Source: Sherwood, G. D., & Horton-Deutsch, S. (2015). Reflective organizations.
On the front lines of QSEN & reflective practice implementation. Indianapolis, IN:
Nursing Knowledge International.

Quantum Leadership
Quantum leadership is another relatively new leadership theory that
is being used by leader-managers to better understand dynamics of
environments, such as health care. This theory, which emerged in
the 1990s, builds on transformational leadership and suggests that
leaders must work together with subordinates to identify common
goals, exploit opportunities, and empower staff to make decisions for
organizational productivity to occur. This is especially true during
periods of rapid change and needed transition.

Building on quantum physics, which suggests that reality is often
discontinuous and deeply paradoxical, quantum leadership suggests
that the environment and context in which people work is complex
and dynamic and that this has a direct impact on organizational
productivity. The theory also suggests that change is constant.
Today’s workplace is a highly fluid, flexible, and mobile environment,
and this calls for an entirely innovative set of interactions and

relationships as well as the leadership necessary to create them
(Porter-O’Grady & Malloch, 2015).

Quantum leadership suggests that the environment and
context in which people work is complex and dynamic
and that this has a direct impact on organizational

Because the health-care industry is characterized by rapid
change, the potential for intraorganizational conflict is high. Porter-
O’Grady and Malloch (2015) suggest that because the unexpected is
becoming the normative, the quantum leader must be able to
address the unsettled space between present and future and resolve
these conflicts appropriately. In addition, they suggest that the ability
to respond to the dynamics of crisis and change is not only an
inherent leadership skill but must now also be inculcated within the
very fabric of the organization and its operation.

Transition From Industrial Age Leadership to
Relationship Age Leadership
In considering all of these emerging leadership theories, it becomes
apparent that a paradigm shift has taken place early in the 21st
century—a transition from industrial age leadership to relationship
age leadership (Scott, 2006). Scott (2006) contends that industrial
age leadership focused primarily on traditional hierarchical
management structures, skill acquisition, competition, and control.
These are the same skills traditionally associated with management.
Relationship age leadership focuses primarily on the relationship
between the leader and his or her followers, on discerning common
purpose, working together cooperatively, and seeking information
rather than wealth (Table 3.1). Servant leadership, authentic

leadership, reflective thought and practice, human and social capital,
and EI are all relationship-centered theories that address the
complexity of the leader–follower relationship.


Scientific/Industrial Age Relationship/Information Age

Technical skills Adaptive skills
Command and control Invitation and interdependence
Competition Cooperation
Gaining advantage Discerning purpose
Gathering facts Finding meaning
What you have (wealth) What you know (information)
Hierarchy (top-down) Circular (egalitarian)
Metaphor for organizations:
machine (separate parts)

Metaphor: organic network
(connected parts)

Leadership: position Leadership: trusteeship
Source: Adapted from Scott, K. T. (2006, September). The gifts of leadership.
Paper presented at the Sigma Theta Tau International Regional Meeting,
Indianapolis, IN. © 2000, Ki ThoughtBridge, LLC. Author, Katherine Tyler Scott. All
rights reserved. Permission for use in this publication granted by Ki
ThoughtBridge, LLC.

A paradigm shift is taking place early in the 21st century
—a transition from industrial age leadership to
relationship age leadership.

Covey (2011) concurs, noting that the primary drivers of economic
prosperity in the industrial age were machines and capital—in other
words, things. People were necessary but replaceable. Covey

argues that many current management practices come from the
industrial age where the focus was on controlling workers, fitting
them into a slot, and using reward and punishment for external
motivation. In contrast, relationship age leadership is all about
leading people who have the power to choose. It is about requiring
leaders to embrace the whole person paradigm (Covey, 2011).

Fred Kofman, a leader development expert from Google, agrees,
suggesting that many employers are trying to attract the new
generation with the same technologies that attracted the past
generation (Should Leadership Feel, 2018). The result is abysmal
levels of engagement. Employee engagement in the United States,
which is probably one of the highest in the world, is about 30%. So,
70% of the people either don’t care or dislike their jobs and the
people they work for, the people they work with, the places where
they work, and the customers they are supposed to serve (Should
Leadership Feel, 2018).

Indeed, Tamara McCleary, speaker, author, and business expert,
suggests that employee engagement is the key to relationship
building in the 21st century (Edmonds, 2018). To build this
engagement, McCleary invests time, energy, and passion into caring
about employees. She also constantly checks to see whether her
plans, decisions, and actions are building relationships effectively,
and she refines those actions if they don’t (Edmonds, 2018).
McCleary’s three-step action plan for engaging employees to build
relationships is shown in Display 3.8.


1. Invest the time. Pay attention to more than just results.
Connect with people at all levels in the organization every day.
Learn their names and their passions. Learn what gets in their
way of cooperative teamwork and top performance. Act to
reduce those frustrations.

2. Get the data. Don’t just monitor performance metrics—monitor
data that indicates how happy employees are working in your
organization. Use reliable data, like turnover, exit interviews,
service levels, and more. Also try to measure other satisfaction
metrics, like the degree of trust, the frequency of proactive
problem solving, etc.

3. Evaluate the progress of employee engagement, service, and
results. Embrace proactive relationship management and pay
close attention to my “big three”—engagement, service, and
results. If the results are not what you want, refine your
approaches, then monitor the impact. Keep those practices that

Source: Edmonds, S. C. (2018). To be the best, invest in relationships AND
results. Retrieved July 15, 2018, from

Yet, the leader-manager in contemporary health-care
organizations cannot and must not focus solely on relationship
building. Ensuring productivity and achieving desired outcomes are
essential to organizational success. The key, then, likely lies in
integrating the two paradigms. Scott (2006) suggests that such
integration is possible (Fig. 3.1).

FIGURE 3.1 Integrated model of leadership. (Reproduced with permission from
Ki ThoughtBridge, LLC, & Scott, K. T. [2006, September]. The gifts of leadership.
Paper presented at the Sigma Theta Tau International Regional Meeting,
Indianapolis, IN. © Ki ThoughtBridge, LLC. All rights reserved.)

Technical skills and competence seeking must be balanced with
the adaptive skills of influencing followers and encouraging their
abilities. Performance and results priorities must be balanced with
authentic leadership and character. In other words, leader-managers
must seek the same tenuous balance between leadership and
management that has existed since time began.

This certainly was the case in research conducted by Blanchard
(2015) that compared strategic leadership with operational
leadership (management focused). Strategic leadership included
activities such as establishing a clear vision, maintaining a culture
that aligns a set of values with that vision, and declaring must-do or
strategic imperatives the organization needed to accomplish.
Operational leadership provided the “how” for the organization:
policies, procedures, systems, and leader behaviors that cascade
from senior management to frontline workers (day-to-day
management practices).

Researchers found that although strategic leadership is a critical
building block to set tone and direction, it has only an indirect effect
on organizational vitality. The real key to organizational vitality was
operational leadership. If this aspect of leadership is done effectively,
employee passion and customer devotion will follow the positive
experiences and overall satisfaction people have with the
organization. Researchers concluded that both strategic and
operational leadership were important—in the right amount, at the
right time, and that both are needed for success in an organization.


Balancing the Focus Between
Productivity and Relationships

You are a top-level nursing administrator in a large,
urban medical center in California. As in many acute care
hospitals, your annual nursing turnover rate is more than
15%. At this point, you have many unfilled licensed
nursing positions, and local recruitment efforts to fill these
positions have been largely unsuccessful.

During a meeting with the chief executive officer (CEO)
today, you are informed that the hospital vacancy rate for
licensed nurses is expected to rise to 20% with the
opening of an additional regional hospital in 3 months.
The CEO states that you must reduce turnover or
increase recruitment efforts immediately or the hospital
will have to consider closing units or reducing available
beds when the new ratios take effect.

You consider the following “industrial leadership”
paradigm options:

1. You could aggressively recruit international nurses to
solve at least the immediate staffing problem.

2. You could increase sign-on bonuses and offer other
incentives for recruiting new nurses.

3. You could expand the job description for unlicensed
assistive personnel and licensed vocational nurses to
relieve the registered nurses of some of their duties.

4. You could make newly recruited nurses sign a
minimum 2-year contract upon hire.

You also consider the following “relationship
leadership” paradigm options:

1. You could hold informal meetings with current staff to
determine major variables affecting their current
satisfaction levels and attempt to increase those
variables that increase worker satisfaction.

2. You could develop an open-door policy in an effort to
be more accessible to workers who wish to discuss
concerns or issues about their work environment.

3. You could implement a shared governance model to
increase worker participation in decision making on
the units in which they work.

4. You could make daily rounds on all the units in an
effort to get to know your nursing staff better on a one-
to-one basis.


Decide which of the options you would select. Rank
order them in terms of what you would do first.
Then look at your list. Did it reflect more of the
industrial leadership paradigm or a relationship
leadership paradigm? What inferences might you
draw from your rank ordering in terms of your
leadership skills? Do you think that your rank
ordering might change with your age? Your

Integrating Leadership Roles and Management
Functions in the 21st Century
Seemingly insurmountable problems, a lack of resources to solve
these problems, and individual apathy have been and will continue to

be issues that contemporary leader-managers face. Effective
leadership is absolutely critical to organizational success in the 21st
century. Becoming a better leader-manager begins with a highly
developed understanding of what leadership and management are
and how these skills can be developed. The problem is that these
skills are dynamic, and what we know and believe to be true about
leadership and management changes constantly in response to new
research and visionary thinking.

Contemporary leader-managers, then, are challenged not only to
know and be able to apply classical leadership and management
theory but also to keep abreast of new insights, new management
decision-making tools, and new research in the field. It is more
important than ever that leader-managers be able to integrate
leadership roles and management functions and that some balance
be achieved between industrial age leadership and relationship age
leadership skills. Leading and managing in the 21st century
promises to be more complex than ever before, and leader-
managers will be expected to have a greater skill set than ever
before. The key to organizational success will likely be having
enough highly qualified and visionary leader-managers to steer the

Key Concepts

■ Many new leadership and management theories have
emerged in the 21st century to explain the complexity of the
leader–follower relationship and the environment in which
work is accomplished and goals are achieved.

■ Strengths-based leadership focuses on the development or
empowerment of workers’ strengths as opposed to identifying

problems, improving underperformance, and addressing
weaknesses and obstacles.

■ Level 5 leadership is characterized by knowledge, team
building skills, the ability to help groups achieve goals,
humility, and the empowerment of others through servant

■ Servant leadership is a contemporary leadership model that
puts serving others as the first priority.

■ Followers can and do influence leaders in both positive and
negative ways.

■ Principal agent theory suggests that followers may have an
informational (expertise or knowledge) advantage over the
leader as well as their own preferences, which may deviate
from those of the principal. This may lead to a misalignment
of goals.

■ Human capital represents the capability of the individual.
Social capital represents what a group can accomplish

■ Emotional intelligence refers to the ability to use emotions
effectively and is considered by many to be critical to
leadership and management success.

■ Authentic leadership suggests that in order to lead, leaders
must be true to themselves and their values and act

■ Thought leadership refers to any situation whereby one
individual convinces another to consider a new idea, product,
or way of looking at things.

■ Thought leaders attract followers not by any promise of
representation or empowerment but by their risk taking and
vision in terms of being innovative.

■ Quantum leadership suggests that the environment and
context in which people work is complex and dynamic and
that this has a direct impact on organizational productivity.

■ A transition has occurred in the 21st century from industrial
age leadership to relationship age leadership.

Additional Learning Exercises and Applications


Reflecting on Emotional Intelligence in

Do you feel that you have emotional intelligence? Do
you express appropriate emotions such as empathy
when taking care of patients? Are you able to identify and
control your own emotions when you are in an
emotionally charged situation?


Describe a recent emotional experience. Write two
to four paragraphs reporting how you responded in
this experience. Were you able to read the
emotions of the other individuals involved? How did
you respond, and were you later able to reflect on
this incident?


Self-Regulation and Emotional

You have just come from your 6-month performance
evaluation as a new charge nurse in a long-term care
facility. Although the director of nursing stated that he
was very pleased in general with how you are performing
in this new role, one area that he suggested you work on
was to learn to be calmer in hectic clinical situations. He
suggested that your anxiety could be transmitted to
patients, coworkers, and subordinates who look to you to
be their role model. He feels that you are especially
anxious when staffing is short and that at times you vent
your frustrations to your staff, which only adds to the
general anxiety level on the unit.


Create a specific plan of 6 to 10 things you can do
to bolster your emotional intelligence in terms of
self-regulation during stressful times.


Human and Social Capital

Examine the institution in which you work or go to
school. Assess both the human capital and social capital

present. Which is greater? Which do you believe
contributes most to this institution in being able to
accomplish its stated mission and goals?


Assessing Emotional Intelligence
(Marquis & Huston, 2012)

You have just completed your first year as a registered
nurse and have begun to think about applying for the next
charge position that opens on your unit. You really like
your unit manager and one of the charge nurses.
However, a couple of the charge nurses are rather rude
and not very empathetic when they are harried and
overworked. At times, the charge nurses are very
frustrated, the team members pick up their frustration,
and the unit becomes chaotic. You feel that although
these nurses are very good clinicians, they are not
effective charge nurses. You know that you do not want
to be like them should you be promoted. You would love
to emulate your manager who is calm, supportive, and
well-grounded emotionally. She is an excellent role model
of a person with emotional intelligence, something you
are not sure you have.


Decide what you can do to determine your
emotional intelligence and identify at least three
strategies you could use to reduce any deficiencies.

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Foundation for
Leadership and
Ethics, Law, and


Ethical Issues
. . . When organizations go astray ethically, it is usually
due to a lack of ethical competence, not bad people.—
John Hooker

. . . All my growth and development led me to believe
that if you really do the right thing, and if you play by the
rules, and if you’ve got good enough, solid judgment
and common sense, that you’re going to be able to do
whatever you want to do with your life.—Barbara

. . . Ethics is knowing the difference between what you
have a right to do and what is right to do.—Potter


This chapter addresses:

BSN Essential II: Basic organizational and systems leadership
for quality care and patient safety

BSN Essential VIII: Professionalism and professional values
BSN Essential IX: Baccalaureate generalist nursing practice
MSN Essential II: Organizational and systems leadership
MSN Essential VI: Health policy and advocacy
MSN Essential IX: Master’s level nursing practice

AONL Nurse Executive Competency III: Leadership
AONL Nurse Executive Competency IV: Professionalism
ANA Standard of Professional Performance 7: Ethics
ANA Standard of Professional Performance 10:

ANA Standard of Professional Performance 11: Leadership
ANA Standard of Professional Performance 15: Professional
practice evaluation

QSEN Competency: Patient-centered care


The learner will:

define ethics and ethical dilemmas
compare and contrast the utilitarian, duty-based, rights-based,
and intuitionist frameworks for ethical decision making

identify and define nine different principles of ethical reasoning
use a systematic problem-solving or decision-making model to
determine appropriate action for select ethical problems

evaluate the quality of ethical problem solving in terms of both
outcome and the process used to make the decision

describe the limitations of using outcome as the sole criterion for
the evaluation of ethical decision making

distinguish between legal and ethical obligations in decision

identify strategies leader-managers can use to promote ethical
behavior as the norm

describe how differences in personal, organizational,
subordinate, and patient obligations increase the risk of
intrapersonal conflict in ethical decision making

demonstrate self-awareness regarding the ethical frameworks
and ethical principles that most strongly influence his or her
personal decision making

role model ethical decision making congruent with the American
Nurses Association (ANA) Code of Ethics for Nurses With
Interpretive Statements and current professional standards

Unit II examines ethical, legal, and legislative issues affecting
leadership and management as well as professional advocacy. This
chapter focuses on applied ethical decision making as a critical
leadership role for managers. Chapter 5 examines the impact of
legislation and the law on leadership and management, and Chapter
6 focuses on advocacy for patients and subordinates and for the
nursing profession in general.

Ethics is the systematic study of what a person’s conduct and
actions should be with regard to self, other human beings, and the
environment; it is the justification of what is right or good and the
study of what a person’s life and relationships should be, not
necessarily what they are. Ethics is a system of moral conduct and
principles that guide a person’s actions in regard to right and wrong
and in regard to oneself and society at large.

Ethics is concerned with doing the right thing, although it
is not always clear what that is.

Applied ethics requires application of normative ethical theory to
everyday problems. The normative ethical theory for each profession
arises from the purpose of the profession. The values and norms of
the nursing profession, therefore, provide the foundation and filter
from which ethical decisions are made. The nurse-manager,

however, has a different ethical responsibility than the clinical nurse
and does not have as clearly defined a foundation to use as a base
for ethical reasoning.

In addition, because management is a discipline and not a
profession, its purpose is not as clearly defined as medicine or law;
therefore, the norms that guide ethical decision making are less
clear. Instead, the organization reflects norms and values to the
manager, and the personal values of managers are reflected through
the organization. The manager’s ethical obligation is tied to the
organization’s purpose, and the purpose of the organization is linked
to the function that it fills in society and the constraints society places
on it. So, the responsibilities of the nurse-manager emerge from a
complex set of interactions.

Society helps define the purposes of various institutions, and the
purposes, in turn, help ensure that the institution fulfills specific
functions. However, the specific values and norms in any institution
determine the focus of its resources and shape its organizational life.
The values of people within institutions influence actual management
practice. In reviewing this set of complex interactions, it becomes
evident that arriving at appropriate ethical management decisions
can be a difficult task.

In addition, nursing management ethics are distinct from clinical
nursing ethics. Although significant research exists regarding ethical
dilemmas and moral distress experienced by staff nurses in clinical
roles, less research exists regarding the ethical distress experienced
by nursing managers.

Nursing management ethics are also distinct from other areas of
management. Although there are many similar areas of responsibility
between nurse-managers and non–nurse-managers, many
leadership roles and management functions are specific to nursing.
These differences require the nurse-manager to deal with unique
obligations and ethical dilemmas that are not encountered in
nonnursing management.

In addition, because personal, organizational, subordinate, and
consumer responsibilities differ, there is great potential for nursing
managers to experience intrapersonal conflict about the appropriate
course of action. Multiple advocacy roles and accountability to the
profession further increase the likelihood that all nurse-managers will
be faced with ethical dilemmas in their practice. Nurses often find
themselves viewed simultaneously as advocates for physicians,
patients, and the organization—all of whose needs and goals may
be dissimilar.

Nurses are often placed in situations where they are
expected to be agents for patients, physicians, and the
organization simultaneously, all of which may have
conflicting needs, wants, and goals.

To make appropriate ethical decisions then, the manager must
have knowledge of ethical principles and frameworks, use a
professional approach that eliminates trial and error and focuses on
proven decision-making models, and use available organizational
processes to assist in making such decisions. Such organizational
processes include institutional review boards (IRBs), ethics
committees, and professional codes of ethics. Using both a
systematic approach and proven ethical tools and technology allows
managers to make better decisions and increases the probability that
they will feel confident about the decisions they have made.
Leadership roles and management functions associated with ethics
are shown in Display 4.1.


Leadership Roles
1. Is self-aware regarding own values and basic beliefs about

the rights, duties, and goals of human beings
2. Accepts that some ambiguity and uncertainty must be a part

of all ethical decision making
3. Accepts that negative outcomes occur in ethical decision

making despite high-quality problem solving and decision

4. Demonstrates risk taking in ethical decision making
5. Role models ethical decision making, which is congruent with

the American Nurses Association (ANA) Code of Ethics for
Nurses With Interpretive Statements (ANA, 2015), the ANA
Nursing Administration: Scope and Standards of Practice
(2016), and professional standards

6. Clearly communicates expected ethical standards of behavior
7. Role models behavior that eliminates theory–practice–ethics

gaps and promotes ethical behavior as the norm
8. Promotes patients’ self-determination and informed decision

9. Collaborates with others to protect human rights and promote

social justice
10. Assures that nurses are represented on interprofessional

teams addressing ethical risks, benefits, and outcomes

Management Functions
1. Uses a systematic approach to problem solving and decision

making when faced with management problems with ethical

2. Identifies outcomes in ethical decision making that should
always be sought or avoided

3. Uses established ethical frameworks to clarify values and

4. Applies principles of ethical reasoning to define what beliefs
or values form the basis for decision making

5. Is aware of legal precedents that may guide ethical decision
making and is accountable for possible liabilities should they
go against the legal precedent

6. Continually reevaluates the quality of personal ethical
decision making based on the process of decision making or
problem solving used

7. Constantly assesses levels of moral uncertainty, moral
distress, and moral outrage in subordinates and intervenes as
necessary to protect quality patient care and worker’s well-

8. Establishes systems whereby ethical issues impacting
stakeholders (health-care consumers, workers, community,
etc.) can be addressed and resolved

9. Recognizes and rewards ethical conduct of subordinates
10. Takes appropriate action when subordinates demonstrate

unethical conduct

Moral Issues Faced by Nurses
Despite 2017 Gallup poll findings that show Americans have ranked
nursing as the most honest ethical profession for the 16th
consecutive year (Jimenez, 2018), ethical issues are commonplace
in nursing. Peter (2018) agrees, noting that “nurses’ moral lives are
growing in complexity given rapid changes that are the result of
scientific advances, a growing business ethos, and technological
processes aimed at standardizing patient care. At times, nurses
believe that they cannot respond adequately to the ethical issues
that they encounter because of their enormity and nurses’

responsibility to continue to care for patients despite the obstacles”
(para. 1).

There are many terms used to describe these moral issues
including moral indifference, moral uncertainty, moral conflict, moral
distress, moral outrage, and ethical dilemmas. Moral indifference
occurs when an individual questions why morality in practice is even
necessary. Moral uncertainty or moral conflict occurs when an
individual is unsure which moral principles or values apply and may
even include uncertainty as to what the moral problem is.

On the other hand, moral distress occurs when the individual
knows the right thing to do, but organizational constraints make it
difficult to take the right course of action. Thus, morally distressed
nurses often demonstrate biological, emotional, and moral stress
because of this intrapersonal conflict (Edmonson, 2015). Indeed,
morally distressed nurses often experience anger, loneliness,
depression, guilt, powerlessness, anxiety, and even emotional
withdrawal. This then leads to turnover as the nurse leaves the
stressful situation for a less stressful environment (Edmonson,
2015). Barlem and Ramos (2015) suggest that moral distress is one
of the main ethical problems affecting nurses in all health systems
and thus is a threat to nurses’ integrity and to the very essence of
quality of patient care.

Moral outrage occurs when an individual witnesses the immoral
act of another but feels powerless to stop it. Lastly, the most difficult
of all moral issues is termed a moral or ethical dilemma, which is
being forced to choose between two or more undesirable
alternatives. For example, a nurse might experience a moral or
ethical dilemma if he or she was required to provide care or
treatments that conflicted with his or her own religious beliefs. In this
case, the nurse would likely experience an intrapersonal moral
conflict about whether his or her values, needs, and wants can or
should supersede those of the patient. Because ethical dilemmas

are so difficult to resolve, many of the learning exercises in this
chapter are devoted to addressing this type of moral issue.

Individual values, beliefs, and personal philosophy play a
major role in the moral or ethical decision making that is
part of the daily routine of all nurses as well as managers.

How do managers decide what is right and what is wrong? What
does the manager do if no right or wrong answer exists? What if all
solutions generated seem to be wrong? Remember that the way
managers approach and solve ethical issues is influenced by their
values and basic beliefs about the rights, duties, and goals of all
human beings. Self-awareness, then, is a vital leadership role in
ethical decision making, just as it is in so many other aspects of

No rules, guidelines, or theories exist that cover all aspects of the
ethical problems that managers face. However, it is the manager’s
responsibility to understand the ethical problem-solving process, to
be familiar with ethical frameworks and principles, and to know
ethical professional codes and standards. It is these tools that will
assist managers in effective problem solving and prevent ethical
failure within their organization. Critical thinking occurs when
managers are able to engage in an orderly process of ethical
problem solving to determine the rightness or wrongness of different
courses of action.

Ethical Frameworks for Decision Making
Ethical frameworks guide individuals in solving ethical dilemmas.
These frameworks do not solve the ethical problem but assist the
manager in clarifying personal values and beliefs. Four of the most
commonly used ethical frameworks are utilitarianism, duty-based
reasoning, rights-based reasoning, and intuitionism (Table 4.1).


Framework Basic Premise


Provide the greatest good for the greatest
number of people.

Rights based

Individuals have basic inherent rights that
should not be interfered with.

Duty based

A duty to do something or to refrain from
doing something


Each case is weighed on a case-by-case
basis to determine relative goals, duties, and

Ethical frameworks do not solve ethical problems, but
they do assist decision makers in clarifying personal
values and beliefs.

The teleological theory of ethics is also called utilitarianism or
consequentialist theory. Using an ethical framework of utilitarianism
encourages decision making based on what provides the greatest
good for the greatest number of people. In doing so, the needs and
wants of the individual are diminished. Utilitarianism also suggests
that the end can justify the means. For example, a manager using a
utilitarian approach might decide to use travel budget money to send
many staff to local workshops rather than to fund one or two people
to attend a national conference. Another example would be an
insurance program that meets the needs of many but refuses
coverage for expensive organ transplants. As illustrated in Learning
Exercise 4.6, the organization uses utilitarianism to justify lying to
employee applicants because their hiring would result in good for
many employees by keeping several units in the hospital open.

Deontological ethical theory judges whether the action is right or
wrong regardless of the consequences and is based on the
philosophy of Immanuel Kant in the 18th century. Primarily, this
theory uses both duty-based reasoning and rights-based reasoning
as the basis for its philosophy. Duty-based reasoning is an ethical
framework stating that some decisions must be made because there
is a duty to do something or to refrain from doing something. In
Learning Exercise 4.5, the supervisor feels a duty to hire the most
qualified person for the job, even if the personal cost is high.

Rights-based reasoning is based on the belief that some things
are a person’s just due (i.e., each individual has basic claims, or
entitlements, with which there should be no interference). Rights are
different from needs, wants, or desires. The supervisor in Learning
Exercise 4.5 believes that both applicants have the right to fair and
impartial consideration of their application. In Learning Exercise 4.6,
Sam believes that all people have the right to truth and, in fact, that
he has the duty to be truthful.

The intuitionist framework allows the decision maker to review
each ethical problem or issue on a case-by-case basis, comparing
the relative weights of goals, duties, and rights. This weighting is
determined primarily by intuition—what the decision maker believes
is right for that particular situation. Recently, some ethical theorists
have begun questioning the appropriateness of intuitionism as an
ethical decision-making framework because of the potential for
subjectivity and bias. Yet, many of the cases solved in this chapter
involve some degree of decision making by intuition.

Other more recent theories of ethical philosophy include ethical
relativism and ethical universalism. Ethical relativism suggests that
individuals make decisions based only on what seems right or
reasonable according to their value system or culture. Conversely,
universalism holds that ethical principles are universal and constant
and that ethical decision making should not vary as a result of
individual circumstances or cultural differences.

Principles of Ethical Reasoning
Both teleological and deontological theorists have developed a group
of moral principles that are used for ethical reasoning. These
principles of ethical reasoning further explore and define what beliefs
or values form the basis for decision making. Respect for people is
the most basic and universal ethical principle. The major ethical
principles stemming from this basic principle are discussed in
Display 4.2.


Autonomy: Promotes self-determination and freedom of choice
Beneficence: Actions are taken in an effort to promote good
Nonmaleficence: Actions are taken in an effort to avoid harm
Paternalism: One individual assumes the right to make decisions

for another
Utility: The good of the many outweighs the wants or needs of

the individual
Justice: Seeks fairness; treats “equals” equally and treats

“unequals” according to their differences
Veracity: Obligation to tell the truth
Fidelity: Need to keep promises
Confidentiality: Keeps privileged information private

Autonomy (Self-Determination)
A form of personal liberty, autonomy, is also called freedom of choice
or accepting the responsibility for one’s choice. Rosenberg (2019)
notes that autonomy means that patients are able to make
independent decisions. This means that nurses should be sure
patients have all the information they need to make a decision about
their medical care. Examples of nurses fostering patient autonomy

include obtaining informed consent from the patient for treatment,
accepting the situation when a patient refuses a medication, and
maintaining confidentiality.

The legal right of self-determination supports autonomy. For
example, progressive discipline recognizes the autonomy of the
employee. The employee has the choice to meet organizational
expectations or to be disciplined further. If the employee’s continued
behavior warrants termination, the principle of autonomy says that
the employee has made the choice to be terminated because of his
or her actions, not by that of the manager. Therefore, nurse-
managers must be cognizant of the ethical component present
whenever an individual’s decisional capacity is in question. To take
away a person’s right to self-determination is a serious but
sometimes necessary action.

Beneficence (Doing Good)
This principle states that the actions one takes should be done in an
effort to promote good. The concept of nonmaleficence, which is
associated with beneficence, says that if one cannot do good, then
one should at least do no harm. For example, if a manager uses this
ethical principle in planning performance appraisals, he or she is
much more likely to view the performance appraisal as a means of
promoting employee growth. Another example would be providing a
standard of care that avoids risk or minimizes it, as it relates to
medical competence (Rosenberg, 2019).

It is not always clear, however, if a nurse’s actions are beneficent
or maleficent. For example, Ganz, Sharfi, Kaufman, and Einav
(2018) point out that cardiopulmonary resuscitation is the default
procedure during cardiopulmonary arrest. If a patient does not want
cardiopulmonary resuscitation, then a “do-not-resuscitate” order
must be documented. Sometimes, this order is not given, even if
thought to be appropriate. This situation then can lead to a slow

code, defined as an ineffective resuscitation, where all resuscitation
procedures are not performed or done slowly (Ganz et al., 2018).
Some nurses perceive slow codes to be a beneficent ethical
alternative, but this is in contrast with most legal and ethical opinions
expressed in the literature (see Examining the Evidence 4.1).

Source: Ganz, F. D., Sharfi, R., Kaufman, N., & Einav,
S. (2018). Perceptions of slow codes by nurses
working on internal medicine wards. Nursing Ethics.
Advance online publication.

Are “Slow Codes” Ethical?
In some health-care institutions, slow codes
(ineffective resuscitation) are used when a do-
not-resuscitate order is not available and
health-care providers perceive it to be more
ethical to have limited intervention (lifesaving
measures are not performed or done slowly)
than to fully attempt to resuscitate the patient.
This cross-sectional, descriptive study sought
to describe the perceptions of nurses working
on internal medicine wards that use slow
codes, including the factors associated with
their implementation.

Most nurses reported that resuscitations
were conducted according to protocol (n = 90;
76.2%). Some took their time calling the code
(n = 22; 18.3%) or waited by the bedside and
did not perform cardiopulmonary resuscitation
(n = 45; 37.5%). Factors most often associated
with slow codes were poor patient prognosis
(mean = 3.52/5) and a low chance of patient
survival (mean = 3.37/5). Two thirds (n = 76;
66.8%) reported that slow codes were done on
their unit, and the majority (n = 80; 69%)
perceived slow codes as ethical. The
researchers concluded that nurses should be

educated about the legal and ethical
implications of slow codes, and qualitative and
quantitative studies should be conducted to
further investigate their implementation.

This principle is related to beneficence in that one person assumes
the authority to decide for another. In clinical nursing, care providers
may become paternalistic when they believe the patient’s judgment
is impaired or that they have knowledge the patient does not have.
Because paternalism limits freedom of choice, however, most ethical
theorists believe that paternalism is justified only to prevent a person
from coming to harm.

Unfortunately, paternalism is present in nursing management as
well as clinical decision making. For example, some managers use
the principle of paternalism in subordinates’ career planning. In doing
so, managers assume that they have greater knowledge of what an
employee’s short- and long-term goals should be than the employee

The most fundamental universal principle is respect for

This principle reflects a belief in utilitarianism—what is best for the
common good outweighs what is best for the individual. Utility
justifies paternalism as a means of restricting individual freedom.
Managers who use the principle of utility need to be careful not to
become so focused on desired group outcomes that they become
less humanistic.

Justice (Treating People Fairly)
This principle states that equals should be treated equally and that
unequals should be treated according to their differences. For
example, Haden (2017) suggests that if two people have the same
relative position in an organization and the same level of
responsibility, then justice is treating them the same in terms of
resources, expectations, rewards, and other factors necessary for
them to succeed. However, if one person has significantly different
responsibilities than another—that is, they are unequal—then the
just leader must treat them as unequals.

Haden (2017) also argues that justice is giving each person his or
her due. From this perspective, justice is defined by the leader’s
responsibility to give each follower what rightfully belongs to him or
her; whether that right is determined by nature or by contract.

The principle of justice is frequently applied when there are
scarcities or competition for resources or benefits. The manager who
uses the principle of justice will work to see that pay raises reflect
consistency in terms of performance and time in service. Nurses
demonstrate this when making impartial medical decisions related to
limited resources or new treatments regardless of economic status,
ethnicity, sexual orientation, etc. (Rosenberg, 2019).


Are Some People More Equal Than

Research suggests that individuals with health
insurance in this country have better access to health-

care services and enjoy better health-care outcomes than
those who do not. This does not mean, however, that all
individuals with health insurance receive “equal
treatment.” Medicaid recipients (people who are
financially indigent) often complain that although they
have public insurance, many private providers refuse to
accept them as patients. Patients enrolled in managed
care suggest that their treatment options are more limited
than traditional private insurance because of the use of
gatekeepers, required authorizations, and queuing. Some
individuals, with lower cost insurance plans under the
Patient Protection and Affordable Care Act, suggest that
high out-of-pocket costs for copayments and deductibles
continue to restrict their choice to access needed care.


Using the ethical principle of justice, determine
whether health care in this country should be a right
or a privilege. Are the uninsured and the insured
“unequals” that should be treated according to their
differences? Does the type of health insurance that
one has also create a system of unequals? If so,
are the unequals being treated according to their

Veracity (Truth Telling)
This principle is used to explain how people feel about the need for
truth telling or the acceptability of deception. A manager who
believes that deception is morally acceptable if it is done with the
objective of beneficence may tell all rejected job applicants that they
were highly considered whether they had been or not.

Fidelity (Keeping Promises)
Fidelity refers to the moral obligation that individuals should be
faithful to their commitments and promises. Breaking a promise is
believed by many ethicists to be wrong regardless of the
consequences. In other words, even if there were no far-reaching
negative results of the broken promise, it is still wrong because it
would render the making of any promise meaningless. However,
there are times when keeping a promise (fidelity) may not be in the
best interest of the other party, as discussed under “Confidentiality
(Respecting Privileged Information)” section. Although nurses have
multiple fidelity duties (patient, physician, organization, profession,
and self) that at times may be in conflict, the American Nurses
Association (ANA) Code of Ethics for Nurses With Interpretive
Statements is clear that the nurse’s primary commitment is to the
patient (ANA, 2015).

Confidentiality (Respecting Privileged
The obligation to observe the privacy of another and to hold certain
information in strict confidence is a basic ethical principle and a
foundation of both medical and nursing ethics. However, as in
deception, there are times when the presumption against disclosing
information must be overridden. For example, health-care managers
are required by law to report certain cases, such as drug abuse in
employees, elder abuse, and child abuse.


Weighing Veracity and Nonmaleficence

You are a second-year nursing student. During the first
year of the nursing program, you formed a close
friendship with Susan, another nursing student, and the
two of you spend many of your free evenings and
weekends together doing fun things. The only thing that
drives you a bit crazy about your friend is that she is
incredibly messy. When you go to her home, you usually
see dirty dishes piled in the sink, dog hair over all the
furniture, clothing strewn all over the apartment, and
uneaten pizza or other half spoiled food sitting on the
floor. You attempt to limit your time at her apartment
because it is so bothersome to you, so it has not been a
factor in your friendship.

Today, when Susan and you are sitting at the dining
table in your apartment, your current roommate tells you
that she is unexpectedly vacating her lease at the end of
the month. Susan becomes excited and shares that her
lease will end at the end of this month as well and
suggests how much fun it would be if the two of you could
move in together. She immediately begins talking about
when she could move in, where she would locate her
furniture in the apartment, and where her dog might stay
when the two of you are in clinical. Although you value
Susan’s friendship and really enjoy the time you spend
together, the idea of living with someone as untidy as
Susan is not something you want to do. Unfortunately,
your current lease does not preclude pets or subleases.


Decide how you will respond to Susan. Will you tell
her the truth? Are your values regarding veracity
stronger or weaker than your desire to cause no
harm to Susan’s feelings (nonmaleficence)?


Family Values

You are the evening shift charge nurse of the
postanesthesia care unit (PACU). You have just admitted
a 32-year-old woman who, 2 hours ago, was thrown from
a Jeep in which she was a passenger. She was rushed to
the emergency department and subsequently to surgery,
where cranial burr holes were placed and an intracranial
monitor was inserted. No further cranial exploration was
attempted because the patient sustained extensive and
massive neurologic damage. She will probably not
survive your shift. The plan is to hold her in the PACU for
1 hour and, if she is still alive, transfer her to the intensive
care unit.

Shortly after receiving the patient, you are approached
by the evening house supervisor, who says that the
patient’s sister is pleading to be allowed into the PACU.
Normally, visitors are not allowed into the PACU when
patients are being held there only temporarily, but
occasionally, exceptions are made. Tonight, the PACU is
empty except for this patient. You decide to bend the
rules and allow the young woman’s sister to come in. The

visiting sister is near collapse; it is obvious that she had
been the driver of the Jeep. As the visitor continues to
speak to the comatose patient, her behavior and words
make you begin to wonder if she is indeed the sister.

Within 15 minutes, the house supervisor returns and
states, “I have made a terrible mistake. The patient’s
family just arrived, and they say that the visitor we just
allowed into the PACU is not a member of the family but
is the patient’s girlfriend. They are very angry and
demand that this woman not be allowed to see the

You approach the visitor and confront her in a kindly
manner regarding the information that you have just
received. She looks at you with tears streaming down her
face and says, “Yes, it is true. Mary and I have been
together for 6 years. Her family disowned her because of
it, but we were everything to each other. She has been
my life, and I have been hers. Please, please let me stay.
I will never see her again. I know the family will not allow
me to attend the funeral. I need to say my goodbyes.
Please let me stay. It is not fair that they have the legal
right to be family when I have been the one to love and
care for Mary.”


1. Review the ANA (2018) Position Statement—
Nursing Advocacy for LGBTQ+ Populations
available at

2. Decide what you will do. Recognize that your
own value system will play a part in your
decision. List several alternatives that are
available to you. Identify which ethical
frameworks or principles most affected your
decision making.

Codes of Ethics and Professional Standards
Professional ethics relates to the values held by a profession. A
professional code of ethics then is a set of principles, established by
a profession, to guide the individual practitioner. The first Code of
Ethics for Nurses was adopted by the ANA in 1950 and has been
revised 6 times since then, most recently in 2015. This code outlines
the important general values, duties, and responsibilities that flow
from the specific role of being a nurse. Although not legally binding,
the code functions as a guide to the highest ethical practice
standards for nurses and as an aid for moral thinking.

The ANA (2015) Code of Ethics for Nurses With Interpretive
Statements has nine statements. The professional issues in the first
three statements are concerned with protection of clients’ rights and
safety; those in the next three pertain to promoting healthy work
cultures and self-care. The social issues of the last three statements
of the code relates to the nurse’s obligations to society and the
profession (Display 4.3).


1. The nurse practices with compassion and respect for the
inherent dignity, worth, and unique attributes of every person.

2. The nurse’s primary commitment is to the patient, whether an
individual, family, group, community, or population.

3. The nurse promotes, advocates for, and protects the rights,
health, and safety of the patient.

4. The nurse has the authority, accountability, and responsibility
for nursing practice; makes decisions; and takes action
consistent with the obligation to promote health and to provide
optimal care.

5. The nurse owes the same duties to self as to others, including
the responsibility to promote health and safety, preserve
wholeness of character and integrity, maintain competence,
and continue personal and professional growth.

6. The nurse, through individual and collective effort, establishes,
maintains, and improves the ethical environment of the work
setting and conditions of employment that are conducive to
safe, quality health care.

7. The nurse, in all roles and settings, advances the profession
through research and scholarly inquiry, professional standards
development, and the generation of both nursing and health

8. The nurse collaborates with other health professionals and the
public to protect human rights, promote health diplomacy, and
reduce health disparities.

9. The profession of nursing, collectively through its professional
organizations, must articulate nursing values, maintain the
integrity of the profession, and integrate principles of social
justice into nursing and health policy.

Source: American Nurses Association. (2015). Code of ethics for nurses with
interpretive statements. Silver Spring, MD: Author.

Regarding ethics, Provisions 5 and 6 focus on ethical issues
related to boundaries of duty and loyalty. Lachman, Swanson, and
Winland-Brown (2015) suggest that the language used in the revised
code makes these provisions more precise and the interpretive
statements supporting the provisions better organized, making them
easier to understand. Lachman et al. also note that Provisions 7 to 9
concentrate on the nurse’s ethical duties beyond individual patient
encounters and suggest that these provisions had the most
significant changes because they focus on the nurse’s obligation to
address social justice issues through direct action and involvement
in health policy as well as a responsibility to contribute to nursing
knowledge through scholarly inquiry and research.

Professional codes of ethics function as a guide to the
highest standards of ethical practice for nurses. They are
not legally binding.

Practitioners may also find ethical guidance in examining the
International Council of Nurses (ICN) Code of Ethics for Nurses,
which was revised most recently in 2012. It provides a guide for
action based on social values and needs and has served as the
standard for nurses worldwide since it was first adopted in 1953
(ICN, 2018).

Another document that may be helpful specifically to the nurse-
manager in creating and maintaining an ethical work environment is
Nursing Administration: Scope and Standards of Practice (ANA,
2016) published by the ANA. These standards specifically delineate
professional standards in management ethics, and these appear in
Display 4.4.


Standard 7. Ethics
The nurse administrator practices ethically.

1. Uses the Code of Ethics for Nurses With Interpretive

Statements (ANA, 2015) to guide leadership and practice
2. Advocates for compassionate systems of care delivery that

preserve and protect health-care consumer, family, and
employee’s dignity, rights, values, belief, and autonomy

3. Provides guidance in situations where the rights of the
individuals conflict with public health or health systems

4. Supports the primary commitment to the health-care
consumer and family regardless of setting

5. Protects health-care consumers’ and others’ privacy,
confidentiality, data, and information within ethical, legal, and
regulatory parameters

6. Promotes health-care consumers’ self-determination and
informed decision making through organizational culture
values and institutional policies

7. Collaborates with nursing and other employees to maintain
therapeutic and professional health-care consumer
relationships within appropriate professional role boundaries

8. Assures protection of the rights, health, and safety of the
health-care consumer, employees, and others

9. Promotes systems to address and resolve ethical issues
involving health-care consumers, colleagues, community
groups, systems, and other stakeholders

10. Collaborates with other health professionals and the public to
protect human rights, promote health diplomacy, enhance

cultural sensitivity and congruence, and reduce health

11. Holds nurses accountable and responsible for competent
nursing practice

12. Institutes effective action to address illegal, unethical,
discriminatory, or inappropriate behavior that can endanger or
jeopardize the best interests of the health-care consumer,
organization, or situation

13. Creates a safe environment for employees and others to
discuss health-care practices, which do not appear to be in
the best interests of the health-care consumer organization,
community, or situation

14. Empowers nurses to participate in interprofessional teams to
address ethical risks, benefits, and outcomes

15. Articulates nursing values to maintain individual nurses’
personal integrity and the integrity of the profession

16. Integrates principles of social justice into nursing and policy
17. Demonstrates commitment to self-reflection and self-care
18. Advocates for the establishment and maintenance of an

ethical environment that is conducive to safe, accessible,
equitable, and quality health care

Source: American Nurses Association. (2016). Nursing administration: Scope and
standards of practice (2nd ed.). Silver Spring, MD: Author.

Ethical Problem Solving and Decision Making
Hooker (2018) suggests solving ethical dilemmas is increasingly
difficult in a complex and fast-moving world. That’s because it
“requires careful analysis, not gut feeling or simplistic platitudes”
(Hooker, 2018, para. 3).

Some of the difficulty people have in making ethical decisions can
be attributed to a lack of formal education about problem solving.
Other individuals lack the thinking skills or risk taking needed to

solve complex ethical problems. Still, other nurses erroneously use
decision-making outcomes as the sole basis for determining the
quality of the decision making. Although decision makers should be
able to identify desirable and undesirable outcomes, outcomes alone
cannot be used to assess the quality of the problem solving.

Many variables affect outcome, and some of these are beyond the
control or foresight of the problem solver. In fact, even the most
ethical courses of action can have undesirable and unavoidable
consequences. Indeed, Ramos (2015) notes that care professionals
must recognize that many outcomes are the result of our practice
circumstance and should not be considered personal or professional
failures. In addition, Ramos argues that although caregivers can
“own” their feelings, they should not take personal responsibility for
the shortcomings of the systems they work in and the impossibilities
of practice. “Care givers can no more control every outcome than
anyone else working within the system” (Ramos, 2015, p. 1).

Thus, the quality of ethical problem solving should be evaluated in
terms of both outcome and the process used to make the decision.
The best possible decisions stem from structured problem solving,
adequate data collection, and examination of multiple alternatives—
even if outcomes are poor.

If a structured approach to problem solving is used, data
gathering is adequate, and multiple alternatives are
analyzed, even with a poor outcome, the nurse should
accept that the best possible decision was made at that
time with the information and resources available.

In addition, Mortell (2012) suggests that some decision making by
nurses reflects a theory–practice–ethics gap despite the moral
obligation, nurses have to ensure theory and practice are integrated.
For example, Mortell notes that noncompliance exists in hand

hygiene among practitioners despite ongoing infection prevention
education and training; easy access to facilities such as washbasins;
antiseptic/alcohol hand gels that are convenient, effective, and skin-
and user-friendly; and organizational recognition and support for
clinicians in handwashing and hand gel practices. Thus, despite
nurses having knowledge of best practices based on current
research, they continue to fail to achieve the required and desired
compliance in hand hygiene. Mortell concludes that more emphasis
should be placed on clinicians’ moral and ethical obligations as part
of training and orientation and that organizations must continue to
emphasize the duty of care toward patients in nurses’ decision


A Nagging Uneasiness

You are a nurse on a pediatric unit. One of your patients
is a 15-month-old girl with a diagnosis of failure to thrive.
The mother says that the child is emotional, cries a lot,
and does not like to be held. You have been taking care
of the child for 2 days since her admission, and she has
smiled and been receptive to being held by you. She has
also eaten well. There is something about the child’s
reaction to the mother’s boyfriend that bothers you. The
child appears to draw away from him when he visits. The
mother is very young and seems to be rather immature
but appears to care for the child.

This is the second hospital admission for this child.
Although you were not on duty for the first admission 6
weeks ago, you check the records and see that the child

was admitted with the same diagnosis. While you are on
duty today, the child’s father calls and asks about her
condition. He lives several hundred miles away and
requests that the child be hospitalized until the weekend
(it is Wednesday) so that he can “check things out.” He
tells you that he believes the child is mistreated. He says
he is also concerned about his ex-wife’s 4-year-old child
from another marriage and is attempting to gain custody
of that child in addition to his own child. From what little
the father said, you are aware that the divorce was bitter
and that the mother has full custody. Because of Health
Insurance Portability and Accountability Act, you tell the
father that you cannot provide any information about the

You talk with the physician at length. He says that after
the last hospitalization, he requested that the community
health agency and Child Protective Services call on the
family. Their subsequent report to him was that the 4-
year-old child appeared happy and well and that the 15-
month-old child appeared clean, although somewhat
underweight. There was no evidence to suggest child
abuse. However, the community health agency plans to
continue following the children. He says that the mother
has been good about keeping doctor appointments and
has kept the children’s immunizations up to date. The
pediatrician proceeds to write an order for discharge. He
says that although he also feels somewhat uneasy,
continued hospitalization is not justified, and Medicaid will
not pay for additional days. He also says that he will
follow up once again with Child Protective Services to
make another visit.

When the mother and her boyfriend come to take the
baby home, the baby clings to you and refuses to go to

the boyfriend. She also seems reluctant to go to the
mother. All during the discharge, you are extremely
uneasy. When you see the car drive away, you feel very

After returning to the unit, you talk with your supervisor,
who listens carefully and questions you at length. Finally,
she says, “It seems as if you have nothing concrete on
which to act and are only experiencing feelings. I think
you would be risking a lot of trouble for yourself and the
hospital if you acted rashly at this time. Accusing people
with no evidence and making them go through a
traumatic experience is something I would hesitate to do.”

You leave the supervisor’s office still troubled. She did
not tell you that you must do nothing, but you believe that
she would disapprove of further action on your part. The
doctor also felt strongly that there was no reason to do
more than was already being done. The child will be
followed by community health nurses. Perhaps, the ex-
husband was just trying to make trouble for his ex-wife
and her new boyfriend. You would certainly not want
anyone to have reported you or created problems
regarding your own children. You remember how often
your 5-year-old bruised himself when he was that age.
You go about your duties and try to shake off your feeling.
What should you do?


1. Solve the case in small groups by using the
traditional problem-solving process. Identify the
problem and several alternative solutions to
solve this ethical dilemma. What should you do
and why? What are the risks? How does your
value system play a part in your decision? Justify
your solution. After completing this assignment,
solve the second part of this assignment below.

2. Assume that this was a real case. Twenty-four
hours after the child’s discharge, she is
readmitted with critical head trauma. Police
reports indicate that the child suffered multiple
skull fractures after being thrown up against the
wall by her mother’s boyfriend. The child is not
expected to live. Does knowing the outcome
change how you would have solved the case?
Does the outcome influence how you feel about
the quality of your group’s problem solving?

Kearney and Penque (2012) provide another example of a theory–
practice–ethics gap in their suggestion that although nurses
recognize that checklists can reduce episodes of patient harm by
ensuring that procedures are being carried out appropriately, some
providers will indicate that an intervention has been undertaken
when it has not. This occurs because of the mantra “If it wasn’t
documented, it wasn’t done” and an increasing emphasis and
reliance on documentation that demands that “all boxes must be
ticked” to ensure complete care has been provided. Kearney and
Penque suggest then that checklists present a context for ethical
decision making in that when providers do not take ethics into
account, checklists could perpetuate rather than prevent unsafe
practices or errors.

The Traditional Problem-Solving Process
Although not recognized specifically as an ethical problem-solving
model, one of the oldest and most frequently used tools for problem
solving is the traditional problem-solving process. This process,
which is discussed in Chapter 1, consists of seven steps, with the
actual decision being made at step 5 (review the seven steps under
“Traditional Problem-Solving Process” section in Chapter 1).
Although many individuals use at least some of these steps in their
decision making, they frequently fail to generate an adequate
number of alternatives or to evaluate the results—two essential
steps in the process.

The Nursing Process
Another problem-solving model not specifically designed for ethical
analysis, but appropriate for it, is the nursing process. Most nurses
are aware of the nursing process and the cyclic nature of its
components of assessment, diagnosis, planning, implementation,
and evaluation (see Fig. 1.2 ). However, most nurses do not
recognize its use as a decision-making tool. The cyclic nature of the
process allows for feedback to occur at any step. It also allows the
cycle to repeat until adequate information is gathered to make a
decision. It does not, however, require clear problem identification.
Learning Exercise 4.5 shows how the nursing process might be used
as an ethical decision-making tool.


One Applicant Too Many

The reorganization of the public health agency has
resulted in the creation of a new position of community
health liaison. A job description has been written, and the
job opening has been posted. As the chief nursing
executive of this agency, it will be your responsibility to
select the best person for the position. Because you are
aware that all hiring decisions have some subjectivity,
you want to eliminate as much personal bias as possible.
Two people have applied for the position; one of them is
a close friend.


Assess: As the chief nursing executive, you have a
responsibility to make personnel decisions as
objectively as you can. This means that the hiring
decision should be based solely on which employee is
best qualified for the position. You do recognize,
however, that there may be a personal cost in terms of
the friendship.

Diagnose: You diagnose this problem as a potential
intrapersonal conflict between your obligation to your
friend and your obligation to your employer.

Plan: You must plan how you are going to collect your
data. The tools you have selected are applications,
resumés, references, and personal interviews.

Implement: Both applicants are contacted and asked to
submit resumés and three letters of reference from
recent employers. In addition, both are scheduled for
structured formal interviews with you and two of the
board members of the agency. Although the board
members will provide feedback, you have been
reserved the right to make the final hiring decision.

Evaluate: As a result of your plan, you have discovered
that both candidates meet the minimal job
requirements. One candidate, however, clearly has
higher level communication skills, and the other
candidate (your friend) has more experience in public
health and is more knowledgeable regarding the
resources in your community. Both employees have
complied with the request to submit resumés and
letters of reference; they are of similar quality.

Assess: Your assessment of the situation is that you
need more information to make the best possible
decision. You must assess whether strong
communication skills or public health experience and
familiarity with the community would be more valuable
in this position.

Plan: You plan how you can gather more information
about what the employee will be doing in this newly
created position.

Diagnose: If the job description is inadequate in
providing this information, it may be necessary to
gather information from other public health agencies
with a similar job classification.

Evaluate: You now believe that excellent communication
skills are essential for the job. The candidate who had
these skills has an acceptable level of public health
experience and seems motivated to learn more about
the community and its resources. This means that
your friend will not receive the job.

Assess: Now, you must assess whether a good decision
has been made.

Plan: You plan to evaluate your decision in 6 months,
basing your criteria on the established job description.

Implement: You are unable to implement your plan
because this employee resigns unexpectedly 4
months after she takes the position. Your friend is now
working in a similar capacity in another state. Although
you correspond infrequently, the relationship has
changed as a result of your decision.

Evaluate: Did you make a good decision? This decision
was based on a carefully thought-out process, which
included adequate data gathering and a weighing of
alternatives. Variables beyond your control resulted in
the employee’s resignation, and there was no
apparent reason for you to suspect that this would
happen. The decision to exclude or minimize personal
bias was a conscious one, and you were aware of the
possible ramifications of this choice. The decision
making appears to have been appropriate.

The Moral Decision-Making Model
Crisham (1985) developed a model for ethical decision making
incorporating the nursing process and principles of biomedical
ethics. This model is especially useful in clarifying ethical problems
that result from conflicting obligations. This model is represented by
the mnemonic MORAL as shown in Display 4.5.


Massage the dilemma: Collect data about the ethical problem and
who should be involved in the decision-making process.

Outline options: Identify alternatives and analyze the causes and
consequences of each.

Review criteria and resolve: Weigh the options against the values
of those involved in the decision. This may be done through a
weighting or grid.

Affirm position and act: Develop the implementation strategy.
Look back: Evaluate the decision making.

Source: Crisham, P. (1985). Moral: How can I do what’s right? Nursing
Management, 16(3), 42A–42N.

Learning Exercise 4.6 demonstrates the MORAL modeling in
solving an ethical issue.


Little White Lies

Sam is the nurse recruiter for a metropolitan hospital
that is experiencing an acute nursing shortage. He has
been told to do or say whatever is necessary to recruit
professional nurses so that the hospital will not have to
close several units. He also has been told that his
position will be eliminated if he does not produce a
substantial number of applicants in the nursing career
days to be held the following week. Sam loves his job
and is the sole provider for his family. Because many

organizations are experiencing severe personnel
shortages, the competition for employees is keen. After
his third career day without a single prospective
applicant, he begins to feel desperate. On the fourth and
final day, Sam begins making many promises to potential
applicants regarding shift preference, unit preference,
salary, and advancement that he is not sure he can keep.
At the end of the day, Sam has a lengthy list of interested
applicants but also feels a great deal of intrapersonal

Massage the Dilemma

In a desperate effort to save his job, Sam finds he has
taken action that has resulted in high intrapersonal value
conflict. Sam must choose between making promises he
likely cannot keep and losing his job. This has far-
reaching consequences for all involved. Sam has the
ultimate responsibility for knowing his values and acting
in a manner that is congruent with his value system. The
organization is, however, involved in the value conflict in
that its values and expectations conflict with those of
Sam. Sam and the organization have some type of
responsibility to these applicants, although the exact
nature of this responsibility is one of the values in conflict.
Because this is Sam’s problem and an intrapersonal
conflict, he must decide the appropriate course of action.
His primary role is to examine his values and act in

Outline Options

Option 1. Quit his job immediately. This would prevent
future intrapersonal conflict, provided that Sam becomes
aware of his value system and behaves in a manner
consistent with that value system in the future. It does
not, however, solve the immediate conflict about the
action Sam has already taken. This action takes away
Sam’s livelihood.

Option 2. Do nothing. Sam could choose not to be
accountable for his own actions. This will require Sam to
rationalize that the philosophy of the organization is in
fact acceptable or that he has no choice regarding his
actions. Thus, the responsibility for meeting the needs
and wants of the new employees is shifted to the
organization. Although Sam will have no credibility with
the new employees, there will be only a negligible impact
on his ability to recruit at least on a short-term basis. Sam
will continue to have a job and be able to support his

Option 3. If after value clarification, Sam has
determined that his values conflict with the organization’s
directive to do or say whatever is needed to recruit
employees, he could approach his superior and share
these concerns. Sam should be very clear about what his
values are and to what extent he is willing to compromise
them. He also should include in this meeting what, if any,
action should be taken to meet the needs of the new
employees. Sam must be realistic about the time and
effort usually required to change the values and beliefs of
an organization. He also must be aware of his bottom line
if the organization is not willing to provide a compromise

Option 4. Sam could contact each of the applicants and
tell them that certain recruitment promises may not be
possible. However, he will do what he can to see that the
promises are fulfilled. This alternative is risky. The
applicants will probably be justifiably suspicious of both
the recruiter and the organization, and Sam has little
formal power at this point to fulfill their requests. This
alternative also requires a time and energy commitment
by Sam and does not prevent the problem from recurring.

Review the Options

In value clarification, Sam discovered that he valued
truth telling. Alternative 3 allows Sam to present a
recruiting plan to his supervisor that includes a bottom
line that this value will not be violated.

Affirm Position and Act

Sam approached his superior and was told that his
beliefs were idealistic and inappropriate in an age of
severe worker shortages. Sam was terminated. Sam did,
however, believe that he made an appropriate decision.
He did become self-aware regarding his values and
attempted to communicate these values to the
organization in an effort to work out a mutually agreeable

Look Back

Although Sam was terminated, he knew that he could
find some type of employment to meet his immediate
fiscal needs. He did become self-aware regarding his

values and used what he had learned in this decision-
making process, in that he planned to evaluate more
carefully the recruitment philosophy of the organization in
relation to his own value system before accepting another

Working Toward Ethical Behavior as the Norm
The concerns about ethical conduct in American institutions are
documented by many news articles in the national press. Many
individuals believe that organizational and institutional ethical failure
has become the norm. Governmental agencies, both branches of
Congress, the stock exchange, oil companies, and savings and loan
institutions have all experienced problems with unethical conduct.
Many members of society wonder what has gone wrong.

Gallagher and Jago (2018) argue that at times, individual ethical
misconduct is excused because of aggravating factors in the
organization. They suggest, however, that the role of individual
responsibility in unethical actions and omissions should not be
downplayed. Nursing practice is challenging, but the privilege of
licensure should compel nurses to behave in an ethical manner.
Nurse-managers, then, have a responsibility to create a climate in
their organizations in which ethical behavior is not only the
expectation but also the norm.

In an era of markedly limited physical, human, and fiscal
resources, nearly all decision making by nurse-managers will involve
some ethical component. Indeed, the following forces ensure that
ethics will become an even greater dimension in management
decision making in the future: increasing technology, regulatory
pressures, and competitiveness among health-care providers;
workforce shortages; an imperative to provide better care at less
cost; spiraling costs of supplies and salaries; and the public’s
increasing distrust of the health-care delivery system and its

institutions. The following actions, as shown in Display 4.6, can help
the manager in ethical problem solving.


1. Separate legal and ethical issues.
2. Collaborate through ethics committees.
3. Use institutional review boards appropriately.
4. Foster an ethical work environment.

Separate Legal and Ethical Issues
Although they are not the same, separating legal and ethical issues
is sometimes difficult. Legal controls are generally clear and
philosophically impartial; ethical controls are much less clear and
individualized. In many ethical issues, courts have made a decision
that may guide managers in their decision making. Often, however,
these guidelines are not comprehensive, or they differ from the
manager’s own philosophy. Managers must be aware of established
legal standards and cognizant of possible liabilities and
consequences for actions that go against the legal precedent.

In general, legal controls are clearer and philosophically
impartial; ethical controls are much less clear and

Legal precedents are frequently overturned later and often do not
keep pace with the changing needs of society. In addition, certain
circumstances may favor an illegal course of action as the “right”
thing to do. If a man were transporting his severely ill wife to the

hospital, it might be morally correct for him to disobey traffic laws.
Therefore, the manager should think of the law as a basic standard
of conduct, whereas ethical behavior requires a greater examination
of the issues involved.

The manager may confront several particularly sensitive legal–
ethical issues, including termination or refusal of treatment, durable
power of attorney, abortion, sterilization, child abuse, and human
experimentation. Most health-care organizations have legal counsel
to assist managers in making decisions in such sensitive areas.
Because legal aspects of management decision making are so
important, Chapter 5 is devoted exclusively to this topic.

Collaborate Through Interprofessional Ethics
The new manager must consult with others when solving sensitive
legal–ethical questions because a person’s own value system may
preclude examining all possible alternatives. Many institutions have
ethics committees to assist with problem solving in ethical issues.
These ethics committees typically are interprofessional and are
organized to consciously and reflectively consider significant and
often difficult or ambiguous value issues related to patient care or
organizational activities. Ethics committees are a core element of
collaborative ethical decision making and should include
representatives of all stakeholders, including patients when they are
involved in the ethical issue.

Use Institutional Review Boards Appropriately
IRBs are primarily formed to protect the rights and welfare of
research subjects. They provide oversight to ensure that individuals
conducting research adhere to ethical principles that were articulated
by the National Commission for the Protection of Human Subjects of

Biomedical and Behavioral Research. The primary role of the
manager regarding IRBs is to make sure that such a board is in
place in the organization where the manager works and that any
research performed within his or her sphere of responsibility has
been approved by such a board.

Foster an Ethical Work Environment
Perhaps the most important thing a leader-manager can do to foster
an ethical work environment, however, is to role model ethical
behavior. Likewise, working as a team with a standard for behavior
can promote a positive ethical climate. Other important interventions
include encouraging staff to openly discuss ethical issues that they
face daily in their practice. This allows subordinates to gain greater
perspective on complex issues and provides a mechanism for peer

Integrating Leadership Roles and Management
Functions in Ethics
Leadership roles in ethics focus on the human element involved in
ethical decision making. Leaders are self-aware regarding their
values and basic beliefs about the rights, duties, and goals of human
beings. As self-aware and ethical people, they role model confidence
in their decision making to subordinates. They also are realists and
recognize that some ambiguity and uncertainty must be a part of all
ethical decision making. Leaders are willing to take risks in their
decision making despite the fact that negative outcomes can occur
even with quality decision making.

In ethical issues, the manager is often the decision maker.
Because ethical decisions are so complex, and the cost of a poor
decision may be high, management functions focus on increasing
the chances that the best possible decision will be made at the least

possible cost in terms of fiscal and human resources. This usually
requires that the manager becomes expert at using systematic
approaches to problem solving or decision making, such as
theoretical models, ethical frameworks, and ethical principles. By
developing expertise, the manager can identify universal outcomes
that should be sought or avoided.

The integrated leader-manager recognizes that ethical issues
pervade every aspect of leadership and management. Rather than
being paralyzed by the complexity and ambiguity of these issues, the
leader-manager seeks counsel as needed, accepts his or her
limitations, and makes the best possible decision at that time with
the information and resources available.

Edmonson (2015) concludes that organizations and health-care
systems today need moral leadership and that the influence of
morally courageous nurses, regardless of position, will be critically
needed to transform health-care and care systems to safeguard
patients. “As nurse leaders in the healthcare system and in specific
facilities, we need to demonstrate moral courage and create
environments that promote morally courageous acts so as to keep
us centered on the very thing that drew us into healthcare, namely
the patient, the families, and the communities we serve” (Edmonson,
2015, Conclusion section, para. 1). Barlem and Ramos (2015)
concur, arguing that “instead of questioning the reason nurses
experience moral distress according to certain situations and
contexts, it is more important to question the reasons why nursing
professionals allow themselves to accept certain contexts as
unchangeable or natural, renouncing the possibility to ethically resist
situations that bring about moral distress” (p. 613).

Key Concepts

■ Ethics is the systematic study of what a person’s conduct and
actions should be with regard to self, other human beings,
and the environment; it is the justification of what is right or
good and the study of what a person’s life and relationships
should be—not necessarily what they are.

■ In an era of markedly limited physical, human, and fiscal
resources, nearly all decision making by nurse-managers
involves some ethical component. Multiple advocacy roles
and accountability to the profession further increase the
likelihood that managers will be faced with ethical dilemmas
in their practice.

■ Many systematic approaches to ethical problem solving are
appropriate. These include the use of theoretical problem-
solving and decision-making models, ethical frameworks, and
ethical principles.

■ Outcomes should never be used as the sole criterion for
assessing the quality of ethical problem solving because
many variables affect outcomes that have no reflection on
whether the problem solving was appropriate. Quality,
instead, should be evaluated both by the outcome and by the
process used to make the decision.

■ If a structured approach to problem solving is used, data
gathering is adequate, and multiple alternatives are analyzed,
regardless of the outcome, the manager should feel
comfortable that the best possible decision was made at that
time with the information and resources available.

■ Four of the most commonly used ethical frameworks for
decision making are utilitarianism, duty-based reasoning,
rights-based reasoning, and intuitionism. These frameworks
do not solve the ethical problem but assist individuals

involved in the problem solving to clarify their values and

■ Principles of ethical reasoning explore and define what
beliefs or values form the basis for our decision making.
These principles include autonomy, beneficence,
nonmaleficence, paternalism, utility, justice, fidelity, veracity,
and confidentiality.

■ Professional codes of ethics and standards for practice are
guides to the highest standards of ethical practice for nurses.

■ Sometimes, it is very difficult to separate legal and ethical
issues, although they are not the same. Legal controls are
generally clear and philosophically impartial. Ethical controls
are much more unclear and individualized.

Additional Learning Exercises and Applications


Everything Is Not What It Seems

You are a perinatal unit coordinator at a large teaching
hospital. In addition to your management responsibilities,
you have been asked to fill in as a member of the hospital
promotion committee, which reviews petitions from
clinicians for a step-level promotion on the clinical
specialist ladder. You believe that you could learn a great
deal on this committee and could be an objective and
contributing member.

The committee has been convened to select the
annual winner of the Outstanding Clinical Specialist
Award. In reviewing the applicant files, you find that one
file from a perinatal clinical specialist contains many
overstatements and several misrepresentations. You
know for a fact that this clinician did not accomplish all
that she has listed because she is a friend and close
colleague. She did not, however, know that you would be
a member of this committee and thus would be aware of
this deception.

When the entire committee met, several members
commented on this clinician’s impressive file. Although
you were able to dissuade them covertly from further
considering her nomination, you are left with many
uneasy feelings and some anger and sadness. You
recognize that she did not receive the nomination, and
thus, there is little real danger regarding the deceptions in
the file being used inappropriately at this time. However,
you will not be on this committee next year, and if she
were to submit an erroneous file again, she could be
highly considered for the award. You also recognize that
even with the best of intentions and the most therapeutic
of communication techniques, confronting your friend with
her deception will cause her to lose face and will probably
result in an unsalvageable friendship. Even if you do
confront her, there is little you can do to stop her from
doing the same in future nomination processes other than
formally reporting her conduct.


Determine what you will do. Do the potential costs
outweigh the potential benefits? Be realistic about
your actions.


The Valuable Employee

Gina has been the supervisor of a 16-bed intensive
care unit (ICU)/critical care unit (CCU) in a 200-bed urban
hospital for 8 years. She is respected and well liked by
her staff. Her unit’s staff retention level and productivity
are higher than any other unit in the hospital. For the last
6 years, Gina has relied heavily on Mark, her permanent
charge nurse on the day shift. He is bright and motivated
and has excellent clinical and managerial skills. Mark
seems satisfied and challenged in his current position,
although Gina has not had any formal career planning
meetings with him to discuss his long-term career goals.
It would be fair to say that Mark’s work has greatly
increased Gina’s scope of power and has enhanced the
reputation of the unit.

Recently, one of the physicians approached Gina about
a plan to open an outpatient cardiac rehabilitation
program. The program will require a strong leader and
manager who is self-motivated. It will not only be a lot of
work but will also provide many opportunities for
advancement. The physician suggests that Mark would

be an excellent choice for the job, although the physician
has given Gina full authority to make the final decision.

Gina is aware that Lynn, a bright and dynamic staff
nurse from the open-heart surgery floor, also would be
very interested in the job. Lynn has been employed at the
hospital for only 1 year but has a proven track record and
would probably be very successful in the job. In addition,
there is a staffing surplus right now on the open-heart
surgery floor because two of the surgeons have recently
retired. It would be difficult and time-consuming to
replace Mark as charge nurse in the ICU/CCU.


What process should this supervisor pursue to
determine who should be hired for the position?
Should the position be posted? When does the
benefit of using transfers/promotions as a means of
reward outweigh the cost of reduced productivity?


To See or Not to See

For the last few days, you have been taking care of Mr.
Cole, a 28-year-old patient with end-stage cystic fibrosis.
You have developed a caring relationship with Mr. Cole
and his wife. They are both aware of the prognosis of his

disease and realize that he has only a short time left to

When Dr. Jones made rounds with you this morning,
she told the Coles that Mr. Cole could be discharged
today if his condition remains stable. They were both
excited about the news because they had been urging
the doctor to let him go home to enjoy his remaining time
surrounded by the people he loves.

When you bring in Mr. Cole’s discharge orders to his
room to review his medications and other treatments, you
find Mrs. Cole assisting Mr. Cole as he coughs up bright
red blood. When you confront them, they both beg you
not to tell the doctor or chart the incident because they do
not want their discharge to be delayed. They believe that
it is their right to go home and let Mr. Cole die surrounded
by his family. They said that they know that they can
leave against their physician’s wishes and go home
against medical advice, but if they do, their insurance will
not pay for home care.


What is your duty in this case? What are Mr. Cole’s
rights? Is it ever justified to withhold information
from the physician? Will you chart the incident, and
will you report it to anyone? Solve this case,
justifying your decision by using ethical principles.


The Untruthful Employee (Marquis &
Huston, 2012)

You are the registered nurse on duty at a skilled nursing
facility. Judy, a 35-year-old, full-time nurse’s aide on the
day shift, has been with the skilled nursing facility for 10
years. You have worked with Judy on numerous
occasions and have found her work to be marginal at
best. She tries to be extra friendly with the staff and
occasionally brings them small treats that she bakes. She
also makes a point of telling everyone how much she
needs this job to support her family and how she loves
working here. She has a disabled daughter who relies on
her hospital-provided health insurance to have her
health-care needs met.

Most of the other staff seem willing to put up with
Judy’s poor work habits, but lately, you have felt that her
work has shown many serious errors. Things are not
reported to you that should have been—intake and output

volumes that are in error, strange recordings for vital
signs, and so on. She has tried to cover up such errors,
with what you suspect are outright lies. She claims to
have bathed patients when this does not appear to be the
case, and has said some patients have refused to eat
when you have found that they were willing to eat for you.
Although the chief nursing officer acknowledges that Judy
is only a marginally adequate employee, she has been
unable to observe directly any of the behaviors that would
require disciplinary action and has told you that you must
have real evidence of her wrongdoing in order to for her
to take action.

During morning report, you made a specific request to
Judy that a confused patient, Mr. Brown, assigned to her,
be assisted to the bathroom, and you told her that
someone must remain in the room to assist him when he
is up, as he fell last evening. You also told Judy that when
in bed, Mr. Brown’s side rails were always to be up. Later
in the morning, you take Mr. Brown his medication and
notice that his side rails are down and after pulling them
up and giving him his medicine, you find Judy and talk
with her. She denies leaving the side rails down and
insisted someone else must have done it. You caution her
again about Mr. Brown’s needs. Thirty minutes later, you
go by Mr. Brown’s room and find his bed empty and
discover he is in the bathroom unattended. As you are
assisting Mr. Brown back to bed, Judy bursts into the
room and pales when she sees you with her patient. At
first, she denies that she had gotten Mr. Brown up, but
when you express your disbelief, she tearfully admits that
she left him unattended but stated that this was an
isolated incident and asked you to forget it. When you
said that it was her lying about the incident that most

disturbed you, she promised never to lie about anything
again. She begged you not to report her to the chief
nursing officer and said she needed her job.

You are torn between wanting to report Judy for her
lying because of concerns about patient safety and also
not wanting to be responsible for getting her fired. To
reduce the emotionalism of the event and to give yourself
time to think, you decide to take a break and think over
the possible actions you should take.


Evaluate this problem. Is this just a simple
leadership–management problem that requires
some problem solving and a decision or does the
problem have ethical dimensions? Using one of the
problem-solving models in this chapter, solve this
problem. Compare your solution with others in your


Sometimes Things Go Wrong (Marquis &
Huston, 2012)

You have been working as a registered nurse on an
orthopedic unit since your graduation from your nursing
program 2 years ago. Both the doctors and supervisor
respect your work, and you have found it exciting to work

with the home health nurses as many of your patients
need home health follow-up for physical therapy and
other needs following their surgeries.

Mrs. George is an elderly widow who has recently had
bilateral hip replacement. Although she has made good
progress, she continues to need quite a bit of assistance
with ambulation. Normally, if family members cannot
assist them at home, patients with bilateral hip
replacements are sent from the hospital to an assisted
living facility for several weeks. Mrs. George does not
have any immediate family to help her, but she has
pleaded with her doctor, you, and the home health nurse
to let her go back to her home, which she refers to as a
cabin in the “piney woods” to complete her recuperation.
The doctor tells you and the home health nurse to work
on a plan to see if it is feasible.

The home health nurse reports after her home
assessment that with some assistance every day, she
could probably manage at home, and although her cabin
is not near any neighbor, she does have a telephone.
Mrs. George is insistent that she will not go to what she
calls “a nursing home” and her insurance will no longer
pay for her to stay at the hospital. Eventually, it is decided
that Meals on Wheels will deliver her meals and that a
home health nurse will call on her every other day and a
physical therapist will visit every other day so that she will
have at least two people in her home each day.

Although you and the home health nurse and the
doctor are a bit uneasy, you feel that you have solved this
ethical dilemma (a choice between two negative
solutions) and have selected the one that is the least
damaging to Mrs. George’s quality of life.

Seven days after Mrs. George is discharged, there is a
severe storm, which disables most phone lines including
Mrs. George’s. The storm also causes the flue in her
wood stove to overheat in the middle of the night causing
a fire. Mrs. George is unable to use her walker fast
enough to get outside before the fire consumes the small
cabin. Mrs. George dies in the fire.


Would you have solved this problem as described?
Does knowing the outcome change the way you
would solve the problem? Having a negative
outcome may or may not mean that the ethical
problem solving was faulty. Do you feel the people
in this story made a faulty decision? If so, what
would you have done differently?


Shortcuts (Marquis & Huston, 2012)

Gina is the charge nurse of the 3:00 PM to 11:00 PM

shift on the acute care unit where you have worked for 18
months since your graduation. Your supervisor has asked
you if you would like to learn the duties of the relief
charge nurse. You were thrilled that she approached you
for this position. Because it was a relief position, it was

permissible for your supervisor to appoint you and not
necessary for you to formally apply for the position.

One day each week, for the last 2 weeks, you have
been working with Gina about the responsibilities of the
position. There are several things Gina does that bother
you, and you are not sure what you should do. For
example, if used supplies were inadvertently not charged
to patients at the time of service, Gina admitted she
would just charge them to whoever patients she thought
were likely to have used them. When you questioned
Gina about this, she said, “Well, at the end of the day, the
unit needs to make sure that all supplies have been
charged for, or the CFO will be after all of us. It is one of
the charge nurses’ responsibilities, and I don’t have time
to chase everyone down to find the correct patient to
charge and besides everyone has insurance and so it
does not come out of the patient’s pocket. Most
importantly, we must make sure the hospital gets
reimbursed or we won’t have our jobs.”

In addition, when Gina does the staffing correlation for
the upcoming shift, you notice that she fudges a bit and
makes sure the night shift is given credit for needing
more staff than they need. When questioned, she said,
“Oh, we have to take care of each other, better too much
staff than not enough.”

You think Gina’s actions are unethical, but you do not
know what to do about it. It does not directly harm a
patient, but you feel uncomfortable about what she is
doing and feel it is not the ethical thing to do.


You have many options here including doing
nothing. Using the MORAL ethical problem-solving
model, solve this case and compare your solution
with others in your class.

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Lippincott Williams & Wilkins.

Mortell, M. (2012). Hand hygiene compliance: Is there a theory-
practice-ethics gap? British Journal of Nursing, 21(17), 1011–

Peter, E. (2018). Overview and summary: Ethics in healthcare:
Nurses respond. OJIN: The Online Journal of Issues in Nursing,
23(1). Retrieved July 16, 2018, from

Ramos, M. (2015). The overwhelming moral and ethical reality of
care management practice. New Definition, 29(2), 1–3.

Rosenberg, S. (2019). Why ethics in nursing matters. Retrieved July
25, 2019, from


Legal and Legislative Issues
. . . It may seem a strange principle to enunciate as the
very first requirement in a hospital that it should do the
sick no harm.—Florence Nightingale

. . . Laws or ordinances unobserved, or partially
attended to, had better never have been made.—
George Washington, letter to James Madison,
March 31, 1787

. . . The best way to get a bad law repealed is to
enforce it strictly.—Abraham Lincoln


This chapter addresses:

BSN Essential II: Basic organizational and systems leadership
for quality care and patient safety

BSN Essential V: Health-care policy, finance, and regulatory

BSN Essential VIII: Professionalism and professional values
MSN Essential II: Organizational and systems leadership
MSN Essential VI: Health policy and advocacy
AONL Nurse Executive Competency II: A knowledge of the
health-care environment

AONL Nurse Executive Competency V: Business skills

ANA Standard of Professional Performance 10:

ANA Standard of Professional Performance 11: Leadership
ANA Standard of Professional Performance 14: Quality of

ANA Standard of Professional Performance 15: Professional
practice evaluation

ANA Standard of Professional Performance 17:
Environmental health

QSEN Competency: Safety


The learner will:

identify the primary sources of law and how each affects nursing

describe the types (criminal, civil, and administrative) of legal
cases nurses may be involved in and differentiate between the
burden of proof and the potential consequences for rule
breaking in each

identify specific doctrines used by the courts to define legal
boundaries for nursing practice

correlate the legal authority of nursing practice and the nursing

assess his or her personal need for malpractice insurance as a
nurse, weighing the potential risks versus benefits

describe the five elements that must be present for a
professional to be held liable for malpractice

identify strategies nurses can use to reduce their likelihood of
being sued for malpractice

describe the liability nurses, other care providers, and
employers share under the concept of joint liability

identify types of intentional torts as well as strategies nurses can
use to reduce their likelihood

describe appropriate nursing actions to ensure informed consent
describe the need for patient and family education regarding
treatment and end-of-life issues as part of the Patient Self-
Determination Act

describe conditions that must exist to receive liability protection
under Good Samaritan laws

recognize his or her legal imperative to protect patient
confidentiality in accordance with the Health Insurance
Portability and Accountability Act of 1996

identify the role State Boards of Nursing play in professional
licensure and discipline

explain how increased consumer awareness of patient rights
has affected the actions of the health-care team

select appropriate legal nursing actions in sensitive clinical

differentiate between legal and ethical accountability

Chapter 4 presented ethics as an internal control of human behavior
and nursing practice. Therefore, ethics has to do with actions that
people should take, not necessarily actions that they are legally
required to take. On the other hand, ethical behavior written into law
is no longer just desired, it is mandated. This chapter focuses on the
external controls of legislation and law. Since the first mandatory
Nurse Practice Act was passed in North Carolina in 1903, nursing
has been legislated, directed, and controlled to some extent.

The primary purpose of law and legislation is to protect the patient
and the nurse. Laws and legislation define the scope of acceptable
practice and protect individual rights. Nurses who are aware of their

rights and duties in legal matters are better able to protect
themselves against liability or loss of professional licensure.

This chapter has five sections. The first section presents the
primary sources of law and how each affects nursing practice. The
nurse’s responsibility to be proactive in establishing and revising
laws affecting nursing practice is emphasized. The second section
presents the types of legal cases in which nurses may be involved
and differentiates between the burden of proof and the
consequences for each if the nurse is found to have broken the law.
The third section identifies specific doctrines used by the courts to
define legal boundaries for nursing practice. The role of state boards
in professional licensure and discipline is examined. The fourth
section deals with the components of malpractice for the individual
practitioner and the manager or supervisor. Legal terms are defined.
The fifth and final section discusses issues such as informed
consent, medical records, intentional torts, the Patient Self-
Determination Act (PSDA), the Good Samaritan Act, and the Health
Insurance Portability and Accountability Act (HIPAA).

This chapter is not meant to be a complete legal guide to nursing
practice. There are many excellent legal textbooks and handbooks
that accomplish that function. The primary function of this chapter is
to emphasize the widely varying and rapidly changing nature of laws
and the responsibility that each manager has to keep abreast of
legislation and laws affecting both nursing and management
practice. Leadership roles and management functions associated
with legal and legislative issues are shown in Display 5.1.


Leadership Roles
1. Serves as a role model by providing nursing care that meets

or exceeds accepted standards of care
2. Practices within the scope of the Nurse Practice Act
3. Creates a work environment where each person understands

he or she has some liability for his or her own conduct
4. Updates knowledge and skills in the field of practice and

seeks professional certification to increase expertise in a
specific field

5. Reports substandard nursing care to appropriate authorities
following the established chain of command

6. Fosters nurse–patient relationships that are respectful, caring,
and honest, thus reducing the possibility of future lawsuits

7. Creates an environment that encourages and supports
diversity and sensitivity

8. Prioritizes patient rights and patient welfare in decision

9. Ensures that patients receive informed consent for treatment
10. Demonstrates vision, risk taking, and energy in applying

appropriate legal boundaries for nursing practice

Management Functions
1. Increases knowledge regarding sources of law and legal

doctrines that affect nursing practice
2. Ensures that organizational guidelines regarding scope of

practice are consistent with the state Nurse Practice Act
3. Delegates to subordinates wisely, looking at the manager’s

scope of practice and that of the individuals he or she

4. Understands and adheres to institutional policies and

5. Minimizes the risk of product liability by assuring that all staff
are appropriately oriented to the appropriate use of equipment
and products

6. Monitors subordinates to ensure they have a valid, current,
and appropriate license to practice nursing

7. Uses foreseeability of harm in delegation and staffing

8. Increases staff awareness of intentional torts and assists
them in developing strategies to reduce their liability in these

9. Provides education for staff and patients on issues
concerning treatment and end-of-life issues under the Patient
Self-Determination Act

10. Protects all patients’ rights to confidentiality under the Health
Insurance Portability and Accountability Act

11. Ensures patients have reasonable access to information in
the medical record, following established organizational

12. Secures appropriate background checks for new employees
to reduce managerial liability

13. Provides educational and training opportunities for staff on
legal issues affecting nursing practice

Sources of Law
The US legal system can be somewhat confusing because there are
not only four sources of the law but also parallel systems at the state
and federal levels. The sources of law include constitutions, statutes,
administrative agencies, and court decisions. A comparison is shown
in Table 5.1.


Origin of
Law Use

Impact on Nursing


The highest law in the
United States; interpreted
by the U.S. Supreme
Court; gives authority to
other three sources of
the law

Constitutional law has
little direct involvement in
the area of malpractice.

Statutes Also called statutory law
or legislative law; laws
that are passed by the
state or federal
legislators and that must
be signed by the
president or governor

Before 1970s, very few
state or federal laws dealt
with malpractice. Since
the malpractice crisis,
many statutes affect


The rules and regulations
established by appointed
agencies of the executive
branch of the
government (governor or

State Boards of Nursing
and agencies, such as
the National Labor
Relations Board and
health and safety boards
significantly impact
nursing practice.


Also called tort law; this
is court mode law, and
the courts interpret the
statutes and set
precedents; in the United
States, there are two
levels of court: trial court
and appellate court

Most malpractice laws
are addressed by the

A constitution is a system of fundamental laws or principles that
govern a nation, society, corporation, or other aggregate of
individuals. The purpose of a constitution is to establish the basis of
a governing system for the future and the present. The U.S.
Constitution establishes the general organization of the federal
government and grants and limits its specific powers. Each state
also has a constitution that establishes the general organization of
the state government and grants and limits its powers.

The second source of law is statutes—laws that govern.
Legislative bodies, such as the U.S. Congress, state legislatures,
and city councils, make these laws. Statutes are officially enacted
(voted on and passed) by the legislative body and are compiled into
codes, collections of statutes, and ordinances. The 51 Nurse
Practice Acts representing the 50 states and the District of Columbia
are examples of statutes. These Nurse Practice Acts define and limit
the practice of nursing, thereby stating what constitutes authorized
practice as well as what exceeds the scope of authority. Although
Nurse Practice Acts may vary among states, all must be consistent
with provisions or statutes established at the federal level.

The 51 Nurse Practice Acts (one for each state and the
District of Columbia) define and limit the practice of
nursing, thereby stating what constitutes authorized
practice as well as what exceeds the scope of authority.

Administrative agencies, the third source of law, are given
authority to act by the legislative bodies and create rules and
regulations that enforce statutory laws. For example, State Boards of
Nursing are administrative agencies set up to implement and enforce
the state Nurse Practice Act by writing rules and regulations and by
conducting investigations and hearings to ensure the law’s
enforcement. Administrative laws are valid only to the extent that

they are within the scope of the authority granted to them by the
legislative body.

The fourth source of law is court decisions. Judicial or decisional
laws are made by the courts to interpret legal issues that are in
dispute. Depending on the type of court involved, judicial or
decisional law may be made by a single justice, with or without a
jury, or by a panel of justices. Generally, initial trial courts have a
single judge or magistrate, intermediary appeal courts have three
justices, and the highest appeal courts have nine justices.

Types of Laws and Courts
Although most nurses worry primarily about being sued for
malpractice, they may actually be involved in three different types of
court cases: criminal, civil, and administrative (Table 5.2). The court
in which each is tried, the burden of proof required for conviction,
and the resulting punishment associated with each is different.



Burden of Proof
Required for Guilty

Likely Consequences of
a Guilty Verdict

Criminal Beyond a reasonable

Incarceration, probation,
and fines

Civil Based on a
preponderance of the

Monetary damages

Administrative Clear and convincing

Suspension or loss of

In criminal cases, the individual faces charges generally filed by
the state or federal attorney general for crimes committed against an

individual or society. In criminal cases, the individual is always
presumed to be innocent unless the state can prove his or her guilt
beyond a reasonable doubt. Incarceration and even death are
possible consequences for being found guilty in criminal matters.
Nurses found guilty of intentionally administering fatal doses of drugs
to patients would be charged in a criminal court.

In civil cases, one individual sues another for money to
compensate for a perceived loss. The burden of proof required to be
found guilty in a civil case is described as a preponderance of the
evidence. In other words, the judge or jury must believe that it was
more likely than not that the accused individual was responsible for
the injuries of the complainant. Consequences of being found guilty
in a civil suit are monetary. Most malpractice cases are tried in civil

In administrative cases, an individual is sued by a state or federal
governmental agency assigned the responsibility of implementing
governmental programs. State Boards of Nursing are one such
governmental agency. When an individual violates the state Nurse
Practice Act, the Boards of Nursing may seek to revoke licensure or
institute some form of discipline. The burden of proof in these cases
varies from state to state. When the clear and convincing standard is
not used, the preponderance of the evidence standard may be used.
Clear and convincing involves higher burdens of proof than
preponderance of evidence but a significantly lower burden of proof
than beyond a reasonable doubt.

The burden of proof required for conviction as well as the
type of punishment given differs in criminal, civil, and
administrative cases.


Both Guilty and Not Guilty

Think of celebrated cases where defendants have been
tried in both civil and criminal courts. What were the
verdicts in both cases? If the verdicts were not the same,
analyze why this happened. Do you agree that taking
away an individual’s personal liberty by incarceration
should require a higher burden of proof than assessing
for monetary damages?


Also complete a literature search to see if you can
find cases where a nurse faced both civil and
administrative charges. Were you able to find cases
where the nurse was found guilty in a civil court but
did not lose his or her license? Did you find the

Legal Doctrines and the Practice of Nursing
Two important legal doctrines frequently guide all three courts in their
decision making. The first of these, stare decisis, means to let the
decision stand. Stare decisis uses precedents as a guide for
decision making. This doctrine gives nurses insight into ways that
the court has previously fixed liability in given situations. However,
the nurse must avoid two pitfalls in determining if stare decisis
should apply to a given situation.

Precedent is often used as a guide for legal decision

The first is that the previous case must be within the jurisdiction of
the court hearing the current case. For example, a previous Florida
case decided by a state court does not set precedent for a Texas
appellate court. Although the Texas court may model its decision
after the Florida case, it is not compelled to do so. The lower courts
in Texas, however, would rely on Texas appellate decisions.

The other pitfall is that the court hearing the current case can
depart from the precedent and set a landmark decision. Landmark
decisions generally occur because societal needs have changed,
technology has become more advanced, or following the precedent
would further harm an already injured person. Roe v. Wade, the
1973 landmark decision to allow a woman to seek and receive a
legal abortion during the first two trimesters of pregnancy, is an
example. Given the influence of politics and varying societal views
about abortion, this precedent could change again at some point in
the future.

The second doctrine that guides courts in their decision making is
res judicata, which means a “thing or matter settled by judgment.” It
applies only when a competent court has decided a legal dispute
and when no further appeals are possible. This doctrine keeps the
same parties in the original lawsuit from retrying the same issues
that were involved in the first lawsuit.

When using doctrines as a guide for nursing practice, the nurse
must remember that all laws are fluid and subject to change. An
example of changing law regarding professional nursing occurred in
an Illinois Supreme Court more than a decade ago when the law
finally recognized nursing as an independent profession with its own
unique body of knowledge. In this case (Sullivan v. Edward Hospital,
2004), the Illinois Supreme Court decided that physicians could not

serve as expert witnesses regarding nursing standards (FindLaw for
Legal Professionals, 2019). This demonstrates how the law is ever-
evolving. Laws cannot be static; they must change to reflect the
growing autonomy and responsibility desired by nurses. It is critical
that all nurses be aware of and sensitive to rapidly changing laws
and legislation that affect their practice. Nurses must also recognize
that state laws may differ from federal laws and that legal guidelines
for nursing practice in the organization may differ from state or
federal guidelines.

Boundaries for practice are defined in the Nurse Practice Act of
each state. These acts are general in most states to allow for some
flexibility in the broad roles and varied situations in which nurses
practice. Because this allows for some interpretation, many
employers have established guidelines for nursing practice in their
own organization. These guidelines regarding scope of practice
cannot, however, exceed the requirements of the state Nursing
Practice Acts. Managers need to be aware of their organization’s
specific practice interpretations and ensure that subordinates are
aware of the same and follow established practices. All nurses must
understand the legal controls for nursing practice in their state.

Professional Negligence (Malpractice)
Elements of Malpractice
All liability suits involve a plaintiff and a defendant. In malpractice
cases, the plaintiff is the injured party and the defendant is the
professional who is alleged to have caused the injury. Negligence is
the omission to do something that a reasonable person, guided by
the considerations that ordinarily regulate human affairs, would do—
or as doing something that a reasonable and prudent person would
not do. Reasonable and prudent generally means the average
judgment, foresight, intelligence, and skill that would be expected of
a person with similar training and experience. Malpractice—the

failure of a person with professional training to act in a reasonable
and prudent manner—also is called professional negligence. Five
elements must be present for a professional to be held liable for
malpractice (Table 5.3).


Elements of
Liability Explanation

Example: Giving

1. Duty to use due
care (defined by
the standard of

The care that should
be given under the
reflects what a
reasonably prudent
nurse would have

A nurse should give
completely, and on

2. Failure to meet
standard of care
(breach of duty)

The care that should
have been given, was

A nurse fails to give
completely, or on

3. Foreseeability of

The nurse must have
reasonable access to
information about
whether the
possibility of harm

The drug handbook
specifies that the
wrong dosage or
route may cause

4. A direct
between failure to
meet the standard
of care (breach)
and injury can be

Patient is harmed
because proper care
is not given.

Wrong dosage
causes the patient to
have a convulsion.

5. Injury Actual harm results to
the patient.

Convulsion or other
serious complication


“Medical malpractice is a lawsuit rooted in professional
negligence. It often requires an act or omission by a
healthcare provider in which the conduct (usually the
treatment provided or withheld) falls below the accepted
standard of practice in the community. The remaining
component is damage—some injury or harm to the
patient” (Silberman, 2015, p. 312).

First, a standard of care must have been established that outlines
the level or degree of quality considered adequate by a given
profession. Standards of care outline the duties a defendant has to a
plaintiff or a nurse to a client. These standards represent the skills
and learning commonly possessed by members of the profession
and generally are the minimal requirements that define an
acceptable level of care. Standards of care, which guarantee clients
safe nursing care, include organizational policy and procedure
statements, job descriptions, and student guidelines.

Second, after the standard of care has been established, it must
be shown that the standard was violated—there must have been a
breach of duty. This breach is shown by calling other nurses who
practice in the same specialty area as the defendant to testify as
expert witnesses.

Third, the nurse must have had the knowledge or availability of
information that not meeting the standard of care could result in
harm. This is called foreseeability of harm. If the average,
reasonable person in the defendant’s position could have anticipated
the plaintiff’s injury as a result of his or her actions, then the plaintiff’s
injury was foreseeable. Ignorance is not an excuse, but lack of
information may have an effect on the ability to foresee harm.

Being ignorant is not a justifiable excuse for malpractice,
but not having all the information in a situation may
impede one’s ability to foresee harm.

For example, a charge nurse assigns another registered nurse
(RN) to care for a critically ill patient. The assigned RN makes a
medication error that injures the patient in some way. If the charge
nurse had reason to believe that the RN was incapable of
adequately caring for the patient or failed to provide adequate
supervision, foreseeability of harm is apparent, and the charge nurse
also could be held liable. If the charge nurse was available as
needed and had good reason to believe that the RN was fully
capable, he or she would be less likely to be held liable.

Many malpractice cases have hinged on whether the nurse was
persistent enough in attempting to notify health-care providers of
changes in a patient’s conditions or to convince the providers of the
seriousness of a patient’s condition. Because the nurse has
foreseeability of harm in these situations, the nurse who is not
persistent can be held liable for failure to intervene because the
intervention was below what was expected of him or her as a patient

The fourth element is that failure to meet the standard of care
must have the potential to injure the patient. There must be a
provable correlation between improper care and injury to the patient.

The final element is that actual patient injury must occur. This
injury must be more than transitory. The plaintiff must show that the
action of the defendant directly caused the injury and that the injury
would not have occurred without the defendant’s actions. It is
important to remember here, however, that not taking action is an

Being Sued for Malpractice

Historically, physicians were the health-care providers most likely to
be held liable for nursing care. As nurses have gained authority,
autonomy, and accountability, they have assumed responsibility,
accountability, and liability for their own practice. As roles have
expanded, nurses have begun performing duties traditionally
reserved for medical practice.


Who Is Responsible for Harm to This
Patient? You Decide

You are a surgical nurse at Memorial Hospital. At 4:00
PM, you receive a patient from the recovery room who
has had a total hip replacement. You note that the hip
dressings are saturated with blood but are aware that
total hip replacements frequently have some
postoperative oozing from the wound. There is an order
on the chart to reinforce the dressing as needed, and you
do so. When you next check the dressing at 6:00 PM, you
find the reinforcements saturated and drainage on the
bed linen. You call the physician and tell her that you
believe the patient is bleeding too heavily. The physician
reassures you that the amount of bleeding you have
described is not excessive but encourages you to
continue to monitor the patient closely. You recheck the
patient’s dressings at 7:00 and 8:00 PM. You again call
the physician and tell her that the bleeding still looks too
heavy. She again reassures you and tells you to continue

to watch the patient closely. At 10:00 PM, the patient’s
blood pressure becomes nonpalpable, and she goes into
shock. You summon the doctor, and she comes


What are the legal ramifications of this case? Using
the components of professional negligence outlined
in Table 5.3, determine who in this case is guilty of
malpractice. Justify your answer. At what point in
the scenario should each character have altered his
or her actions to reduce the probability of a negative

Because of an increased scope of practice, many nurses now
carry individual malpractice insurance. This is a double-edged
sword. Nurses need malpractice insurance in basic practice as well
as in expanded practice roles. They do incur a greater likelihood of
being sued, however, if they have malpractice insurance because
injured parties will always seek damages from as many individuals
with financial resources as possible. In fact, a recent study by the
Nurses Service Organization found that $90 million was paid out in
nursing malpractice claims over a recent 5-year period (Injury Trial
Lawyers, 2018).

In addition, some nurses count on their employer-provided
professional liability policies to protect them from malpractice claims,
but such policies often have limitations. For example, employers may
not provide coverage once an employee has terminated his or her
employment, even if the situation that led to the complaint occurred
while the nurse was employed there, and some employer-provided

policies have inadequate limits of liability for the individual employee.
Nurses then are advised to obtain their own personal liability policy.

In addition, Neil (2015) notes that without personal nursing
malpractice insurance, nurses are dependent on the attorney
representing the facility and their first priority is to defend the facility.
During a lawsuit, the nurse needs an attorney dedicated solely to his
or her own interests. Unfortunately, both the enhanced role of nurses
and the increase in the number of insured nurses have led to a great
increase in the number of liability suits seeking damages from
nurses as individuals over the past few decades.

In particular, malpractice has become a greater concern to
advanced practice nurses such as nurse practitioners (NPs) and
nurse midwives. An analysis of 67 malpractice claims filed against
NPs that closed over a 6-year period (January 2011 to December
2016) is shown in Examining the Evidence 5.1. As a result of their
increased risk for litigation, NPs pay high costs for their insurance
premiums and are subject to strict professional liability (malpractice)
insurance requirements.

Source: Troxel, D. B. (2018). In primary care, who
gets sued and why? Retrieved July 19, 2018, from

Malpractice Claims for Nurse Practitioners
Working in Primary Care
The Doctors Company analyzed 67
malpractice claims against nurse practitioners
(NPs) that closed over a 6-year period from
January 2011 to December 2016. These claims
arose in family medicine (FM) and internal
medicine (IM) practices.

Study findings revealed that the three most
common claim allegations against NPs working
in FM and IM accounted for 88% of their total
claim allegations. The most common claim
(48%) was diagnosis related (failure, delay,
wrong diagnosis). The second most common
was medication related (24%), and the third
was medical treatment related (16%).

An allegation of failure or delay in obtaining a
specialty consultation or referral often occurred
when an NP managed a complication that was
beyond his or her expertise or scope of
practice (SOP). Failure to perform an adequate
patient assessment often occurred when an NP
relied on the medical history or diagnosis in a
previous medical record rather than performing
a new, comprehensive exam.

In addition, many NP malpractice claims
could be traced to clinical and administrative

factors including failure to adhere to the SOP,
inadequate physician supervision, the absence
of written protocols, deviation from written
protocols, and failure or delay in seeking
physician collaboration or referral.

Avoiding Malpractice Claims
Interactions between nurses and clients that are less businesslike
and more personal are more satisfying to both. It has been shown
that despite technical competence, nurses who have difficulty
establishing positive interpersonal relationships with patients and
their families are at greater risk for being sued. Communication that
proceeds in a caring and professional manner has been shown
repeatedly to be a major reason that people do not sue despite
adequate grounds for a successful lawsuit.

In addition, many experts have suggested a need to create safer
environments for care so that less patients are injured during their
care. This has especially been true since the release of To Err Is
Human by the Institute of Medicine (IOM, 1999), a congressionally
chartered independent organization. The IOM report indicated that
errors are simply a part of the human condition and that the health-
care system itself needs to be redesigned so that fewer errors can
occur. For example, even though there are unit-dose systems in
play, nurse-leaders often look the other way when staff pour all the
medications into a soufflé cup and hand them to patients, thus
increasing the possibility of medication errors.

Strategies recommended by The Joint Commission, in its 2005
seminal report, Health care in the Crossroads (Joint Commission on
Accreditation of Healthcare Organizations, 2005), can be viewed in
Display 5.2. The three major areas of focus in the call to action are to

prevent injuries, improve communication, and examine mechanisms
for injury compensation.


1. Pursue patient safety initiatives that prevent medical injury by
Strengthening oversight and accountability mechanisms to

better ensure the competencies of physicians and nurses
Encouraging appropriate adherence to clinical guidelines to

improve quality and reduce liability risk
Supporting team development through team training
Continuing to leverage patient safety initiatives through

regulatory and oversight bodies
Building an evidence-based information and technology

system that impacts patient safety and pursue proposals to
offset implementation costs

Promoting the creation of cultures of patient safety in health-
care organizations

Establishing a federal leadership locus for advocacy of
patient safety and health-care quality

Pursuing “pay-for-performance” strategies that provide
incentives to improve patient safety and health-care quality

2. Promote open communication between patients and
practitioners by
Involving health-care consumers as active members of the

health-care team
Encouraging open communication between practitioners and

patients when adverse events occur
Pursuing legislation that protects disclosure and apology

from being used as evidence against practitioners in litigation

Encouraging nonpunitive reporting of errors to third parties
that promote information and data analysis as a basis for
developing safety improvement

Enacting federal safety legislation that provides legal
protection for when information is reported to patient safety

3. Create an injury compensation system that is patient centered
and serves the common good by
Conducting demonstration projects of alternatives to medical

liability that promote patient safety and transparency and
provide swift compensation for injured patients

Encouraging continued development of mediation and early-
offer initiatives

Prohibiting confidential settlements that prevent learning from

Redesigning the National Practitioner Data Bank
Advocating for court-appointed, independent expert

witnesses to mitigate bias in expert witness testimony

Source: Joint Commission on Accreditation of Healthcare Organizations. (2005).
Health care in the crossroads: Strategies for improving the medical liability system
and preventing patient injury. Oakbrook Terrace, IL: Author.

Nurses then can reduce the risk of malpractice claims by taking
the following actions:

Practice within the scope of the Nurse Practice Act.
Observe agency policies and procedures.
Model practice after established standards by using evidence-

based practice.
Always put patient rights and welfare first.
Be aware of relevant law and legal doctrines and combine such

with the biological, psychological, and social sciences that form
the basis of all rational nursing decisions.

Practice within the area of individual competence.
Upgrade technical skills consistently by attending continuing

education programs and seeking specialty certification.

Nurses should also purchase their own liability insurance and
understand the limits of their policies. Although this will not prevent a
malpractice suit, it should help protect a nurse from financial ruin
should there be a malpractice claim.

Extending the Liability
In recent years, the concept of joint liability, in which the nurse,
physician, and employing organization are all held liable, has
become the current position of the legal system. This probably more
accurately reflects the higher level of accountability now present in
the nursing profession. Before 1965, nurses were rarely held
accountable for their own acts, and hospitals were usually exempt
due to charitable immunity. However, following precedent-setting
cases in the 1960s, employers are now held liable for the nurse’s
acts under a concept known as vicarious liability.

One form of vicarious liability is called respondeat superior, which
means “the master is responsible for the acts of his servants.”
Respondeat superior applies when an employee causes damages or
injuries while working on behalf of his or her employer (Hale Law
Firm, 2018). In such a scenario, the employer would also be liable
for the injuries. The theory behind the doctrine is that an employer
should be held legally liable for the conduct of employees whose
actions he or she has a right to direct or control.

The difficulty in interpreting respondeat superior is that many
exceptions exist. The first and most important exception is related to
the state in which the nurse practices. In some states, the doctrine of
charitable immunity applies, which holds that a charitable (nonprofit)
hospital cannot be sued by a person who has been injured because

of a hospital employee’s negligence. Thus, liability is limited to the


Understanding Limitations and Rules

Have you ever been directed in your nursing practice to
do something that you believed might be unsafe or that
you felt inadequately trained or prepared to do? What did
you do? Would you act differently if the situation occurred
now? What risks are inherent in refusing to follow the
direct orders of a physician or superior? What are the
risks of performing a task that you believe may be

Another exception to respondeat superior occurs when the state or
federal government employs the nurse. The common law rule of
governmental immunity provides that governments cannot be held
liable for the negligent acts of their employees while carrying out
government activities. Some states have changed this rule by
statute, however, and in these particular jurisdictions, respondeat
superior continues to apply to the acts of nurses employed by the
state government.

The purpose of respondeat superior is not to shift the
burden of blame from the employee to the organization
but rather to share the blame, increasing the possibility
of larger financial compensation to the injured party.

Some nurses erroneously assume that they do not need to carry
malpractice insurance because their employer will probably be sued
as well and thus will be responsible for financial damages. Under the
doctrine of respondeat superior, any employer required to pay
damages to an injured person because of an employee’s negligence
may have the legal right to recover or be reimbursed that amount
from the negligent employee.

One rule that all nurses must know and understand is that of
personal liability, which says that every person is liable for his or her
own conduct. The law does not permit a wrongdoer to avoid legal
liability for his or her own wrongdoing, even though someone else
also may be sued and held legally liable. For example, if a manager
directs a subordinate to do something that both know to be improper,
the injured party can recover damages against the subordinate even
if the supervisor agreed to accept full responsibility for the delegation
at the time. In the end, each nurse is always held liable for his or her
own negligent practice.

Managers are not automatically held liable for all acts of
negligence on the part of those they supervise, but they may be held
liable if they were negligent in the supervision of those employees at
the time that they committed the negligent acts. Liability for
negligence is generally based on the manager’s failure to determine
which of the patient needs can be assigned safely to a subordinate
or the failure to supervise a subordinate adequately for the assigned
task (Huston, 2020c). Both the abilities of the staff member and the
complexity of the task assigned must be considered when
determining the type and amount of direction and supervision

Hospitals have also been found liable for assigning personnel who
were unqualified to perform duties as shown by their evaluation
reports. Managers, therefore, need to be cognizant of their
responsibilities in assigning and appointing personnel because they
could be found liable for ignoring organizational policies or for

assigning employees duties that they are not capable of performing.
In such cases, though, the employee must provide the supervisor
with the information that he or she is not qualified for the assignment.
The manager does have the right to reassign employees as long as
they are capable of discharging the anticipated duties of the

In addition, there has been a push to have more in-depth
background checks when health-care employees are hired, with
some states already mandating such checks. For example,
California, as of 2009, determined that it would no longer issue
temporary or permanent licenses to nurses without a criminal
background check. Indeed, many states are now requiring a criminal
background check on all license renewals, and federal legislation
has recently been introduced along these lines.

At present, except in a few states, personnel directors in hospitals
(those making hiring decisions) are required to request information
from the National Practitioner Data Bank for those individuals who
seek clinical privileges, and many states now require nursing
students to be fingerprinted before they can work with vulnerable
populations. In the future, hiring someone without an adequate
background check, who later commits a crime involving a patient,
could be another area of liability for the manager. This is an example
of the type of pending legislation with which a manager must keep
abreast so that if it becomes law, its impact on future management
practices will be minimized.

Incident Reports and Adverse Event Forms
Incident reports or adverse event forms are records of unusual or
unexpected incidents that occur during a client’s treatment. Because
attorneys use incident reports to defend the health agency against
lawsuits brought by clients, the reports are generally considered
confidential communications and cannot be subpoenaed by clients

or used as evidence in their lawsuits in most states. (Be sure,
however, that you know the law for the state in which you live, as this
does vary.) However, incident reports that are inadvertently disclosed
to the plaintiff are no longer considered confidential and can be
subpoenaed in court. Thus, a copy of an incident report should not
be left in the chart. In addition, no entry should be made in the
patient’s record about the existence of an incident report. The chart
should, however, provide enough information about the incident or
occurrence so that appropriate treatment can be given.

Intentional Torts
Torts are legal wrongs committed against a person or property,
independent of a contract, that render the person who commits them
liable for damages in a civil action. Whereas professional negligence
is considered to be an unintentional tort, assault, battery, false
imprisonment, invasion of privacy, defamation, and slander are
intentional torts. Intentional torts are a direct invasion of someone’s
legal rights. Managers are responsible for seeing that staff members
are aware of and adhere to laws governing intentional torts. In
addition, the manager must clearly delineate policies and procedures
about these issues in the work environment.

Nurses can be sued for assault and battery. Assault is conduct
that makes a person fearful and produces a reasonable
apprehension of harm, and battery is an intentional and wrongful
physical contact with a person that entails an injury or offensive
touching. Thompson Defense Firm (2019) notes that actual battery is
not necessary to be charged with either first- or second-degree
assault and battery. It is only necessary that body injury could have

Unit managers must be alert to patient complaints of being
handled in a rough manner or complaints of excessive force in
restraining patients. In fact, performing any treatment without

patient’s permission or without receiving an informed consent might
constitute both assault and battery. In addition, many battery suits
have been won based on the use of restraints when dealing with
confused patients.


Discussing Lawsuits and Liability

In small groups, discuss the following questions:

1. Do you believe that there are unnecessary lawsuits in
the health-care industry? What criteria can be used to
distinguish between appropriate and unnecessary

2. Have you ever advised a friend or family member to
sue to recover damages that you believed they
suffered because of poor-quality health care? What
motivated you to encourage them to do so?

3. Do you think that you will make clinical errors in
judgment as a nurse? If so, what types of errors
should be considered acceptable (if any) and what
types are not acceptable?

4. Do you believe that the recent national spotlight on
medical error identification and prevention will
encourage the reporting of medical errors when they
do occur?

The use of physical restraints also has led to claims of false
imprisonment. False imprisonment occurs when a person (who

doesn’t have legal authority or justification) intentionally restrains
another person’s ability to move freely (FindLaw, 2019). Practitioners
are liable for false imprisonment when they unlawfully restrain the
movement of their patients.

Unfortunately, the use of restraints continues to be common
practice in many health-care institutions (especially skilled nursing
facilities) despite a growing body of evidence that supports the
implementation of alternative strategies to promote resident safety.
Physical restraints should be applied only with a physician’s direct
order. Likewise, the patient who wishes to sign out against medical
advice should not be held against his or her will. This tort also is
frequently applicable to involuntary commitments to mental health
facilities. Managers in mental health settings must be careful to
institutionalize patients in accordance with all laws governing

Another intentional tort is defamation. Defamation is
communicating to a third-party false information that injures a
person’s reputation. When defamation is written, printed, or
broadcasted, it is called libel. When it is spoken, it is called slander.
The damages for defamation can be enhanced by how widespread
the publication of the defamatory information was. “Each additional
disclosure has the potential of increasing the damages for the
aggrieved party and thus the exposure for the improper actor
(person acting improperly)” (Silberman, 2015, p. 313).

Other Legal Responsibilities of the Manager
Managers also have some legal responsibility for the quality control
of nursing practice at the unit level, including such duties as
reporting dangerous understaffing, checking staff credentials and
qualifications, and carrying out appropriate discipline. Health-care
facilities may also be held responsible for seeing that staff know how

to operate equipment safely. Sources of liability for managers vary
from facility to facility and from position to position.

For example, standards of care as depicted in policies and
procedures may pose a liability for the nurse if such policies and
procedures are not followed. The chain of command in reporting
inadequate care by a physician is another area in which
management liability may occur if employees are not taught proper
protocols. Managers have a responsibility to see that written
protocols, policies, and procedures are followed to reduce liability. In
addition, the manager, like all professional nurses, is responsible for
reporting improper or substandard medical care, child and elder
abuse, and communicable diseases, as specified by the Centers for
Disease Control and Prevention.

Individual nurses also may be held liable for product liability.
Historically, a contractual relationship known as privity of contract
had to exist for a product liability claim to be filed. This meant that
the injured party had to have purchased a product directly from the
manufacturer to sue the manufacturer for injury caused by the
product (Mascaranhas, 2018). By the 1950s and 1960s, the courts
moved away from privity of contract because more wholesalers and
retailers were selling products directly to the consumer. In 1963,
California became the first state to adopt strict product liability, and in
1986, many other states followed (Mascaranhas, 2018).

Essentially, strict liability holds that a product may be held to a
higher level of liability than a person. In other words, if it can be
proved that the equipment or product had a defect that caused an
injury, then it would be debated in court by using all the elements
essential for negligence, such as duty and breach. Therefore,
equipment and other products fall within the scope of nursing
responsibility. In general, if they are aware that equipment is faulty,
nurses have a duty to refuse to use the equipment. If the fault in the
equipment is not readily apparent, risks are low that the nurse will be
found liable for the results of its use.

Neil (2015) concurs, noting that to avoid product liability, nurses
should not use equipment they are unfamiliar with. In addition,
nurses should make sure they have documented competency in
using equipment and know how to detect and document equipment

Informed Consent
Many nurses erroneously believe that they have obtained informed
consent when they witness a patient’s signature on a consent form
for surgery or procedure. Strictly speaking, informed consent
(Display 5.3) can be given only after the patient has received a
complete explanation of the surgery, procedure, or treatment and
indicates that he or she understands the risks and benefits related to


The person(s) giving consent must fully comprehend
1. The procedure to be performed
2. The risks involved
3. Expected or desired outcomes
4. Expected complications or side effects that may occur as a

result of treatment
5. Alternative treatments that are available

Consent may be given by
1. A competent adult
2. A legal guardian or an individual holding durable power of

3. An emancipated or married minor
4. A mature minor (varies by state)
5. A parent of a minor child
6. A court order

The information must be in a language that the patient can
understand and should be conveyed by the individual who will be
performing the procedure. Patients must be invited to ask questions
and have a clear understanding of the options as well.

Informed consent is obtained only after the patient
receives full disclosure of all pertinent information
regarding the surgery or procedure and only if the patient
understands the potential benefits and risks associated
with doing so.

Only a competent adult can legally sign the form that shows
informed consent. To be considered competent, patients must be

capable of understanding the nature and consequences of the
decision and of communicating their decision. Spouses or other
family members cannot legally sign unless there is an approved
guardianship or conservatorship or unless they hold a durable power
of attorney for health care. If the patient is younger than 16 years (18
years in some states), a parent or guardian must generally give

In an emergency, the physician can invoke implied consent, in
which the physician states in the progress notes of the medical
record that the patient is unable to sign but that treatment is
immediately needed and is in the patient’s best interest. Usually, this
type of implied consent must be validated by another physician.

Nurses frequently seek express consent from patients by
witnessing patients sign a standard consent form. In express
consent, the role of the nurse is to be sure that the patient has
received informed consent and to seek remedy if he or she has not.


Is It Really Informed Consent?

You are a staff nurse in a surgical unit. Shortly after
reporting for duty, you make rounds on all your patients.
Mrs. Jones is a 36-year-old woman scheduled for a
bilateral salpingo-oophorectomy and hysterectomy. In the
course of conversation, Mrs. Jones comments that she is
glad she will not be undergoing menopause as a result of
this surgery. She elaborates by stating that one of her
friends had surgery that resulted in “surgical menopause”
and that it was devastating to her. You return to the chart

and check the surgical permit and doctor’s progress
notes. The operating room permit reads “bilateral
salpingo-oophorectomy and hysterectomy,” and it is
signed by Mrs. Jones. The physician has noted
“discussed surgery with patient” in the progress notes.

You return to Mrs. Jones’s room and ask her what type
of surgery she is having. She states, “I’m having my
uterus removed.” You phone the physician and relate
your information to the surgeon who says, “Mrs. Jones
knows that I will take out her ovaries if necessary; I’ve
discussed it with her. She signed the permit. Now, please
get her ready for surgery—she is the next case.”


Discuss what you should do at this point. Why did
you select this course of action? What issues are
involved here? Be able to discuss legal
ramifications of this case.

Informed consent does pose ethical issues for nurses. Although
nurses are obligated to provide teaching and to clarify information
given to patients by their physicians, nurses must be careful not to
give new information that contradicts information given by the
physician, thus interfering in the physician–patient relationship. The
nurse is not responsible for explaining the procedure to be
performed. The role, rather, is to be a patient advocate by
determining their level of understanding and seeing that the
appropriate person answers their questions. At times, this can be a
cloudy issue both legally and ethically.

Informed Consent for Clinical Research
The intent of informed consent in clinical research is to give patients
adequate information, through a full explanation of a proposed
treatment, including any possible harms, so they can make an
informed decision. Studies, however, repeatedly suggest that
participants often have incomplete understanding of various features
of clinical trials and issues associated with written informed consent
are common.

Medical Records
One source of information that people seek to help them make
decisions about their health care is their medical record. Nurses
have a legal responsibility for accurately recording appropriate
information in the client’s medical record. The alteration of medical
records can result in license suspension or revocation.

Although the patient owns the information in that medical record,
the actual record belongs to the facility that originally made the
record and is storing it. Although patients must have “reasonable
access” to their records, the method for retrieving the record varies
greatly from one institution to another. Generally, a patient who
wishes to inspect his or her records must make a written request and

pay reasonable clerical costs to make such records available. The
health-care provider generally permits such inspection during
business hours within several working days of the inspection
request. Nurses should be aware of the procedure for procuring
medical records for patients at the facilities where they work. Often,
a patient’s attempt to procure medical records results from a lack of
trust or a need for additional teaching and education. Nurses can do
a great deal to reduce this confusion and foster an open, trusting
relationship between the patient and his or her health-care providers.
Collaboration between health-care providers and patients, and
documentation thereof, is a good indication of well-provided clinical

If it is not documented in the health-care record . . . it did
not happen.

The Patient Self-Determination Act
The PSDA, enacted in 1991, required health-care organizations that
received federal funding (Medicare and Medicaid) to provide
education for staff and patients on issues concerning treatment and
end-of-life issues. This education included the use of advance
directives (ADs), written instructions regarding desired end-of-life
care. Most ADs address the use of dialysis and respirators; if you
want to be resuscitated if breathing or heartbeat stops; tube feeding;
and organ or tissue donation (MedlinePlus, 2019). They also likely
include a durable power of attorney for health care, which names
your health-care proxy, someone you trust to make health decisions
if you are unable to do so (MedlinePlus, 2019).

The PSDA requires acute care facilities to document on the
medical record whether a patient has an AD and to provide written
information to patients who do not. However, despite mechanisms

within most health-care institutions to provide this information, the
AD completion rate remains low and many patients do not
understand what is included in the AD or whether this is something
important they should have.

The reality is that many people do not express their wishes about
end-of-life treatment before a crisis exists and then they may be
unable to do so. This problem prompted Cooper, Chidwick, Cybulski,
and Sibbald (2015) to develop a five-question checklist to elicit an
incapable patient’s perspective on treatment based on the wishes
and values he or she expressed while capable. The goal was to
ensure that basic legal obligations were met for patients who were
no longer able to advocate for themselves. Findings from a 2-year
pilot project suggested that the use of such a checklist gave nurses a
way to fulfill their professional roles as patient advocates in end-of-
life care, when many patients and families were most vulnerable.


Mrs. Brown’s Chart

You are a nurse in a multiphysician office that treats
oncology patients. Mrs. Brown, a patient seen by Dr.
Watson in your office, was recently diagnosed with
invasive cancer. She started radiation treatments last
week. Her husband attends her radiation treatments and
office visits with her and seems to be very devoted. They
both are very interested in her progress.

Although they have asked many questions during the
last two office visits and you have given truthful answers,
Dr. Watson’s interactions have sometimes been a bit

short and you felt that Mr. and Mrs. Brown may have left
with unanswered questions. In addition, Dr. Watson has
not shared much with them yet about Mrs. Brown’s
prognosis as he continues to refine his differential

Today, when you walk into Mrs. Brown’s exam room,
you find Mr. Brown reading her electronic record on the
computer tablet that was inadvertently left on the counter
in her room. The look on his face is one of feeling
overwhelmed and confused.


Identify several alternatives for action that you
have. Discuss what you would do and why. Is there
a problem here? What follow-up is indicated?
Attempt to solve this learning exercise on your own
before reading the sample analysis that follows.

The nurse needs to determine the most important goal in
this situation. Possible goals include (a) eliminating Mr.
Brown’s access to the medical record as soon as
possible, (b) protecting the privacy of Mrs. Brown, (c)
gathering more information, or (d) becoming an advocate
for the Browns.

In solving the case, it is apparent that not enough
information has been gathered. Mr. Brown has already
viewed at least a portion of his wife’s electronic medical
record. Usually, the danger in patients’ families reading a
patient’s record lies in the direction of their not
understanding the information contained within or the
patient’s privacy being invaded because the patient has

not consented to family members’ access to their

Using this as the basis for rationale, the nurse could
use the following approach:

1. Clarify that Mr. Brown has Mrs. Brown’s permission to
read her records by asking her directly.

2. Ask Mr. Brown if there is anything in the electronic
health record that he did not understand or anything
that he questions. You may even ask him to
summarize what he has read. Clarify the things that
are appropriate for the nurse to address, such as
terminology, procedures, and nursing care.

3. Refer questions that are inappropriate for the nurse to
answer to the physician and let Mr. Brown know that
you will help him in talking with the physician regarding
the medical plan and prognosis.

4. When finished talking with Mr. Brown, the nurse
should secure the electronic health record.

5. The nurse should notify Dr. Watson about the incident
and Mr. Brown’s concerns and assist the Browns in
obtaining the information they have requested.

The nurse first gathered more information before
becoming the adversary or advocate. It is possible that
the Browns had only simple questions to ask and that the
problem was a lack of communication between staff and
their patients rather than a physician–patient
communication deficit. Legally, patients have a right to
understand what is happening to them, and that should
be the basis for the decisions in this case.

Good Samaritan Laws
Nurses are not required to stop and provide emergency services as
a matter of law, although most health-care workers feel ethically
compelled to stop if they believe they can help. Good Samaritan
laws suggest that health-care providers are typically protected from
potential liability if they volunteer their nursing skills away from the
workplace (generally limited to emergencies), if actions taken are not
grossly negligent, and if the health-care worker does not exceed his
or her training or scope of practice in performing the emergency

Hermosillo (2019) suggests that an example of gross negligence
that would negate Good Samaritan protection would be to pull an
injured victim from the scene of a car accident without imminent
danger such as fire, drowning, or other harm. Due to the high risk of
spinal cord injury, it is expected that even those without medical
training would know better than to move an injured person in the
absence of further threat of injury or death. Also, there will likely be
no protection for those who are deemed to have caused or
contributed to the accident.

Good Samaritan laws apply only if the health-care worker
does not exceed his or her training or scope of practice
in performing the emergency services.

In addition, protections under Good Samaritan laws vary from
state to state. Some states’ protections only apply to those with
some medical training or background. Fortunately, many courts in
these states have been willing to extend those protections to
untrained passersby as well (Hermosillo, 2019). In some states, the
law grants immunity to RNs but does not protect licensed vocational
nurses (LVNs) or licensed professional nurses. Other states offer
protection to anyone who offers assistance, even if they do not have

a health-care background. Nurses should be familiar with the Good
Samaritan laws in their state.

Health Insurance Portability and Accountability
Act of 1996
Another area of the law that nurses must understand is the right to
confidentiality. Efforts to preserve patient confidentiality increased
tremendously with the passage of the HIPAA of 1996 (also known as
the Kassebaum–Kennedy Act). Unauthorized release of information
or photographs in medical records may make the person who
discloses the information civilly liable for invasion of privacy,
defamation, or slander. Written authorization by the patient to
release information is needed to allow such disclosure.

Many nurses have been caught unaware by the telephone call
requesting information about a patient’s condition. It is extremely
important that the nurse does not give out unauthorized information,
regardless of the urgency of the person making the request. In
addition, nurses must be careful not to discuss patient information in
venues where it can be inadvertently overheard, read, transmitted, or
otherwise unintentionally disclosed. For example, nurses talking in
elevators, the hospital gift shop, or in a restaurant for lunch need to
be aware of their surroundings and remain alert about not revealing
any patient information in a public place.

HIPAA essentially represents two areas for implementation. The
first is the Administrative Simplification plan, and the second area
includes the Privacy Rule. The Administrative Simplification plan is
directed at restructuring the coding of health information to simplify
the digital exchange of information among health-care providers and
to improve the efficiency of health-care delivery. The privacy rules
are directed at ensuring strong privacy protections for patient without
threatening access to care.

The Privacy Rule applies to health plans, health-care
clearinghouses, and health-care providers. It also covers all patient
records and other individually identifiable health information.
Although there are many components to HIPAA, key components of
the Privacy Rule are that direct treatment providers must make a
good faith effort to obtain written acknowledgment of the notice of
privacy rights and practices from patients. In addition, health-care
providers must disclose protected health information to patients
requesting their own information or when oversight agencies request
the data. Reasonable efforts must be taken, however, to limit the
disclosure of personal health information to the minimum information
necessary to complete the transaction. There are situations,
however, when limiting the information is not required. For example,
a minimum of information is not required for treatment purposes
because it is clearly better to have too much information than too
little. The HIPAA Privacy Rule and Common Rule also require that
individuals participating in research studies should be assured
privacy, particularly regarding personal health information.

The Privacy Rule attempts to balance the need for the
protection of personal health information with the need to
disclose that information for patient care.

Because of the complexity of the HIPAA regulations, it is not
expected that a nurse-manager would be responsible for compliance
alone. Instead, it is most important that the manager work with the
administrative team to develop compliance procedures. For
example, managers must ensure that unauthorized people do not
have access to patient charts or medical records and that
unauthorized people are not allowed to observe procedures.

It is equally important that managers remain cognizant of ongoing
changes to the guidelines and are aware of how rules governing

these issues may differ in the state in which they are employed.
Some provisions of the Privacy Rules mention “reasonable efforts”
toward achieving compliance, but being reasonable is provision
specific. The American Recovery and Reinvestment Act applies
several of HIPAA’s security and privacy requirements to business
associates and changes data restrictions, disclosure, and reporting

Legal Considerations of Managing a Diverse
Diversity has been defined as the differences among groups or
between individuals and comes in many forms, including age,
gender, religion, customs, sexual orientation, physical size, physical
and mental capabilities, beliefs, culture, ethnicity, and skin color
(Huston, 2020b). Demographic data from the United States Census
Bureau continue to show increased diversification of the US
population, a trend that began almost 40 years ago.

As discussed in later chapters, a primary area of diversity is
language, including word meanings, accents, and dialects. Problems
arising from this could be misunderstanding or reluctance to ask
questions. Staff from cultures in which assertiveness is not promoted
may find it difficult to disagree with or question others. How the
manager handles these manifestations of cultural diversity is of
major importance. If the manager’s response is seen as
discriminatory, the employee may file a complaint with one of the
state or federal agencies that oversee civil rights or equal opportunity
enforcement. Such things as overt or subtle discrimination are
prohibited by Title VII (Civil Rights Act of 1964). Managers have a
responsibility to be fair and just. Lack of promotions and unfair
assignments may occur with minority employees just because they
are different and this is illegal.

In addition, English-only rules in the workplace may be viewed as
discriminatory under Title VII. Such rules may not violate Title VII if
employers require English only during certain periods of time. Even
in these circumstances, the employees must be notified of the rules
and how they are to be enforced.

Clearly, managers should be taught how to deal sensitively and
appropriately with an increasingly diverse workforce. Enhancing self-
awareness and staff awareness of personal cultural biases,
developing a comprehensive cultural diversity program, and role
modeling cultural sensitivity are some of the ways that managers can
effectively avoid many legal problems associated with discriminatory
issues. However, it is hoped that future goals for the manager would
go beyond compliance with Title VII and move toward understanding
of and respect for other cultures.

Professional Versus Institutional Licensure
In general, a license is a legal document that permits a person to
offer special skills and knowledge to the public in a particular
jurisdiction when such practice would otherwise be unlawful.
Licensure establishes standards for entry into practice, defines a
scope of practice, and allows for disciplinary action. Currently,
licensing for nurses is a responsibility of State Boards of Nursing or
State Boards of Nurse Examiners, which also provide discipline as
necessary. The manager, however, is responsible for monitoring that
all licensed subordinates have a valid, appropriate, and current
license to practice.

Professional licensure is a privilege and not a right.

All nurses must safeguard the privilege of licensure by knowing
the standards of care applicable to their work setting. Deviation from
that standard should be undertaken only when nurses are prepared

to accept the consequences of their actions, in terms of both liability
and loss of licensure.

Nurses who violate specific norms of conduct, such as securing a
license by fraud, performing specific actions prohibited by the Nurse
Practice Act, exhibiting unprofessional or illegal conduct, performing
malpractice, and abusing alcohol or drugs, may have their licenses
suspended or revoked by the licensing boards in all states. Frequent
causes of license revocation are shown in Display 5.4.


Professional negligence
Practicing medicine or nursing without a license
Obtaining a nursing license by fraud or allowing others to use

your license
Felony conviction for any offense substantially related to the

function or duties of a registered nurse
Participating professionally in criminal abortions
Failing to follow accepted standards of care
Not reporting substandard medical or nursing care
Providing patient care while under the influence of drugs or

Giving narcotic drugs without an order
Falsely holding oneself out to the public or to any health-care

practitioner as a “nurse practitioner”
Failing to use equipment safely and responsibly

Typically, suspension and revocation proceedings are
administrative. Following a complaint, the Board of Nursing
completes an investigation. Most of these investigations reveal no
grounds for discipline; however, there are things a nurse should do if

he or she becomes aware they are being investigated by the board.
These are shown in Display 5.5.


1. Do not ignore the Board’s notification. It won’t go away.
2. Do not unnecessarily share news of the complaint with friends

and colleagues as it may undermine your credibility.
3. Read employee handbooks/contracts/policy and procedures

to determine if must report the investigation to your employer.
4. Consider contacting an attorney.
5. If a lawyer is needed, hire an experienced one.
6. Carefully consider anything you put in writing.
7. Contact your malpractice insurance provider.
8. If the investigation involves a patient, do not violate HIPAA by

copying the patient’s medical record.
9. Do not alter the patient’s medical record.
10. Be prepared for a lengthy process of investigation.

Source: Extracted from Mackay, T. R. (2018). What do you mean there’s a
complaint?! Texas Nursing, 92(1), 20–22.

If the investigation supports the need for discipline, nurses are
notified of the charges and can prepare a defense. At the hearing,
which is very similar to a trial, the nurse can present evidence.
Based on the evidence, an administrative law judge makes a
recommendation to the State Board of Nursing, which makes the
final decision. The entire process, from complaint to final decision,
may take up to 2 years or longer.

Some professionals have advocated shifting the burden of
licensure, and thus accountability, from individual practitioners to an
institution or agency. Proponents for this move believe that

institutional licensure would provide more effective use of personnel
and greater flexibility. Most professional nursing organizations
oppose this move strongly because they believe that it has the
potential for diluting the quality of nursing care.

An alternative to institutional licensure has been the development
of certification programs by the American Nurses Association (ANA).
By passing specifically prepared written examinations, nurses are
able to qualify for certification in most nurse practice areas. This
voluntary testing program represents professional organizational
certification. In addition to ANA certification, other specialties, such
as cardiac care, offer their own certification examinations. Many
nursing leaders today strongly advocate professional certification as
a means of enhancing the profession. However, certification is really
only helpful in determining a nurse’s continued competence if that
nurse is functioning in the areas of his or her certified competence
(Huston, 2020a).

Integrating Leadership Roles and Management
Functions in Legal and Legislative Issues
Legislative and legal controls for nursing practice have been
established to clarify the boundaries of nursing practice and to
protect clients. The leader uses established legal guidelines to role
model nursing practice that meets or exceeds accepted standards of
care. Leaders also are role models in their efforts to expand
expertise in their field and to achieve specialty certification. Perhaps
the most important leadership roles in law and legislation are those
of vision, risk taking, and energy. The leader is active in professional
organizations and groups that define what nursing is and what it
should be in the future. This is an internalized responsibility that
must be adopted by many more nurses if the profession is to be a
recognized and vital force in the political arena.

Management functions in legal and legislative issues are more
directive. Managers are responsible for seeing that their practice and
the practice of their subordinates are in accord with current legal
guidelines. This requires that managers have a working knowledge
of current laws and legal doctrines that affect nursing practice.
Because laws are not static, this is an active and ongoing function.
The manager has a legal obligation to uphold the laws, rules, and
regulations affecting the organization, the patient, and nursing

Managers have a responsibility to be fair and nondiscriminatory in
dealing with all members of the workforce, including those whose
culture differs from their own. The effective leader goes beyond
merely preventing discriminatory charges and instead strives to
develop sensitivity to the needs of a culturally diverse staff.

The integrated leader-manager reduces the personal risk of legal
liability by creating an environment that prioritizes patient needs and
welfare. In addition, caring, respect, and honesty as part of nurse–
patient relationships are emphasized. If these functions and roles are
truly integrated, the risks of patient harm and nursing liability are
greatly reduced.

Key Concepts

■ Sources of law include constitutions, statutes, administrative
agencies, and court decisions.

■ The burden of proof required to be found guilty and the
punishment for the crime varies significantly between
criminal, civil, and administrative courts.

■ Nurse Practice Acts define and limit the practice of nursing in
each state.

■ Professional organizations generally espouse standards of
care that are higher than those required by law. These
voluntary controls often are forerunners of legal controls.

■ Legal doctrines such as stare decisis and res judicata
frequently guide courts in their decision making.

■ Currently, licensing for nurses is a responsibility of State
Boards of Nursing or State Boards of Nurse Examiners.
These state boards also provide discipline as necessary.

■ Some professionals have advocated shifting the burden of
licensure, and thus accountability, from individual
practitioners to an institution or agency. Many professional
nursing organizations oppose this move.

■ Malpractice or professional negligence is the failure of a
person with professional training to act in a reasonable and
prudent manner. Five components must be present for an
individual to be found guilty of malpractice.

■ Employers of nurses can now be held liable for an
employee’s acts under the concept of vicarious liability.

■ Each person, however, is liable for his or her own tortuous

■ Managers are not automatically held liable for all acts of
negligence on the part of those they supervise, but they may
be held liable if they were negligent in supervising those
employees at the time that they committed the negligent acts.

■ Although professional negligence is considered to be an
unintentional tort, assault, battery, false imprisonment,
invasion of privacy, defamation, and slander are intentional

■ Consent can be informed, implied, or expressed. Nurses
need to understand the differences between these types of
consents and use the appropriate one.

■ Although the patient owns the information in a medical
record, the actual record belongs to the facility that originally

made it and is storing it.
■ It has been shown that despite good technical competence,

nurses who have difficulty establishing positive interpersonal
relationships with clients and their families are at greater risk
for being sued for malpractice.

■ Each nurse should be aware of how laws such as Good
Samaritan immunity or legal access to incident reports are
implemented in the state in which they live.

■ New legislation pertaining to confidentiality (HIPAA) and
patient rights (e.g., PSDA) continues to shape nurse–client
interactions in the health-care system.

Additional Learning Exercises and Applications


Where Does Your Responsibility Lie?

Mrs. Shin is a 68-year-old patient with liver cancer. She
has been admitted to the oncology unit at Memorial
Hospital. Her admitting physician has advised
chemotherapy, even though she believes that there is
little chance of it working. The patient asks her doctor, in
your presence, if there is an alternative treatment to
chemotherapy. She replies, “Nothing else has proved to
be effective. Everything else is quackery, and you would
be wasting your money.” After the doctor leaves, the
patient and her family ask you if you know anything about
alternative treatments. When you indicate that you do

have some current literature available, they beg you to
share your information with them.


What do you do? What is your legal responsibility to
your patient, the doctor, and the hospital? Using
your knowledge of the legal process, the Nurse
Practice Act, patients’ rights, and legal precedents
(look for the case Tuma v. Board of Nursing, 1979;
The Climate Change and Public Health Law Site,
n.d.), explain what you would do and defend your


Legal Ramifications for Exceeding One’s

You have been the evening charge nurse in the
emergency department at Memorial Hospital for the last 2
years. Besides yourself, you have two licensed vocational
nurses (LVNs) and four registered nurses (RNs) working
in your department. Your normal staffing is to have two
RNs and one LVN on duty Monday to Thursday and one
LVN and three RNs on duty during the weekend.

It has become apparent that one of the LVNs, Maggie,
resents the recently imposed limitations of LVN duties

because she has had 10 years of experience in nursing,
including a tour of duty as a medic in the first Gulf War.
The emergency department physicians admire her and
are always asking her to assist them with any minor
wound repair. Occasionally, she has exceeded her job
description as an LVN in the hospital, although she has
done nothing illegal of which you are aware. You have
given her satisfactory performance evaluations in the
past, even though everyone is aware that she sometimes
pretends to be a “junior physician.” You also suspect that
the physicians sometimes allow her to perform duties
outside her licensure, but you have not investigated this
or seen it yourself.

Tonight, you come back from supper and find Maggie
suturing a deep laceration while the physician looks on.
They both realize that you are upset, and the physician
takes over the suturing. Later, the doctor comes to you
and says, “Don’t worry! She does a great job, and I’ll take
the responsibility for her actions.” You are not sure what
you should do. Maggie is a good employee, and taking
any action will result in unit conflict.


What are the legal ramifications of this case?
Discuss what you should do, if anything. What
responsibility and liability exist for the physician,
Maggie, and yourself? Use appropriate rationale to
support your decision.


To Float or Not to Float

You have been an obstetrical staff nurse at Memorial
Hospital for 25 years. The obstetrical unit census has
been abnormally low lately, although the patient census
in other areas of the hospital has been extremely high.
When you arrive at work today, you are told to float to the
thoracic surgery unit. This is a specialized unit, and you
feel ill prepared to work with the equipment on the unit
and the type of patients who are there. You call the
staffing office and ask to be reassigned to a different
area. You are told that the entire hospital is critically short
staffed, that the thoracic surgery unit is four nurses short,
and that you are at least as well equipped to handle that
unit as the other three staff who also are being floated.
Now, your anxiety level is even higher. You will be
expected to handle a full registered nurse patient load.
You also are aware that more than half of the staff on the
unit today will have no experience in thoracic surgery.
You consider whether to refuse to float. You do not want
to place your nursing license in jeopardy, yet you feel
conflicting obligations.


To whom do you have conflicting obligations? You
have little time to make this decision. Outline the
steps that you use to reach your final decision.
Identify the legal and ethical ramifications that may
result from your decision. Are they in conflict?


Is It Your Responsibility to Force the
Surgeon to See the Patient? (Marquis &
Huston, 2012)

Jimmy Smith is a 19-year-old male who had a severe
compound fracture of his tibia today in football practice.
He returned from the surgery to set and cast the leg at
4:00 PM today. The evening shift reported that he was
having quite a bit of swelling from the severe trauma that
accompanied the fracture, but that the toes on the
effected leg were warm and he had good pedal pulses.

By the time you received report tonight at 11:00 PM and
went to check on Jimmy, you felt that his pedal pulses
were slightly diminished and that his foot was slightly cool
to touch. By 2:00 AM, you felt the swelling had increased
slightly and his toes were quite cool, although they were
not blue.

You phoned his physician, and he was quite upset to
be awakened in the middle of the night. He instructed you
to put ice on the cast and to elevate Jimmy’s leg higher to
reduce the swelling. He promised you that he would see
Jimmy first thing in the morning. As the night wears on,
you become increasingly alarmed. By the time the night
supervisor arrived at 4:00 AM, you were so concerned
that you asked her to check the casted leg. The
supervisor rushed out of the room and said, “The
circulation in this boy’s leg is severely compromised, why
haven’t you gotten the doctor here to cut the cast?”


Have you committed malpractice? Has the doctor?
What is the nurse’s responsibility in reporting a
patient’s condition to their physician? Examine the
elements of malpractice. If there is permanent
damage to Jimmy’s leg, who will be liable for the
failure to act soon enough to prevent injury?

Cooper, A. B., Chidwick, P., Cybulski, P., & Sibbald, R. (2015).

Checklist to meet Ethical and Legal Obligations in the consent
pathway for critically ill patients (ChELO): A quality improvement
project and case studies. Canadian Journal of Critical Care
Nursing, 26(3), 16–24.

FindLaw. (2019). False imprisonment. Retrieved June 8, 2019, from

FindLaw for Legal Professionals. (2019). JUANITA SULLIVAN, indiv.
and as special adm’r of the estate of Burns Sullivan, deceased,
appellant, v. EDWARD HOSPITAL et al., appellees. No. 95409.
Retrieved June 8, 2019, from

Hale Law Firm. (2018). What is respondeat superior? Retrieved July
16, 2018, from

Hermosillo, A. (2019). Good Samaritan laws reduce the risk of
helping strangers. Retrieved June 8, 2019, from

Huston, C. J. (2020a). Assuring provider competence through
licensure, continuing education, and certification. In C. J. Huston

(Ed.), Professional issues in nursing: Challenges and
opportunities (5th ed., pp. 287–300). Philadelphia, PA: Wolters

Huston, C. J. (2020b). Diversity in the nursing workforce. In C. J.
Huston (Ed.), Professional issues in nursing: Challenges and
opportunities (5th ed., pp. 124–138). Philadelphia, PA: Wolters

Huston, C. J. (2020c). Unlicensed assistive personnel and the
registered nurse. In C. J. Huston (Ed.), Professional issues in
nursing: Challenges and opportunities (5th ed., pp. 112–123).
Philadelphia, PA: Wolters Kluwer.

Injury Trial Lawyers. (2018). Can nurses be sued for medical
malpractice? Retrieved July 19, 2018, from

Institute of Medicine. (1999). To err is human: Building a safer health
system. Retrieved July 17, 2018, from

Joint Commission on Accreditation of Healthcare Organizations.
(2005). Health care in the crossroads: Strategies for improving
the medical liability system and preventing patient injury.
Oakbrook Terrace, IL: Author.

Marquis, B., & Huston, C. (2012). Leadership and management tools
for the new nurse. Philadelphia, PA: Lippincott Williams &

Mascaranhas, C. (2018). The legal nurse consultant’s primer on
product liability. Journal of Legal Nurse Consulting, 29(1), 18–21.

MedlinePlus. (2019). Advance directives. Retrieved June 8, 2019,

Neil, H. P. (2015). Legally: What is quality care? Understanding
nursing standards. Medsurg Nursing, 24(1),14–15.

Silberman, M. J. (2015). Back to basics: The importance of patient
respect. AANA Journal, 83(5), 312–315.

The Climate Change and Public Health Law Site. (n.d.). Nurse
disciplined for telling patient about alternative treatments (court
reverses)—Tuma v. Board of Nursing, 100 Idaho 74, 593 P.2d
711 (Idaho Apr 17, 1979). Retrieved July 16, 2018, from

Thompson Defense Firm. (2019). Assault and battery. Retrieved
June 8, 2019, from



Patient, Subordinate,
Workplace, and Professional

. . . to see what is right, and not do it, is want of
courage, or of principles.—Confucius

. . . in our imperfect state of conscience and
enlightenment, publicity and the collision resulting from
publicity are the best guardians of the interest in the
sick.—Florence Nightingale

. . . No voice is too soft when that voice speaks for
others.—Janna Cachola


This chapter addresses:

BSN Essential II: Basic organizational and systems leadership
for quality care and patient safety

BSN Essential V: Health-care policy, finance, and regulatory

BSN Essential VI: Interprofessional communication and
collaboration for improving patient health outcomes

BSN Essential VIII: Professionalism and professional values

MSN Essential II: Organizational and systems leadership
MSN Essential VI: Health policy and advocacy
AONL Nurse Executive Competency II: A knowledge of the
health-care environment

AONL Nurse Executive Competency III: Leadership
AONL Nurse Executive Competency IV: Professionalism
ANA Standard of Professional Performance 7: Ethics
ANA Standard of Professional Performance 8: Culturally
congruent practice

ANA Standard of Professional Performance 9:

ANA Standard of Professional Performance 10:

ANA Standard of Professional Performance 11: Leadership
ANA Standard of Professional Performance 14: Quality of

ANA Standard of Professional Performance 16: Resource

ANA Standard of Professional Performance 17:
Environmental health

QSEN Competency: Patient-centered care
QSEN Competency: Teamwork and collaboration


The learner will:

differentiate between the manager’s responsibility to advocate
for patients, for subordinates, for the organization, for the
profession, and for self

identify values central to advocacy
differentiate between controlling patient choices and assisting
patients to choose

select an appropriate response that exemplifies advocacy in
given situations

identify entry points for user engagement in the health-care
system as well as strategies for patient and family engagement
in health care

describe the core concepts of person- and family-centered care
identify how the Patient’s Bill of Rights protects patients
describe ways a manager can advocate for subordinates
identify ways individual nurses can become advocates for the

identify both the risks and potential benefits of becoming a

specify both direct and indirect strategies to influence legislation
that promotes advocacy

describe strategies nurses can use to successfully interact with
the media

Advocacy—helping others to grow and self-actualize—is a critically
important leadership role. Many of the leadership skills that are
described in the following chapters, such as risk taking, vision, self-
confidence, ability to articulate needs, and assertiveness, are used in
the advocacy role.

Managers, by their many roles, must be advocates for the
profession, subordinates, workplace, and patients. The actions of an
advocate are to inform others of their rights and to be sure they have
adequate information on which to base their decisions. The term
advocacy can be stated in its simplest form as protecting and
defending what one believes in for both self and others (The Free
Dictionary, 2003–2019).

Nurses often are expected to advocate for patients when they are
unable to speak for themselves. Indeed, advocacy has been
recognized as one of the most vital and basic roles of the nursing
profession since the time of Florence Nightingale. Nurses, as the
frontline care providers, often have comprehensive knowledge and a
well-rounded perspective about patient care issues, both those of
direct care and system issues. When patients in the system are
without insurance, are denied care, or do not know how to access
appropriate care, nurses should have the knowledge competencies
to provide informational guidance regarding these or similar issues.

For example, one vulnerable population is the incarcerated, and
this is particularly true for the incarcerated with opioid addictions.
Indeed, only a small percentage of incarcerated people with opioid
addictions in the United States have access to what leading medical
organizations consider to be the standard of care: medication-
assisted treatment (MAT) (Linden, Marullo, Bone, Barry, & Bell,
2018). Of the nation’s 5,100 jails and prisons, fewer than 30
administer methadone or buprenorphine—the most proven method
of recovery. This forces inmates to suffer withdrawal and puts them
at risk of life-altering diseases, only to release them back into a world
with reduced tolerance, primed for unintentional overdose (Linden et
al., 2018).

Linden et al. (2018) suggest that denying access to MAT for
patients who medically require it violates the Eighth Amendment’s
prohibition of cruel and unusual punishment because it is
deliberately indifferent to the serious medical needs that opioid
dependency presents. Failure to provide MAT may also violate other
laws such as the Americans with Disabilities Act of 1990. It is nurses
who may be in the best position to advocate for compassionate
medical care in this vulnerable population (see Examining the
Evidence 6.1).

Source: Linden, M., Marullo, S., Bone, C., Barry, D. T.,
& Bell, K. (2018). Prisoners as patients: The opioid
epidemic, medication-assisted treatment, and the
eighth amendment. Journal of Law, Medicine &
Ethics, 46(2), 252–267.

A Case Study in Advocacy: Prisoners as
The United States has the highest rate of
incarceration of any nation in the world. The
prevalence of opioid use disorder is extremely
high in this population, putting the lives and
well-being of incarcerated people at risk. Yet in
the face of such great need, only a small
percentage of incarcerated people with opioid
addictions have access to what leading
medical organizations take to be the standard
of care: medication-assisted treatment (MAT).
MAT typically uses medications that are opioid
agonists, such as methadone and
buprenorphine-naloxone. Both allow patients to
pursue normal activities of daily living without
debilitating drug cravings.

In 2016, a Rhode Island government–
appointed task force advocated for a
comprehensive corrections-based MAT for
about 2,200 prisoners in that state. That
program was implemented in 2017.

Preliminary results, published in 2018,
compared results from the first 6 months of the
program to the period 1 year prior. As
expected, the number of inmates receiving

MAT in a given month grew significantly, from
80 inmates preimplementation to over 300
inmates afterward. The number of individuals
dying of overdose within 6 months of release
fell by 61%, from 26 deaths to 9 deaths, a
statistically significant result. Although these
results are preliminary and did not take place in
the context of a randomized controlled trial, the
reduction in deaths is remarkable and points to
both the impact of advocacy on the health of a
vulnerable population and the impact of MAT
programs themselves.

Nurses may act as advocates by helping others make
informed decisions, by acting as an intermediary in the
environment, or by directly intervening on behalf of

This chapter examines the processes through which advocacy is
learned as well as the ways in which leader-managers can advocate
for their patients, subordinates, and the profession. The role of
“whistleblower” as an advocacy role is discussed. Specific
suggestions for interacting with legislators and the media to influence
health policy are also included. Leadership roles and management
functions essential for advocacy are shown in Display 6.1.


Leadership Roles
1. Creates a climate where advocacy and its associated risk

taking are valued
2. Seeks fairness and justice for individuals who are unable to

advocate for themselves
3. Seeks to strengthen patient and subordinate support systems

to encourage autonomous, well-informed decision making
4. Role models the use of patient and family engagement

5. Influences others by providing information necessary to

empower them to act autonomously
6. Assertively advocates on behalf of patients and subordinates

when an intermediary is necessary
7. Participates in professional nursing organizations and other

groups that seek to advance the profession of nursing
8. Role models proactive involvement in health-care policy

through both formal and informal interactions with the media
and legislative representatives

9. Works to establish the creation of a national, legally binding
Patient’s Bill of Rights

10. Speaks up when appropriate to advocate for health-care
practices necessary for safety and quality improvement

11. Supports workers who report perceived wrongdoings through

12. Advocates for social justice in addition to individual patient

13. Appropriately differentiates between controlling patient
choices (domination and dependence) and in assisting patient
choices (allowing freedom)

Management Functions
1. Assures that subordinates and patients have adequate

information to make informed decisions
2. Establishes a work climate that prioritizes the rights and

values of patients in health-care decision making
3. Seeks appropriate consultation when advocacy results in

intrapersonal or interpersonal conflict
4. Promotes and protects the workplace safety and health of

subordinates and patients
5. Encourages subordinates to bring forth concerns about the

employment setting and seeks impunity for whistleblowers
6. Demonstrates the skills needed to interact appropriately with

the media and legislators regarding nursing and health-care

7. Is aware of current legislative efforts affecting nursing practice
and organizational and unit management

8. Assures that the work environment is both safe and
conducive to professional and personal growth for

9. Creates work environments that promote subordinate
empowerment so that workers have the courage to speak up
for patients, themselves, and their profession

10. Takes immediate action when illegal, unethical, or
inappropriate behavior occurs that can endanger or jeopardize
the best interests of the patient, the employee, or the

Becoming an Advocate
Although advocacy is present in all clinical practice settings, the
nursing literature contains only limited descriptions of how nurses
learn the advocacy role, and some experts have even questioned

whether advocacy can be taught at all. Some students learn about
the advocacy role as part of ethics or policy content in their nursing
education, and although most undergraduate and graduate
programs likely include some type of advocacy instruction, the extent
or impact of this education is largely unknown.

Regardless of how or when advocacy is learned, or the extent to
which it is used, there are nursing values central to advocacy. These
values emphasize caring, autonomy, respect, and empowerment
(Display 6.2).


1. Every individual has a right to autonomy in deciding what
course of action is most appropriate to meet his or her health-
care goals.

2. Every individual has a right to hold personal values and to use
those values in making health-care decisions.

3. All individuals should have access to the information they need
to make informed decisions and choices.

4. The nurse must act on behalf of patients who are unable to
advocate for themselves.

5. Empowerment of patients and subordinates to make decisions
and act on their own is the essence of advocacy.

The nursing values central to advocacy emphasize
caring, autonomy, respect, and empowerment.

Patient Advocacy
Standard VII of the American Nurses Association (ANA, 2015b)
Scope and Standards of Practice states that the registered nurse
practices ethically. As such, the registered nurse is expected to take

appropriate action regarding instances of illegal, unethical, and
inappropriate behaviors that can endanger or jeopardize the best
interests of the health-care consumer or situation; speak up when
appropriate to question health-care practice when necessary for
safety and quality improvement; and advocate for equitable health-
care consumer care.


Values and Advocacy

How important a role do you believe advocacy to be in
nursing? Do you believe that your willingness to assume
this role is a learned value? Were the values of caring
and service emphasized in your family and/or community
when you were growing up? Have you identified any role
models in nursing who actively advocate for patients,
subordinates, or the profession? What strategies might
you use as a new nurse to impart the need for advocacy
to your peers and to the student nurses who work with

This patient advocacy is necessary because disease almost
always results in decreased independence, loss of freedom, and
interference with the ability to make choices autonomously. In
addition, aging, as well as physical, mental, or social disability, may
make individuals more vulnerable and in need of advocacy. Thus,
advocacy becomes the foundation and essence of nursing, and
nurses have a responsibility to promote human advocacy.

These ideas are also reinforced in the ANA (2015a) Code of
Ethics for Nurses With Interpretive Statements. Provision 2 of the
Code suggests that the nurse’s primary commitment is to the patient,
whether an individual, family, group, community or population.
Provision 3 suggests that the nurse promotes, advocates for, and
protects the rights, health and safety of the patient.

Patient and Family Engagement
In addition, in 2013, the American Hospital Association (AHA)
Committee on Research released a report entitled Engaging Health
Care Users: A Framework for Healthy Individuals and Communities,
suggesting that health-care user engagement is a key ingredient in
reaching the triple aim of better population health, enhanced patient
experience, and lower costs (AHA, 2019). The report suggested that
hospitals must become more “activist” in their efforts to engage
patients and that a continuum for engagement from information
sharing to partnerships must exist. The report went on to
recommend entry points for user engagement at four different levels
of the health-care system as shown in Display 6.3.


Individual: The aim is to increase the skills, knowledge, and
understanding of patients and families about what to expect
when receiving care.

Health-care team: The focus is to promote shared
understanding of expectations among patients and providers
when seeking care.

Organization: The objective is to encourage partnerships and
integrate the patient and family perspective into all aspects of
hospital operations.

Community: The emphasis is to expand the focus beyond the
hospital setting and find opportunities to improve overall
community health.

Source: American Hospital Association. (2019). Engaging health care users: A
framework for healthy individuals and communities. Retrieved June 8, 2019, from

In addition, the Agency for Healthcare Research and Quality
(AHRQ, 2017) developed the Guide to Patient and Family
Engagement in Hospital Quality and Safety to help patients, families,
and health professionals work together as partners to promote
improvements in care. The Guide (AHRQ, 2017) outlines four
strategies hospitals can use to connect with patients and families,
including the following:

Encourage patients and family members to participate as

Promote better communication among patients, family
members, and health-care professionals from the point of

Implement safe continuity of care by keeping the patient and
family informed through nurse bedside change-of-shift reports.

Engage patients and families in discharge planning throughout
the hospital stay.

Managers also must advocate for patients regarding distribution of
resources and the use of technology. The advances in science and
limits of financial resources have created new problems and ethical
dilemmas. For example, although diagnosis-related groupings may
have eased the strain on government fiscal resources, they have
created ethical problems, such as patient dumping, premature
patient discharge, and inequality of care.

Common areas in which nurses must advocate for patients are
shown in Display 6.4.


1. End-of-life decisions
2. Technological advances
3. Health-care reimbursement
4. Access to health care
5. Transitions in health care
6. Provider–patient conflicts regarding expectations and desired

7. Withholding of information or blatant lying to patients
8. Insurance authorizations, denials, and delays in coverage
9. Medical errors
10. Patient information disclosure (privacy and confidentiality)
11. Patient grievance and appeals processes
12. Cultural and ethnic diversity and sensitivity
13. Respect for patient dignity
14. Inadequate consents
15. Incompetent health-care providers
16. Complex social problems including AIDS, teenage pregnancy,

violence, and poverty
17. Aging population


Culture and Decisions

You are a staff nurse on a medical unit. One of your
patients, Mr. Dau, is a 56-year-old Hmong immigrant to

the United States. He has lived in the United States for 4
years and became a citizen 2 years ago. His English is
marginal, although he understands more than he can
verbalize. He was admitted to the hospital with sepsis
resulting from urinary tract infection. His condition is now

Today, Mr. Dau’s physician informed him that his
computed tomography scan shows a large tumor in his
prostate. The physician wants to do immediate follow-up
testing and surgical resection of the tumor to relieve his
symptoms of hesitancy and urinary retention. Although
the tumor is probably cancerous, the physician believes
that it will respond well to traditional oncology treatments.
The expectation is that Mr. Dau should recover fully.

One hour later, when you go in to check on Mr. Dau,
you find him sitting on his bed with his suitcase packed,
waiting for a ride home. He informs you that he is
checking out of the hospital. He states that he believes
he can make himself better at home with herbs and
through prayers by the Hmong shaman. He concludes by
telling you, “If I am meant to die, there is little anyone can
do.” When you reaffirm the hopeful prognosis reported by
his physician that morning, Mr. Dau says, “The doctor is
just trying to give me false hope. I need to go home and
prepare for my death.”


What should you do? How can you best advocate
for this patient? Is the problem a lack of
information? How does culture play a role in the
patient’s decision? Does a lack of understanding on
this patient’s part justify paternalism?

Person- and Family-Centered Care
The Institute for Healthcare Improvement (2019) notes that patient-
and family-centered care (also known as patient-centered care) is an
innovative approach to the planning, delivery, and evaluation of
health care that emphasizes partnerships between clinicians and
individuals where the values, needs, and preferences of the
individual are honored; the best evidence is applied; and the shared
goal is optimal functional health and quality of life. Thus, it

humanizes, personalizes, and demystifies the patient experience
(Planetree, 2018).

Planetree argues that patient-centered care is the “right thing to
do” (Planetree, 2018). The Institute for Patient- and Family-Centered
Care (IPFCC, 2019) agrees, suggesting that patient- and family-
centered care is an approach to the planning, delivery, and
evaluation of health care that is grounded in mutually beneficial
partnerships among health-care providers, patients, and families,
thus redefining the relationships in health care. Core concepts of
patient- and family-centered care are shown in Display 6.5.


Patient care is organized first and foremost around the needs of

Patient and family perspectives are sought out, and their
choices are honored.

Patient and family knowledge, values, beliefs, and cultural
backgrounds are incorporated into the planning and delivery of

Health-care providers communicate openly and honestly with
patients and families to empower them to be effective partners
in their health-care decision making.

Patients and families are encouraged and supported in
participating in care and decision making at the level they

Patients, families, and health-care providers collaborate in
policy and program development, implementation, and
evaluation; in research; in facility design; and in professional
education as well as in the delivery of care.

The voice of the patient and family is represented at both the
organizational and policy levels as well as at the health
system’s strategic planning.

Sources: Planetree. (2018). History of Planetree. Retrieved June 8, 2019, from; and Institute for Patient-
and Family-Centered Care. (2019). Patient- and family-centered care. Retrieved
June 8, 2019, from

Planetree and the IPFCC have been two of the most prominent
pioneers in developing and promoting patient- and family-centered
care. Planetree is a mission-based, not-for-profit organization that
partners with health-care organizations around the world and across
the care continuum to transform how care is delivered (Planetree,

2018). Guided by a foundation in 10 components of patient-centered
care, Planetree informs policy at a national level, aligns strategies at
a system level, guides implementation of care delivery practices at
an organizational level, and facilitates compassionate human
interactions at a deeply personal level. Their philosophical conviction
that patient-centered care is the right thing to do is supported by a
structured process that enables sustainable change (Planetree,

Founded in 1992, the IPFCC is a not-for-profit organization
offering health-care providers and institutions information and core
guiding concepts related to patient- and family-centered care. These
concepts include open visitation; family presence during all
procedures; patient, family, and staff communication and
collaboration in care plan development, multidisciplinary rounds, and
bedside handoffs between nurses; information availability in patient
and family resource centers; and the use of patient and family
advisors in performance and safety improvement efforts (IPFCC,
2019). In addition, the model encourages the use of soft colors,
lighting, homelike fabrics, and music for patient rooms and common
areas as well as opportunities for patients and families to learn about
their illness to foster participation in their care.


Changing Organization Cultures to Be
Patient and Family Centered

Adoption of patient- and family-centered care often
requires changing an organization culture so that patients
and families are truly recognized as partners in care,

whether at the bedside or at the institutional level in
strategic planning. It also requires a reconsideration of
many of the rules and barriers often in place that pose
obstacles for patients and families to be active
participants in care decisions.


Select any one of the following
rules/procedures/situations common to many
hospitals and write a one-page essay outlining why
it would not be consistent with a patient- and family-
centered care approach. Include in the discussion
how the rule/procedure/situation could be changed
to better reflect the core concepts shown in Display
1. Visiting hours end at 9:00 PM unless someone is

willing to “bend the rules.”
2. Only one visitor is allowed at a time in the critical

care units and then for only 20 minutes every

3. Flat, comfortable sleeping surfaces are not
readily available for family members who wish to
spend the night in patient rooms.

4. Physicians typically make patient care rounds
between 7:00 AM and 8:00 PM before family
members have arrived.

5. Handoff report occurs behind closed doors, and
family members do not participate.

6. Family lounges are too small to accommodate
all visitors during peak visiting hours.

7. Staff complain in handoff report that patients are
unwilling to follow the plan of care rather than
asking if the patients themselves were involved
in determining the plan of care.

8. Dining halls are open only to staff in the middle
of the night.

Patient Rights

Until the 1960s, patients had few rights; in fact, patients often were
denied basic human rights during a time when they were most
vulnerable. This changed with the adoption of the Consumer Bill of
Rights and Responsibilities, also known as the Patient’s Bill of Rights
in 1998. This document had three key goals: (a) to help patients feel
more confident in the US health-care system, (b) to stress the
importance of a strong relationship between patients and their
health-care providers, and (c) to stress the key role patients play in
staying healthy by laying out rights and responsibilities for all
patients and health-care providers (American Cancer Society, 2019).

Since that time, the National League for Nursing, the AHA, and
many other organizations have created documents outlining the
rights of patients. Although not legally binding, these documents do
guide health-care organizations and practitioners in terms of
professional expectations for patient advocacy. Some federal laws
do exist, though, in terms of patient rights such as the right to get a
copy of one’s medical records and the right to keep them private
(MedlinePlus, 2019).

In addition, with the passage of the Patient Protection and
Affordable Care Act in 2010, a new Patient’s Bill of Rights was
established to give new patient protections in dealing with insurance
companies (American Cancer Society, 2019). These protections,
which phased in between 2010 and 2014, included the elimination of
annual and lifetime coverage limits, provided for choice of physician
from a plan’s network, allowed children to get health insurance in
spite of existing medical conditions, allowed children to stay on a
parent’s policy until age 26 years if they met other requirements, and
restricted health insurance companies from being able to rescind
(take back) health coverage because of honest mistakes on
insurance applications.

The government, in its role as the single largest insurer of health
care, has also influenced the protection of patient rights by linking
reimbursement with patient right provisions. For example, in 2011,

the U.S. Department of Health and Human Services mandated that
all hospitals that receive Medicare and Medicaid funding must
protect the visitation rights of lesbian, gay, bisexual, and transgender
(LGBT) patients (The Human Rights Campaign, 2019). Learning
Exercise 6.4 addresses the rights of LGBT patients.


Advocating for a Transgender Patient

You are the charge nurse on a medical unit. Today,
during walking rounds, a male-to-female transgender
patient tells you that she hears the staff whispering and
making fun of her in the hallway outside her room. She
says this is hurtful and that although the staff may lack
clarity about her gender identity, she does not, and that
becoming a woman is all she ever wanted. She said that
friends who have come to visit her have also been made
to feel uncomfortable.


1. How best can you advocate for this patient?
2. What leadership roles could you employ to

address the lack of compassion and advocacy
for this patient with the staff?

3. What policies should be created to assure
compliance with the U.S. Department of Health
and Human Services mandate to protect the
visitation rights of this patient’s friends and
significant others?

There has also been significant progress in patient rights related to
the privacy of health-care information, including the Health Insurance
Portability and Accountability Act of 1996 (HIPAA). In addition,
legislation—the American Recovery and Reinvestment Act of 2009—
maintains and expands HIPAA guidelines as they are related to
patient health information privacy and security protections.

States have also created bills of rights. In 1994, the Illinois
General Assembly (n.d.) established a Medical Patient Rights Act
that established certain rights for medical patients and provided a
penalty for violations of these rights. California has adopted a similar
patient guide pertaining to health-care rights and remedies (Display
6.6). These guidelines, however, are not legally binding, although
they may influence federal or state funding and certainly should be
considered professionally binding.


In accordance with Section 70707 of the California Administrative
Code, the hospital and medical staff have adopted the following
list of patient rights to
1. Exercise these rights without regard to sex; cultural,

economic, educational, or religious background; or the source
of payment for care

2. Considerate and respectful care
3. Knowledge of the name of the physician who has primary

responsibility for coordinating care and the names and
professional relationships of other physicians who will see the

4. Receive information from the physician about illness, course
of treatment, and prospects for recovery in terms the patient
can understand.

5. Receive as much information about any proposed treatment
or procedure as the patient may need to give informed
consent or to refuse this course of treatment. Except in
emergencies, this information shall include a description of the
procedure or treatment, the medically significant risks involved
in this treatment, alternate course of treatment or
nontreatment and the risks involved in each, and the name of
the person who will carry out the procedure or treatment.

6. Participate actively in decisions regarding medical care. To
the extent permitted by law, this includes the right to refuse

7. Full consideration of privacy concerning medical care
program. Case discussion, consultation, examination, and
treatment are confidential and should be conducted discreetly.
The patient has the right to be advised of the reason for the
presence of any individual.

8. Confidential treatment of all communications and records
pertaining to the patient’s care and stay in the hospital. Written
permission shall be obtained before medical records are made
available to anyone not directly concerned with the patient’s

9. Reasonable responses to any reasonable requests for

10. Ability to leave the hospital even against the advice of the

11. Reasonable continuity of care and to know in advance the
time and location of appointment and the physician providing

12. Be advised if hospital/personal physician proposes to engage
in or perform human experimentation affecting care or
treatment. The patient has the right to refuse to participate in
such research projects.

13. Be informed by the physician or a delegate of the physician of
continuing health-care requirements following discharge from
the hospital

14. Examine and receive an explanation of the bill, regardless of
source of payment.

15. Know which hospital rules and policies apply to the patient’s

16. Have all patient’s rights apply to the person who may have
legal responsibility to make decisions regarding medical care
on behalf of the patient.

Source: Consumer Watchdog. (n.d.). The California patient’s guide. Your health
care rights and remedies. Retrieved August 2, 2018, from

Some legally binding legislation has been passed, however, to
safeguard vulnerable populations. One such legislation, the Genetic

Information Nondiscrimination Act, is a federal law passed in 2008,
making it illegal for health insurers or employers to discriminate
against individuals based on their genetic information (Genetics
Home Reference, 2019).

Genetics Home Reference (2019) notes that

the law has two parts: Title I, which prohibits genetic
discrimination in health insurance, and Title II, which prohibits
genetic discrimination in employment. Title I makes it illegal for
health insurance providers to use or require genetic information
to make decisions about a person’s insurance eligibility or
coverage. This part of the law went into effect on May 21, 2009.
Title II makes it illegal for employers to use a person’s genetic
information when making decisions about hiring, promotion, and
several other terms of employment. This part of the law went
into effect on November 21, 2009. (para. 2–3)

Other countries have passed legally binding legislation as well.
The Deprivation of Liberty Safeguards, an amendment to the United
Kingdom’s 2005 Mental Capacity Act, provides some protection for
residents in care homes from unneeded use of physical restraints
and other loss of liberties. Similarly, mental health patients who are
involuntarily admitted to hospitals in Alberta, Canada, are afforded
some legal protections, including the Mental Health Act of Alberta.
This act provides the authority, protocols, and timelines for admitting,
detaining, and treating persons with serious mental disorders.

The Right to Die Movement and Physician-
Assisted Suicide
At times, individual rights must be superseded to ensure the safety
of all parties involved. It is important, however, for the patient
advocate to know the difference between controlling patient choices
and assisting patients to choose. Health-care professionals often

have knowledge that patients do not have but must be careful not to
use paternalism at the cost of patient autonomy.

It is important for the patient advocate to be able to
differentiate between controlling patient choices
(domination and dependence) and assisting patient
choices (allowing freedom).

For example, the right to die movement has gained momentum in
the past decade. In 1997, Oregon became the first state to allow
terminally ill people to receive lethal doses of medication from their
doctors. By mid-2019, seven other states had followed suit
(Washington, Vermont, California, Colorado, Hawaii, New Jersey,
and District of Columbia), and Montana allowed it by court decision
(Death with Dignity, 2019). Multiple other states are considering
legislation for physician-assisted suicide (PAS) as well.

Typically, right to die laws apply only to patients who are at least
18 years old, with the capacity to make medical decisions, with a
terminal disease expected to result in death within 6 months. The
California End of Life Option Act requires the patient to make two
verbal requests at least 15 days apart and one written request that is
signed, dated, and witnessed by two adults (McGreevy, 2016). The
patient may rescind the request for an aid-in-dying drug at any time
and in any manner, and a request for a prescription cannot be made
on behalf of a patient through an agent under a power of attorney, an
advance health-care directive, a conservator, or any other person
(McGreevy, 2016). Once the prescription is filled, the patient must
complete a “Final Attestation for an Aid-in-Dying Drug to End My Life
in a Humane and Dignified Manner” form within 48 hours before self-
administering the drug. Although the law is silent as to what cause of
death should be identified on the death certificate, it does say taking
an aid-in-dying drug “shall not constitute suicide” (McGreevy, 2016).

Debates, however, around the impetus for and ethics of PAS
continue to rage. Although many proponents characterize the action
as a liberation from suffering, opponents suggest that advances in
pain control and hospice care could address many of the issues
driving terminally ill patients to seek PAS (McGreevy, 2016).

Physicians do have the legal right to choose whether they will
participate in PAS. “A healthcare provider who refuses to participate
in activities under the act on the basis of conscience, morality or
ethics cannot be subject to censure, discipline . . . or other penalty
by a healthcare provider, professional association or organization”
(McGreevy, 2016, para. 19). Physicians who do participate are
protected from criminal, civil, and administrative liability if they follow
the requirements.

Gallagher (2016) notes, however, that helping patients make
decisions about PAS, and supporting them in their choices, is difficult
even when impending death is a certainty. “All anyone can do is
guarantee each individual the freedom of decision and to determine
what he or she deems best for his or her own body or mental well-
being” (Gallagher, 2016, para. 5).

The bottom line is that patients are increasingly aware that they
have rights, and as a result, they are more assertive and involved in
their health care. They want to know and understand their treatment
options and to be participants in decisions about their health care.
Leader-managers have a responsibility to see that all patient rights
are met, including the right to privacy and personal liberty, which are
guaranteed by the Constitution.

Subordinate and Workplace Advocacy
Subordinate advocacy is a neglected concept in management theory
but is an essential part of the leadership role. Standard 7 of the ANA
(2016) Nursing Administration: Scope and Standards of Practice
suggests that nurse administrators should advocate for other health-

care providers (including subordinates) as well as patients,
especially when this is related to health and safety.

For example, workplace advocacy is a critical role that managers
assume to promote subordinate advocacy. In this type of advocacy,
the manager assures the work environment is both safe and
conducive to professional and personal growth for subordinates. For
example, managers should assure that Occupational Safety and
Health Administration (OSHA) guidelines for worker safety are
followed. Educating staff about proper body mechanics and assuring
that staffing is adequate for safely ambulating and turning patients
can reduce the incidence of back injuries in health-care workers. In
addition, occupational health and safety must be assured by
interventions such as reducing worker exposure to workplace
violence, needle sticks, or blood and body fluids. When these
working conditions do not exist, managers must advocate to higher
levels of the administrative hierarchy to correct the problems.

In addition, workplace advocacy is needed to address workplace
violence, an ever-increasing problem in contemporary society but
particularly in the health-care system. OSHA reported that from 2002
to 2013, incidents of serious workplace violence were 4 times more
common in health-care settings than in private industry, leading
Durkin (2017) to suggest that workplace violence occurs so often in
the hospital that some health-care workers consider it part of the job.

Clearly, no health-care worker is immune to workplace violence,
but nurses are at particularly high risk. Durkin (2017) noted that
among participants in a Minnesota Nurses’ Study, the yearly
incidence of verbal and physical assaults was 39% and 13%,
respectively. Yet, only 30% of nurses and 26% of physicians report
workplace violence that has occurred.

In addition, the AHA reported in 2017 that beyond the human toll,
hospitals spent an estimated $1.1 billion in security and training
costs to prevent violence within their facilities, plus $429 million in
medical care, staffing, indemnity, and other costs resulting from

violence against hospital workers (Durkin, 2017). “Hospitals and
clinicians must increasingly recognize workplace violence as a
problem and employ strategies to deal with it, or better yet, stop it
before it happens” (Durkin, 2017, para. 1).

Subordinates should also be able to have the expectation that
their work hours and schedules will be reasonable, that staffing
ratios will be adequate to support safe patient care, that wages will
be fair and equitable, and that nurses will be allowed participation in
organizational decision making. When the health-care industry has
faced the crisis of inadequate human resources and nursing
shortages, many organizations have made quick, poorly thought-out
decisions to find short-term solutions to a long-term and severe
problem. New workers have been recruited at a phenomenally high
cost; yet, the problems that caused high worker attrition were not
solved. Upper level managers must advocate for subordinates in
solving problems and making decisions about how best to use
limited resources. These decisions must be made carefully, following
a thorough examination of the political, social, economic, and ethical

Another way leaders advocate for subordinates is in creating a
work environment that promotes risk taking and leadership. For
example, administrators should foster work environments that
promote subordinate empowerment so that workers have the
courage to speak up for patients, themselves, and their profession.
In addition, managers must help members of their health-care team
resolve ethical problems and work effectively with solutions at the
unit level.

Gerber (2018) agrees, noting that the organization’s commitment
to promoting nurse–patient advocacy is of utmost importance.
Health-care administrators must maintain an effective and efficient
chain of command so that clinical nurses know where to report
concerns and how to access the chain of command.

The following are suggestions for creating an environment that
promotes subordinate advocacy:

Invite collaborative decision making.
Listen to staff needs.
Get to know staff personally.
Take time to understand the challenges faced by the staff in

delivering care.
Face challenges and solve problems together.
Support staff as needed.
Promote shared governance.
Empower staff.
Promote nurse autonomy.
Provide staff with workable systems.

Managers must recognize what subordinates are striving for and
the goals and values that subordinates consider appropriate. The
leader-manager should be able to guide subordinates toward
actualization while defending their right to autonomy. To help nurses
deal with ethical dilemmas in their practice, nurse-managers should
establish and utilize appropriate support groups, ethics committees,
and channels for dealing with ethical problems.


How Can You Best Advocate?

You are a unit supervisor in a skilled nursing facility.
One of your aides, Martha Greenwald, recently reported
that she suffered a “back strain” several weeks ago when
she was lifting an elderly patient. She did not report the

injury at the time because she did not think it was
serious. Indeed, she finished the remainder of her shift
and has performed all her normal work duties since that

Today, Martha reports that she has just left her
physician’s office and that he has advised her to take 4 to
6 weeks off from work to fully recover from her injury. He
has also prescribed physical therapy and electrical nerve
stimulation for the chronic pain. Martha is a relatively new
employee, so she has not yet accrued enough sick leave
to cover her absence. She asks you to complete the
paperwork for her absence and the cost of her treatments
to be covered as a work-related injury.

When you contact the workers’ compensation case
manager for your facility, she states that the claim will be
investigated; however, with no written or verbal report of
the injury at the time it occurred, there is great likelihood
that the claim will be rejected.


How best can you advocate for this subordinate?

Whistleblowing as Advocacy
The public has become much more aware of ethical malfeasance
within its institutions and corporate organizations because of various
scandals that have occurred in the last 50 years. From Watergate to
Morgan Stanley to Bernard Madoff’s Ponzi scheme, the American
public has been fed a diet of wrongdoing that has led to an increase
in moral awareness.

Wrongdoing does not stop at large corporations or political activity,
it also occurs within health-care organizations. Huston (2020c)
suggests that in an era of managed care, declining reimbursements,
and the ongoing pressure to remain fiscally solvent, the risk of fraud,
misrepresentation, and ethical malfeasance in health-care
organizations has never been higher. As a result, the need for
whistleblowing has also likely never been greater.

Huston (2020c) also suggests that there are basically two types of
whistleblowing. Internal whistleblowing occurs within an organization,
reporting up the chain of command. External whistleblowing involves
reporting outside the organization such as the media and an elected
official. An example of whistleblowing by a health-care provider
might be to report inflated practices of documentation and coding
that result in elevated cost reimbursement.

Huston (2020c) notes that nurses as health-care professionals
have a responsibility to uncover, openly discuss, and condemn
shortcuts, which threaten the clients they serve. It is important,
however, to remember that whistleblowing should never be
considered the first solution to ethically troubling behavior. Indeed, it
should be considered only after other prescribed avenues of solving

problems have been attempted. This is true, however, only if
patients’ lives are not at stake. In those cases, immediate action
must be taken.

In addition, the employee should typically go up the chain of
command in reporting his or her concerns. This process, however,
must be modified when the immediate supervisor is the source of the
problem. In such a case, the employee might need to skip that level
to see that the problem is addressed. Indeed, most whistleblowers
would rather raise the issue internally to their manager than take it
outside. Thus, companies generally get the opportunity to resolve
issues internally—the question is whether they will take this
opportunity or miss it.

There are other general guidelines for blowing the whistle that
should also be followed, including carefully documenting all attempts
to address the problem and being sure to report facts and not
personal interpretations. These guidelines, as well as others, are
presented in Display 6.7.


Stay calm and think about the risks and outcomes before you

Know your legal rights because laws protecting whistleblowers
vary by state.

First, make sure that there really is a problem. Check resources
such as the medical library, the Internet, and institutional policy
manuals to be sure.

Seek validation from colleagues that there is a problem, but do
not get swayed by groupthink into not doing anything if you

Follow the chain of command in reporting your concerns
whenever possible.

Confront those accused of the wrongdoing as a group whenever

Present just the evidence; leave the interpretation of facts to
others. Remember that there may be an innocent or good
explanation for what is occurring.

Use internal mechanisms within your organization.
If internal mechanisms do not work, use external mechanisms.
Private groups, such as The Joint Commission or the National

Committee for Quality Assurance, do not confer protection. You
must report to a state or national regulator.

Although it is not required by every regulatory agency, it is a
good rule of thumb to put your complaint in writing.

Document carefully the problem that you have seen and the
steps that you have taken to see that it is addressed.

Do not lose your temper, even if those who learn of your actions
attempt to provoke you.

Do not expect thanks for your efforts.

Source: Adapted from American Nurses Association. (n.d.). Things to know about
whistle blowing. Retrieved July 19, 2018, from

It is interesting to note that although much of the public wants
wrongdoing or corruption to be reported, such behavior is often
looked on with distrust, and whistleblowers may be considered
disloyal or experience repercussions for their actions, even if the
whistleblowing was done with the best of intentions. The
whistleblower cannot even trust that other health-care professionals,
with similar belief systems about advocacy, will value their efforts
because the public’s feelings about whistleblowers are so mixed
(Huston, 2020c).

Ahern (2018) agrees, noting that despite health-care codes of
conduct, retaliation against nurses who report misconduct is
common, as are outcomes of sadness, anxiety, and a pervasive loss
of sense of worth in the whistleblower. Whistleblowers often feel
traumatized by the emotional manipulation many employers routinely
use to discredit and punish employees who report misconduct. This
creates a situation where the whistleblower doubts his or her
perceptions, competence, and mental state, and over time, these
strategies can trap the whistleblower in a maze of enforced
helplessness (Ahern, 2018).

Speaking out as a whistleblower is often honored more in
theory than in fact.

Leader-managers then must be willing to advocate for
whistleblowers so that they feel assured, that if they are acting within
the scope of their expertise, and that remedy can be sought through
appropriate channels without fear of retaliation. Unfortunately, there
has been a collective silence in many cases of ethical malfeasance.

The reality is that whistleblowing offers no guarantee that the
situation will change or the problem will improve, and the literature is
replete with horror stories regarding negative consequences endured
by whistleblowers. For all these reasons, it takes tremendous
courage to come forward as a whistleblower. It also takes a
tremendous sense of what is right and what is wrong as well as a
commitment to follow a problem through until an acceptable level of
resolution is reached (Huston, 2020c).

Leader-managers must be willing to advocate for
whistleblowers who speak out about organizational
practices that they believe may be harmful or

Although whistleblower protection has been advocated at the
federal level and has passed in some states, many employees are
reluctant to report unsafe conditions for fear of retaliation. Nurses
should check with their state association to assess the status of
whistleblower protection in their state. At present, there is no
universal legal protection for whistleblowers in the United States.

Professional Advocacy
Leader-managers also must be advocates for the nursing profession.
This type of advocacy has a long history in nursing. It was nurses
who pushed for accountability through state Nurse Practice Acts and
state licensing, although this was not accomplished until 1903.
Advocating for professional nursing is a leadership role.

Joining a profession requires making a personal decision to
involve oneself in a system of socially defined roles. Thus, entry into
a profession involves a personal and public promise to serve others
with the special expertise that a profession can provide and that
society legitimately expects it to provide.


Write It Down. How Can You Advocate?

Write a two-page essay about one of the following
1. List five things that you would like to change

about nursing or the health-care system.
Prioritize the changes that you have identified.
Identify the strategies that you could use
individually and collectively as a profession to
make the change happen. Be sure that you are
realistic about the time, energy, and fiscal
resources you have to implement your plan.

2. Do you belong to your state nursing organization
or student nursing organization? Why or why
not? Make a list of six other things that you could
do to advocate for the profession. Be specific
and realistic in terms of your energy and
commitment to nursing as a profession.

Professional issues are always ethical issues. When nurses find a
discrepancy between their perceived role and society’s expectations,
they have a responsibility to advocate for the profession. At times,
individual nurses believe that the problems of the profession are too
big for them to make a difference; however, their commitment to their
profession obligates them to ask questions and think about problems
that affect the profession. They cannot afford to become powerless
or helpless or claim that one person cannot make a difference.

Often, one voice is all it takes to raise the consciousness of
colleagues within a profession. Accepting the challenge to be an
advocate for the profession is a choice.

A professional commitment means that people cannot
shrink from their duty to question and contemplate
problems that face the profession.

Nursing’s Advocacy Role in Legislation and
Public Policy
A distinctive feature of American society is how citizens can
participate in the political process. People have the right to express
their opinions about issues and candidates by voting. People also
have relatively easy access to lawmakers and policy makers and can
make their individual needs and wants known. Theoretically, then,
any one person can influence those in policy-making positions. This
rarely happens, however; policy decisions are generally focused on
group needs or wants.

Much attention has recently been paid to nurses and the
importance of the nursing profession and how nurses impact health-
care delivery. This has been especially true in the areas of patient
safety, staff shortages, and full practice authority.

In addition to active participation in national nursing organizations,
nurses can influence legislation and health policy in many other
ways. Nurses who want to be directly involved can lobby legislators
either in person or by letter. This process may seem intimidating to
the new nurse; however, there are many books and workshops
available that deal with the subject, and a common format is used.
Nurses can also influence legislators through social media.

In addition to nurse-leaders and individual nurses, there is a need
for collective influence to impact health-care policy. The need for

organized group efforts by nurses to influence legislative policy has
long been recognized in this country. In fact, the first state
associations were organized expressly for unifying nurses to
influence the passage of state licensure laws.

Nurses must exert their collective influence and make
their concerns known to policy makers before they can
have a major impact on political and legislative

Political action committees (PACs) attempt to persuade legislators
to vote in a particular way. Lobbyists of the PAC may be members of
a group interested in a specific law or paid agents of the group that
wants a specific bill passed or defeated. Nursing must become more
actively involved with PACs to influence health-care legislation, and
PACs provide one opportunity for small donors to feel like they are
making a difference.

In addition, professional organizations generally espouse
standards of care that are higher than those required by law.
Voluntary controls often are forerunners of legal controls. What
nursing is and should be depends on nurses taking an active part in
their professional organizations. Currently, nursing lobbyists in our
nation’s capital are influencing legislation on quality of care, access
to care issues, patient and health worker safety, health-care
restructuring, direct reimbursement for advanced practice nurses,
and funding for nursing education. Representatives of the ANA
regularly participate in meetings of the U.S. Department of Health
and Human Services, the National Institutes of Health, OSHA, and
the White House to be sure that the “nursing perspective” is heard in
health policy issues (Huston, 2020a).

Collectively, the nursing profession has not yet recognized the full
potential of collective political activity. Nurses must exert their

collective influence and make their concerns known to policy makers
before they can have a major impact on political and legislative
outcomes. Because they have been reluctant to become politically
involved, nurses have failed to have a strong legislative voice in the
past. Legislators and policy makers are more willing to deal with
nurses as a group rather than as individuals; thus, joining and
supporting professional organizations allow nurses to become active
in lobbying for a stronger nurse practice act or for the creation or
expansion of advanced nursing roles.

Personal letters are more influential than form letters, and the tone
should be formal but polite. The letter should also be concise (not
more than one page). Be sure to address the legislator properly by
title. Establish your credibility early in the letter as both a constituent
and a health-care expert. State your reason for writing the letter in
the first paragraph and refer to the specific bill that you are writing
about. Then, state your position on the issue and give personal
examples as necessary to support your position. Offer your
assistance as a resource person for additional information. Sign the
letter, including your name and contact information. Remember to be
persistent and write to legislators repeatedly who are undecided on
an issue. Display 6.8 presents a format common to letters written to


March 15, 2019
The Honorable John Doe
Member of the Senate
State Capitol, Room _______
City, State, Zip Code

Dear Senator Doe,
I am a registered nurse and member of the American Nurses

Association (ANA). I am also a constituent in your district. I am
writing in support of SB XXX, which requires the establishment of
minimum RN staffing ratios in acute care facilities. As a staff nurse
on an oncology unit in our local hospital, I see firsthand the
problems that occur when staffing is inadequate to meet the
complex needs of acutely ill patients: medical errors, patient and
nurse dissatisfaction, workplace injuries, and perhaps most
important, the inability to spend adequate time with and comfort
patients who are dying.

I have enclosed a copy of a recent study conducted by John
Smith that was published in the January 2019 edition of Nurses
Today. This article details the positive impact of legislative staffing
ratio implementation on patient outcomes as measured by
medication errors, patient falls, and nosocomial infection rates.

I strongly encourage you to vote for SB XXX when it is heard by
the Senate Business and Professions Committee next week.
Thank you for your ongoing concern with nursing and health-care
issues and for your past support of legislation to improve health-
care staffing. Please feel free to contact me if you have any
questions or would like additional information.

Nancy Thompson, RN, BSN

City, State, Zip Code
Phone number including area code
E-mail address

Other nurses may choose to monitor the progress of legislation,
count congressional votes, and track a specific legislator’s voting
intents as well as past voting records. Still, other nurses may choose
to join network groups, where colleagues meet to discuss
professional issues and pending legislation.

For nurses interested in a more indirect approach to professional
advocacy, their role may be to influence and educate the public
about nursing and the nursing agenda to reform health care. This
may be done by speaking with professional and community groups
about health-care and nursing issues and by interacting directly with
the media. Never underestimate the influence that a single nurse
may have even in writing letters to the editor of local newspapers or
by talking about nursing and health-care issues with friends, family,
neighbors, teachers, clergy, and civic leaders.

Nursing and the Media
Although registered nurses are among the most knowledgeable,
frontline health-care providers in the country, their interactions with
mainstream media are often limited. This is because too few nurses
are willing to interact with the media about vital nursing and health-
care issues. Often, this is because they believe that they lack the
expertise to do so or because they lack self-confidence. This is
especially unfortunate because both the media and the public place
a high trust in nurses and want to hear about health-care issues from
a nursing perspective.

The reality is that the responsibility for nursing’s image as
perceived by the public lies solely on the shoulders of those who
claim nursing as their profession. Until nurses are able to agree on

the desired collective image and are willing to do what is necessary
to both tell and show the public what that image is, little will change
(Huston, 2020b). Nurses should take every opportunity to appear in
the media—in newspapers, radio, and television. Nurses should also
complete special training programs to increase their self-confidence
in working with journalists and other media representatives. Bendure
(2018) suggests that everyone can benefit from media training
because the key to becoming good at interviewing (and speaking in
general) is through repetition and practice.

Regardless, the first few media interactions will likely be stressful,
just like any new task or learning. The following tips may be helpful
to nurses learning to navigate media waters:

Dress professionally for the interview.
Remember that reporters often have short deadlines. A delay in

responding to a reporter’s request for an interview usually
results in the reporter looking elsewhere for a source.

Do not be unduly paranoid that the reporter “is out to get you” by
inaccurately representing what you have to say. The reporter
has a job to do, and most reporters do their best to be fair and
accurate in their reporting.

Come to the interview prepared with any statistics, important
dates and times, anecdotes, or other information you want to

Limit your key points to two or three and frame them as bullet
points to reduce the likelihood that you will be misheard or
misinterpreted. Brief but concise sound bites are much more
quotable than rambling arguments.

Avoid technical or academic jargon.

Speak with credibility and confidence but do not be afraid to say
that you do not know if asked a question beyond your expertise
or which would be better answered by someone else. If you
choose not to answer a question, give a brief reason for not
wanting to do so rather than simply saying “no comment.”

Avoid being pulled into inflammatory arguments or blame
setting. If you feel that you have been baited or that you are
being pulled off on tangents, simply repeat the key points you
intended to make and refocus the conversation if possible.
Remember that you cannot control the questions you are asked,
but you can control your responses.

Be prepared to respond to follow-up media inquiries via e-mail.
Provide contact information so that the reporter can reach you if
additional information or clarifications are needed. Be aware,
however, that most reporters will not allow you to preview their
story prior to publication.

These strategies are summarized in Display 6.9.


1. Establish proactive, routine communication with local,
regional, and national media to promote cooperation and

2. Attend media training and/or practice speaking in front of a
camera with a microphone.

3. Dress professionally for interviews.
4. Respect and meet the reporter’s deadlines.
5. Assume, until proven otherwise, that the reporter will be fair

and accurate in his or her reporting.
6. Have key facts and figures ready for the interview.
7. Limit your key points to two or three and frame them as bullet

8. Avoid technical or academic jargon.
9. Speak confidently but do not be afraid to say when you do not

have the expertise to answer a question or when a question is
better directed to someone else.

10. Avoid being pulled into inflammatory arguments or blame
setting and repeat key points if you are pulled off into

11. Provide the reporter with contact information for follow-up and
needed clarifications.


Preparing for a Media Interview

You are the staffing coordinator for a medium-sized
community hospital in California. Minimum staffing ratios
were implemented in January 2004. Although this has
represented an even greater challenge in terms of
meeting your organization’s daily staffing needs, you
believe that the impetus behind the legislative mandate
was sound. You also are a member of the state nursing
association that sponsored this legislation and wrote
letters of support for its passage. The hospital that
employs you and the state hospital association fought
unsuccessfully against the passage of minimum staffing

The local newspaper contacted you this morning and
wants to interview you about staffing ratios in general as
well as how these ratios are impacting the local hospital.
You approach your chief nursing officer, and she tells you
to go ahead and do the interview if you want but to
remember that you are a representative of the hospital.


Assume that you have agreed to participate in the
1. How might you go about preparing for the

2. Identify three factual points that you can state

during the interview as your sound bites. What
would be your primary points of emphasis?

3. Is there a way to reconcile the conflict between
your personal feelings about staffing ratios and
those of your employer? How would you respond

if asked directly by the reporter to comment
about whether staffing ratios are a good idea?

Integrating Leadership Roles and Management
Functions in Advocacy
Nursing leaders and managers recognize that they have an
obligation not only to advocate for the needs of their patients,
subordinates, and themselves but also to be active in furthering the
goals of the profession. To accomplish these types of advocacy,
nurses must value autonomy and empowerment.

However, the leadership roles and management functions to
achieve advocacy with patients and subordinates and for the
profession differ greatly. Advocating for patients requires that the
manager create a work environment that recognizes patient’s needs
and goals as paramount. This means creating a work culture where
patients are respected, well informed, and empowered. The
leadership role required to advocate for patients is often one of risk
taking, particularly when advocating for a client may be in direct
conflict with a provider or institutional goal. Leaders must also be
willing to accept and support patient choices that may be different
from their own.

Advocating for subordinates requires that the manager create a
safe and equitable work environment where employees feel valued
and appreciated. When working conditions are less than favorable,
the manager is responsible for relaying these concerns to higher
levels of management and advocating for needed changes.

The same risk taking that is required in patient advocacy is a
leadership role in subordinate advocacy because subordinate needs
and wants may conflict with the organization. There is always a risk
that the organization will view the advocate as a troublemaker, but
this does not provide an excuse for managers to be complacent in

this role. Managers also must advocate for subordinates in creating
an environment where ethical concerns, needs, and dilemmas can
be openly discussed and resolved.

Advocating for the profession requires that the nurse-manager be
informed and involved in all legislation affecting the unit,
organization, and the profession. The manager must also be an
astute handler of public relations and demonstrate skill in working
with the media. It is the leader, however, who proactively steps forth
to be a role model and an active participant in educating the public
and improving health care through the political process.

Key Concepts

■ Advocacy is helping others to grow and self-actualize and is a
leadership role.

■ Managers, by virtue of their many roles, must be advocates
for patients, subordinates, and the profession.

■ It is important for the patient advocate to be able to
differentiate between controlling patient choices (domination
and dependence) and assisting patient choices (allowing

■ Since the 1960s, some advocacy groups, professional
associations, and states have passed bills of rights for
patients. Although these are not legally binding, they can be
used to guide professional practice.

■ The philosophy of person- and family-centered care suggests
that care should be organized first and foremost around the
needs of patients and family members.

■ In workplace advocacy, the manager works to see that the
work environment is both safe and conducive to professional
and personal growth for subordinates.

■ Although much of the public wants wrongdoing or corruption
to be reported, such behavior is often looked on with distrust,
and whistleblowers are often considered disloyal and
experience negative repercussions for their actions.

■ Leader-managers must be willing to advocate for
whistleblowers who speak out about organizational practices
that they believe may be harmful or inappropriate.

■ Professional issues are ethical issues. When nurses find a
discrepancy between their perceived role and society’s
expectations, they have a responsibility to advocate for the

■ If nursing is to advance as a profession, practitioners and
managers must broaden their sociopolitical knowledge base
to better understand the bureaucracies in which they live.

■ Because legislators and policy makers are more willing to
deal with nurses as a group rather than as individuals, joining
and actively supporting professional organizations allow
nurses to have a greater voice in health-care and
professional issues.

■ Nurses need to exert their collective influence and make their
concerns known to policy makers before they can have a
major impact on political and legislative outcomes.

■ Nurses have great potential to educate the public and
influence policy through the media as a result of the public’s
high trust in nurses and because the public wants to hear
about health-care issues from a nursing perspective.

Additional Learning Exercises and Applications


Ethics and Advocacy

You are a new graduate staff nurse in a home health
agency. One of your clients is a 23-year-old man with
acute schizophrenia who was just released from the local
county, acute care, behavioral health-care facility,
following a 72-hour hold. He has no insurance. His family
no longer has contact with him, and he is unable to hold a
permanent job. He is noncompliant in taking his
prescription drugs for schizophrenia. He is homeless and
has been sleeping and eating intermittently at the local
homeless shelter; however, he was recently asked not to
return because he is increasingly agitated and, at times,
violent. He calls you today and asks you “to help him with
the voices in his head.”

You approach the senior registered nurse (RN) case
manager in the facility for help in identifying options for
this individual to get the behavioral health-care services
that he needs. She suggests that you tell the patient to go
to Maxwell’s Mini Mart, a local convenience store, at 3:00
PM today and wait by the counter. Then she tells you that
you should contact the police at 2:55 PM and tell them
that Maxwell’s Mini Mart is being robbed by your patient
so that he will be arrested. She states, “I do this with all of
my uninsured mental health patients, since the state
Medicaid program offers only limited mental health
services and the state penal system provides full mental
health services for the incarcerated.” She goes on to say
that the store owner and the police are aware of what she
is doing and support the idea because it is the only way
“patients really have a chance of getting better.” She

ends the conversation by saying, “I know you are a new
nurse and don’t understand how the ‘real world’ works,
but the reality is that this is the only way I can advocate
for patients like this, and you need to do the same for
your patients.”


1. Will you follow the advice of the senior RN case

2. If not, how else can you advocate for this


Determining Nursing’s Entry Level

Grandfathering is the term used to grant certain people
working within the profession for a given time period or
prior to a deadline date the privilege of applying for a
license without having to take the licensing examination.
Grandfathering clauses have been used to allow
licensure for wartime nurses—those with on-the-job
training and expertise—even though they did not
graduate from an approved school of nursing.

Some professional nursing organizations are once
again proposing that the Bachelor of Science in Nursing
(BSN) become the entry-level requirement for
professional nursing. Some have suggested that as a

concession to current associate degree in nursing and
diploma-prepared nurses, all nurses who have passed
the registered nursing licensure examination before the
new legislation, regardless of educational preparation or
experience, would retain the title of professional nurse.
Nonbaccalaureate-educated nurses after that time would
be unable to use the title of professional nurse.


Do you believe that the “BSN as entry level”
proposal advocates the advancement of the nursing
profession? Is grandfathering conducive to meeting
this goal? Would you personally support both
proposals? Does the long-standing internal
dissension about making the BSN the entry level
into professional nursing reduce nursing’s status as
a profession? Do lawmakers or the public
understand this dilemma or care about it?


How Would You Proceed?

You are a registered nurse case manager for a large
insurance company. Sheila Johannsen is a 34-year-old
mother of two small children. She was diagnosed with
advanced metastatic breast cancer 6 months ago.
Traditional chemotherapy and radiation seem to have

slowed the spread of the cancer, but the prognosis is not

Sheila contacted you this morning to report that she
has been in contact with a physician at one of the most
innovative medical centers in the country. He told her that
she might benefit from an experimental gene therapy
treatment; however, she is ineligible for participation in
the free clinical trials because her cancer is so advanced.
The cost for the treatment is approximately $250,000.
Sheila states that she does not have the financial
resources to pay for the treatment and begs you “to do
whatever you can to get the insurance company to pay;
otherwise, I’ll die.”

You know that the cost of experimental treatments is
almost always disallowed by Sheila’s insurance company.
You also know that even with the experimental treatment,
Sheila’s probability of a cure is very small.


Decide how you will proceed. How can you best
advocate for this patient?


Conflict of Values

You are a case manager in an outpatient disease
management program assigned to coordinate the care

needs of Sam, a 72-year-old man with multiple chronic
health problems. His medical history includes myocardial
infarctions, implantation of a pacemaker, open-heart
surgery, an inoperable abdominal aneurysm, and
repeated episodes of congestive heart failure. Because of
his poor health, he cannot operate the small business he
owns or work for any length of time at his gardening or
other hobbies.

Although Sam has told you that death would be a relief
to his nearly constant discomfort and depression, his wife
dismisses such talk as “nonsense” and tells Sam that
“she still needs him and will always do everything in her
power to keep him here with her.” In deference to his
wife’s wishes, Sam has not completed any of the legal
paperwork necessary to create a durable power of
attorney or a living will should he become unable to make
his own health-care decisions. Today, Sam takes you
aside and suggests that he “wants to fill out this
paperwork so that no extraordinary means of life support
are used,” and he “wants you to witness it so that his wife
will not know.”


Decide what you will do. What is your obligation to
Sam? To his wife? To yourself? Whose needs are
paramount? How do the ethical principles of
autonomy, duty, and veracity intersect or compete in
this case?


Peer Advocacy

You are a nursing student. Like many of the students in
your nursing program, sometimes you feel you study too
much and therefore miss out on partying with friends,

something many of your college friends do on a regular
basis. Today, after a particularly grueling exam, three of
your nursing school peers approach you and ask you to
go out with them to a party tonight, off campus, which is
being cohosted by Matt, another nursing student. Alcohol
will be readily available, although not everyone at the
party is of legal drinking age, including you and one of
your nursing peers (Jenny). Because you really do not
want to drink anyway, you agree to be the designated

Almost immediately after you arrive at the party, all
three of your nursing peers begin drinking. At first, it
seems pretty harmless, but after several hours, you
decide the tenor of the party is changing and becoming
less controlled and that it is time to take your friends
home. Two of your peers agree, but you cannot find
Jenny. As you begin searching for her, several partygoers
tell you that she has been drinking “kamikazes” all night
and that she “looked pretty wasted” the last time they saw
her. They suggest that you check the bathroom because
Jenny said she was not feeling very well.

When you enter the bathroom, you see Jenny slumped
in the corner by the toilet. She has vomited all over the
floor as well as her clothing and she reeks of alcohol.
When you attempt to rouse her, her eyelids flutter but she
is unable to wake up or answer any questions. Her
breathing seems regular and unlabored, but she is
continuing to vomit in her “blacked-out” state. Her skin
feels somewhat clammy to the touch and she cannot
stand or walk on her own. You are not sure how much
Jenny actually had to drink or how long it has been since
she “passed out.”

You are worried that Jenny is experiencing acute
alcohol poisoning but are not very experienced with this
sort of thing. The other two nursing students you brought
to the party feel you are overreacting, although they
agree that Jenny has had too much to drink and needs to
be watched. One of your peers suggests calling the new
young, clinical instructor in the nursing program, who
offered just the other day to provide rides to students who
have been drinking. You think she might be able to
provide some guidance. Another one tells you that she
feels Jenny just needs to “sleep it off” and that she will
stay with Jenny tonight to make sure she is OK, although
she has had a fair amount to drink herself.

You think Jenny should be seen in the local emergency
department (ED) for treatment and are contemplating
calling for an ambulance. One partygoer agrees with you
that Jenny should be seen at the hospital but suggests
you drop Jenny off anonymously at the front door of the
ED so “you won’t get in any trouble.” Matt encourages
you not to take her to the ED at all because he is afraid
the incident will be reported to the local police because
Jenny is a minor and that he could be in “real trouble” for
furnishing alcohol to a minor. He argues that this could
threaten both his progression and Jenny’s in the nursing
program. He says that she can just stay at the house
tonight and that he will check in on her on a regular basis.

To complicate things, you, Jenny, and the other two
students you brought to the party live in the college
dormitories and they lock down for the evening in another
30 minutes. It will take you at least 20 minutes to gather
the manpower you need to get Jenny down to your car
and up to her dormitory room by lockdown, if that is what
you decide to do. If you are not inside the dormitories by

lockdown, you will need to find another place to spend
the evening. In addition, there will likely be someone at
the door to the dormitory assigned to turn away students
who are clearly intoxicated.


Decide what you will do. How do you best advocate
for a peer when they are unable to advocate for
themselves? Does it matter if the risk is self-
induced? How do you weigh the benefits of
advocating for one person when it can result in
potential harm or risk to another person?

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and standards of practice (2nd ed.). Silver Spring, MD: Author.

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advocate. Nursing, 48(4), 55–58.

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increase its power base. In C. J. Huston (Ed.), Professional
issues in nursing: Challenges and opportunities (5th ed., pp.
318–333). Philadelphia, PA: Wolters Kluwer.

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Huston (Ed.), Professional issues in nursing: Challenges and
opportunities (5th ed., pp. 334–349). Philadelphia, PA: Wolters

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Roles and
Functions in


Organizational Planning
. . . in the absence of clearly defined goals, we are
forced to concentrate on activity and ultimately become
enslaved by it.—Chuck Conradt

. . . people buy into the leader long before they buy into
the vision.—Neslyn Watson Druee

. . . a goal without a plan is just a wish.—Antoine de


This chapter addresses:

BSN Essential II: Basic organizational and systems leadership
for quality care and patient safety

BSN Essential III: Scholarship for evidence-based practice
BSN Essential V: Health-care policy, finance, and regulatory

BSN Essential VIII: Professionalism and professional values
MSN Essential II: Organizational and systems leadership
MSN Essential IV: Translating and integrating scholarship into

MSN Essential VI: Health policy and advocacy
AONL Nurse Executive Competency II: A knowledge of the
health-care environment

AONL Nurse Executive Competency III: Leadership
AONL Nurse Executive Competency V: Business skills
ANA Standard of Professional Performance 10:

ANA Standard of Professional Performance 11: Leadership
ANA Standard of Professional Performance 13: Evidence-
based practice and research

ANA Standard of Professional Performance 14: Quality of

ANA Standard of Professional Performance 16: Resource

ANA Standard of Professional Performance 17:
Environmental health

QSEN Competency: Teamwork and collaboration
QSEN Competency: Evidence-based practice


The learner will:

identify contemporary paradigm shifts and trends impacting
health-care organizations

analyze social, political, and cultural forces that may affect the
ability of 21st-century health-care organizations to forecast
accurately in strategic planning

describe how tools such as SWOT analysis and balanced
scorecards can facilitate the strategic planning process

describe the steps necessary for successful strategic planning
identify barriers to planning as well as actions the leader-
manager can take to reduce or eliminate these barriers

include evaluation checkpoints in organizational planning to
allow for midcourse corrections as needed

discuss the relationship between an organizational mission
statement, philosophy, goals, objectives, policies, procedures,
and rules

write an appropriate mission statement, organization philosophy,
nursing service philosophy, goals, and objectives for a known or
fictitious organization

discuss appropriate actions that may be taken when personal
values are found to be in conflict with those of an employing

recognize the need for periodic value clarification to promote

reflect on which personal planning style (reactive, inactive,
preactive, or proactive) is used most often

Planning is critically important to and precedes all other
management functions. Without adequate planning, the
management process fails, and organizational needs and objectives
cannot be met. Planning may be defined as deciding in advance
what to do; who is to do it; and how, when, and where it is to be
done. Therefore, all planning involves choosing among alternatives.

All planning involves choice: a necessity to choose from
among alternatives.

This implies that planning is a proactive and deliberate process
that reduces risk and uncertainty. It also encourages unity of goals
and continuity of energy expenditure (human and fiscal resources)
and directs attention to the objectives of the organization. Adequate
planning also provides the manager with some means of control and
encourages the most appropriate use of resources.

In effective planning, the manager must identify short- and long-
term goals and changes needed to ensure that the unit will continue
to meet its goals. Identifying such short- and long-term goals
requires leadership skills such as vision and creativity because it is
impossible to plan what cannot be dreamed or envisioned.

Likewise, planning requires flexibility and energy—two other
leadership characteristics. Yet, planning also requires management
skills such as data gathering, forecasting, and transforming ideas
into action.

Unit III focuses on several aspects of planning, including
organizational planning, planned change, time management, fiscal
planning, and career planning. This chapter deals with skills needed
by the leader-manager to implement both day-to-day and future
organizational planning. In addition, the leadership roles and
management functions involved in developing, implementing, and
evaluating the planning hierarchy are discussed (Display 7.1).


Leadership Roles
1. Translates knowledge regarding contemporary paradigm

shifts and trends impacting health care into vision and
insights, which foster goal attainment

2. Assesses the organization’s internal and external environment
in forecasting and identifying driving forces and barriers to
strategic planning

3. Demonstrates visionary, innovative, and creative thinking in
organizational and unit planning, thus inspiring proactive
rather than reactive planning

4. Influences and inspires group members to be actively
involved in both short- and long-term planning

5. Periodically completes value clarification to increase self-

6. Encourages subordinates toward value clarification by
actively listening and providing feedback

7. Communicates and clarifies organizational goals and values
to subordinates

8. Encourages subordinates to be involved in policy formation,
including developing, implementing, and reviewing unit
philosophy, goals, objectives, policies, procedures, and rules

9. Is receptive to new and varied ideas
10. Role models proactive planning methods to followers

Management Functions
1. Is knowledgeable regarding legal, political, economic, and

social factors affecting health-care planning
2. Demonstrates knowledge of and uses appropriate techniques

in both personal and organizational planning

3. Provides opportunities for subordinates, peers, competitors,
regulatory agencies, and the general public to participate in
organizational planning

4. Coordinates unit-level planning to be congruent with
organizational goals

5. Periodically assesses unit constraints and assets to
determine available resources for planning

6. Develops and articulates a unit philosophy that is congruent
with the organization’s philosophy

7. Develops and articulates unit goals and objectives that reflect
unit philosophy

8. Develops and articulates unit policies, procedures, and rules
that put unit objectives into operation

9. Periodically reviews unit philosophy, goals, policies,
procedures, and rules and revises them to meet the unit’s
changing needs

10. Actively participates in organizational planning, defining, and
operationalizing plans at the unit level

Visioning: Looking to the Future
Because of health-care reform, rapidly changing technology,
increasing government involvement in regulating health care, and
scientific advances, health-care organizations are finding it
increasingly difficult to identify long-term needs appropriately and
plan accordingly. In fact, most long-term planners find it difficult to
plan more than a few years ahead.

Unlike the 20-year strategic plans of the 1960s and 1970s,
most long-term planners today find it difficult to look
even 5 years in the future.

The health-care system is in chaos, as is much of the business
world. Traditional management solutions no longer apply, and a lack
of strong leadership in the health-care system has limited the
innovation needed to create solutions to the new and complex
problems that the future will bring. Because change is occurring so
rapidly, managers can easily become focused on short-range plans
and miss changes that can drastically alter specific long-term plans.

Health-care facilities are particularly vulnerable to external social,
economic, and political forces; long-range planning, then, must
address these changing dynamics. It is imperative, therefore, that
long-range plans be flexible, permitting change as external forces
assert their impact on health-care facilities. In as far as it is possible,
a picture of the future should be used to formulate long-range
planning. One reason for envisioning the future is to study
developments that may have an impact on the organization. This
process of learning about the future allows us to determine what we
want to happen. Identifying what may or could happen allows us to
avert, encourage, or direct the course of events.

There are many factors emerging in the rapidly changing health-
care system that must be incorporated in planning for a health-care
organization’s future. Some emerging paradigms include the

Further consolidation of hospitals/systems, medical groups,
ancillary services, health plans, and postacute providers is

The tension between “value” and “volume” has reached a tipping
point. With growing linkages between expected quality
outcomes and reimbursement, health-care organizations must
increasingly determine whether value drives volume or whether
volume is necessary to achieve value.

The transformation from revenue management to cost
management will continue as declining reimbursement forces

providers to focus on how to maximize limited resources and
provide care at less cost.

Physician integration, an interdependence between physicians
and health-care organizations (typically hospitals) that may
involve employment, as well as shared decision making and
mutual goal setting, is changing practice patterns and
reimbursement patterns as hospitals increasingly assume more
of the financial and liability risks for what was historically private
physician practice.

Health-care costs will continue to rise, and employers will be
challenged to find ways to provide affordable health-care
insurance coverage to employees, including cost shifting via
higher copayments and deductibles.

The International Classification of Diseases, 10th revision (ICD-
10), pricing, information technology (IT), in-patient volumes,
physician relationships, and physician recruitment will
increasingly become intertwined.

The rising cost of pharmaceuticals and ongoing drug shortages
will continue to be a problem for US hospitals. Two hundred and
fifty-five common brand drugs increased the price of their drugs
between February 1 and July 15, 2018, alone. The most
common increase in that window was 9% to 10% (Langreth,
Koons, & Gu, 2018).

The way in which work relationships are built will need to
change because the way we manage systems is changing. For
example, health care continues to move toward managing
populations rather than individuals. In addition, hospitals and
health-care systems now must integrate long-term care and
extended care into their continuum of care (Weldon, 2015).

The ongoing movement away from illness care to wellness care
and the use of disease management programs will continue to
reduce the demand for expensive, acute care services.

The use of complementary and alternative medicine will
increase as public acceptance and demand for these services

The interdependence of professionals and the need for
interprofessional collaboration rather than professional
autonomy will continue. Thus, the autonomy for all health-care
professionals will decrease, including managers.

The shift in framework to the patient as a consumer of cost and
quality information will continue. Historically, many providers
assumed that consumers, both payers and patients, had
minimal interest in or knowledge about the services that they
received. Currently, a change in the balance of power among
payers, patients, and providers has occurred, and providers are
increasingly being held accountable for the quality of outcomes
that their patients experience. Quality data will be increasingly
public, and transparency regarding organizational effectiveness
(quality and costs) will be a public expectation.

A transition from continuity of provider to continuity of
information will occur. Historically, continuity of care was
maintained by continuity of provider. In the future, however, the
meaning and operationalizing of continuity will become
predicated on having complete, accurate, and timely information
that moves with the patient. For example, electronic health
records (EHRs) provide such real-time, point-of-care information
as well as a longitudinal medical record with full information
about each patient.

Technology, which facilitates mobility and portability of
relationships, interactions, and operational processes, will
increasingly be a part of high-functioning organizations. EHRs
and clinical decision support are examples of such technology
because both impact not only what health-care data is collected
but also how it is used, communicated, and stored.

Commercially purchased expert networks (communities of top
thinkers, managers, and scientists) as well as electronic
decision support systems will increasingly be used to improve
the decision making required of health-care leaders. Such
network panels are typically made up of researchers, health-
care professionals, attorneys, and industry executives.

The health-care team will be characterized by highly educated,
multidisciplinary experts. Although this would appear to ease the
leadership challenges of managing such a team, it is far easier
to build teams of experts than to build expert teams.

In addition, Huston (2020) suggests the following factors will
further influence the future of health care:

Robotic technology and the use of prototype nurse robots called
nursebots will serve as an adjunct to scarce human resources in
the provision of health care.

Biomechatronics, which creates machines that replicate or
mimic how the body works, will increase in prominence in the
future. This interdisciplinary field encompasses biology,
neurosciences, mechanics, electronics, and robotics to create
devices that interact with human muscle, skeleton, and nervous
systems to establish or restore human motor or nervous system

Biometrics, the science of identifying people through physical
characteristics such as fingerprints, handprints, retinal scans,
voice recognition, and facial structure, will be used to assure
targeted and appropriate access to client records.

Health-care organizations will integrate biometrics with “smart
cards” (credit card–sized devices with a chip, stored memory,
and an operating system) to ensure that an individual presenting
a secure ID credential really has the right to use that credential.

Point-of-care testing will improve bedside care and promote
more positive outcomes because of more timely decision

making and treatment.
Given declining reimbursement, the current nursing shortage,

and an increasing shift in care to outpatient settings, home care
agencies will increasingly explore technology-aided options,
such as telehealth, that allow them to avoid the traditional 1:1
nurse–patient ratio with face-to-face contact.

The Internet will continue to improve Americans’ health by
enhancing communications and improving access to information
for care providers, patients, health plan administrators, public
health officials, biomedical researchers, and other health
professionals. It will also change how providers interact with
patients with consumers increasingly adopting the role of expert

A growing elderly population, medical advances that increase
the need for well-educated nurses, consumerism, the increased
acuity of hospitalized patients, and a ballooning health-care
system will continue to increase the demand for registered
nurses (RNs).

An aging workforce, improving economy, inadequate enrollment
in nursing schools to meet projected demand, increased
employment of nurses in outpatient or ambulatory care settings,
and inadequate long-term pay incentives will lead to new
nursing shortages.

Such paradigm shifts and trends change almost constantly.
Successful leader-managers stay abreast of the dynamic
environments in which health care are provided so that this can be
reflected in their planning. The result is proactive or visionary
planning that allows health-care agencies to function successfully in
the 21st century.

An example of such visionary planning was the Federal Health IT
Strategic Plan 2015–2020. This plan represents the collective
strategy of federal offices that use or influence the use of health IT in

the United States and sets a blueprint for federal partners to
implement strategies that will support the nation’s continued
development of a responsive and secure health IT and information-
use infrastructure (“Federal Health IT Strategic Plan,” 2015) (Display
7.2). The first two goals of this plan prioritized increasing the
electronic collection and sharing of health information while
protecting individual privacy. The final three goals focused on federal
efforts to create an environment where interoperable information is
used by health-care providers, public health entities, researchers,
and individuals to improve health and health care and reduce costs.
With this plan, the federal government signals that although we will
continue to work toward more widespread adoption of health IT,
efforts will begin to include new sources of information and ways to
disseminate knowledge quickly, securely, and efficiently.


The final strategic plan reflecting input from more than 400 public
comments, collaboration between federal contributors, and
recommendations from the Health IT Policy Committee identified
the following strategic goals and objectives:

Goal 1: Expand Adoption of Health IT
Objective A: Increase the adoption and effective use of health

information technology (IT) products, systems, and services.
Objective B: Increase user and market confidence in the safety

and safe use of health IT products, systems, and services.
Objective C: Advance a national communications infrastructure

that supports health, safety, and care delivery.

Goal 2: Advance Secure and Interoperable Health Information
Objective A: Enable individuals, providers, and public health

entities to securely send, receive, find, and use electronic health

Objective B: Identify, prioritize, and advance technical
standards to support secure and interoperable health

Objective C: Protect the privacy and security of health

Goal 3: Strengthen Health-Care Delivery
Objective A: Improve health-care quality, access, and

experience through safe, timely, effective, efficient, equitable,
and person-centered care.

Objective B: Support the delivery of high-value health care.
Objective C: Improve clinical and community services and

population health.

Goal 4: Advance the Health and Well-Being of Individuals and
Objective A: Empower individual, family, and caregiver health

management and engagement.
Objective B: Protect and promote public health and healthy,

resilient communities.

Goal 5: Advance Research, Scientific Knowledge, and
Objective A: Increase access to and usability of high-quality

electronic health information and services.
Objective B: Accelerate the development and

commercialization of innovative technologies and solutions.
Objective C: Invest, disseminate, and translate research on

how health IT can improve health and care delivery.

Sources: Federal Health IT Strategic Plan 2015–2020 released. (2015). American
Nurse, 47(5), 9 and Office of the National Coordinator for Health Information
Technology, Office of the Secretary, U.S. Department of Health and Human
Services. (2015). Federal health strategic plan 2015–2020. Retrieved August 3,
2018, from


Forces Affecting Health Care

In small groups, identify six additional forces, beyond
those identified in this chapter, affecting today’s health-
care system. You may include legal, political, economic,
social, or ethical forces. Try to prioritize these forces in

terms of how they will affect you as a manager or
registered nurse. For at least one of the six forces you
have identified, brainstorm how that force would affect
your strategic planning as a unit manager or director of a
health-care agency.

Proactive Planning
Planning has a specific purpose and is one approach to developing
strategy. In addition, planning represents specific activities that help
achieve objectives; therefore, planning should be purposeful and
proactive. Although there is always some crossover between types
of planning within organizations, there is generally an orientation
toward one of four planning modes: reactive planning, inactivism,
preactivism, or proactive planning.

Reactive planning occurs after a problem exists. Because there is
dissatisfaction with the current situation, planning efforts are directed
at returning the organization to a previous, more comfortable state.
Frequently, in reactive planning, problems are dealt with separately
without integration with the whole organization. In addition, because
it is done in response to a crisis, this type of planning can lead to
hasty decisions and mistakes.

Inactivism is another type of conventional planning. Inactivists
seek the status quo, and they spend their energy preventing change
and maintaining conformity. When changes do occur, they occur
slowly and incrementally.

A third planning mode is preactivism. Preactive planners utilize
technology to accelerate change and are future oriented. Unsatisfied
with the past or present, preactivists do not value experience and
believe that the future is always preferable to the present.

Proactive planning is dynamic, and adaptation is
considered to be a key requirement because the
environment changes so frequently.

The last planning mode is interactive or proactive planning.
Planners who fall into this category consider the past, present, and
future and attempt to plan the future of their organization rather than
react to it. Because the organizational setting changes often,
adaptability is a key requirement for proactive planning. Proactive
planning occurs, then, in anticipation of changing needs or to
promote growth within an organization and is required of all leader-
managers so that personal as well as organizational needs and
objectives are met.


What Is Your Planning Style?

How would you describe your planning? Is your
planning more likely to be reactive, inactive, preactive, or
proactive? Write a brief essay that describes your most
commonly used planning style. Use specific examples
and then share your insights in a group.

One example of recent, successful organizational proactive
planning was evident in pharmacy management at Houston-based
hospitals during extensive flooding in 2017 from Hurricane Harvey
(see Examining the Evidence 7.1). Having learned lessons from the
disastrous flooding of Tropical Storm Allison in 2001, floodgates

were installed, employees who were part of designated “ride-out”
teams knew to be ready to stay at their hospital until the storm
passed, and the preordering of large quantities of commonly used
drugs avoided shortages. As a result, despite receiving more than 30
inches of rain in a 4-day period, Memorial Hermann Health System
was able to demonstrate a high degree of organization and
teamwork to assure that patient needs were met.

Source: Traynor, K. (2017). Planning, teamwork made
Harvey manageable for Houston hospitals. American
Journal of Health-System Pharmacy, 74(21), 1752–

A Case Study of Proactive Planning Using
Historical Data
Flooding is an ongoing problem in Houston,
Texas. Heeding lessons learned from the
disastrous flooding that accompanied Tropical
Storm Allison in 2001, pharmacy directors from
Memorial Hermann Health System’s 16 acute
care hospitals began planning almost
immediately what would be done the next time
such a situation emerged.

When Hurricane Harvey (and the 30 inches
of rain it brought in over 4 days) hit the Texas
coastline in 2017, they were ready and able to
serve patients throughout the storm.
Floodgates had been installed in and around
the hospital campuses allowing them to stay
open. Pharmacy directors had already
assessed their worst-case-scenario medication
needs and placed large orders with their
wholesaler before the storm hit, eliminating
possible drug shortages. When hospitals
urgently needed critical medications that
weren’t on hand, the health system used its air
ambulance helicopters to ferry those items
around town. In addition, pharmacy employees
who were part of designated “ride-out” teams
knew to be ready to stay at their hospital until

the storm passed. In addition, throughout the
storm, health system leaders kept in touch with
the pharmacy directors to address urgent
needs and ensure that each hospital had
enough medications and resources to continue
caring for patients.

Because of this proactive planning, Memorial
Hermann Health System announced that
during the 5 days of Harvey’s disruption, the
health system was still able to treat 9,624
emergency center patients, perform 748
surgeries, and deliver 564 babies. The author
concludes that planning and teamwork helped
these hospitals survive and even thrive during
Hurricane Harvey’s disruption.

A mistake common to novice managers is a failure to complete
adequate proactive planning. Instead, many managers operate in a
crisis mode and fail to use available historical patterns to assist them
in planning or they fail to examine present clues and projected
statistics to determine future needs. In other words, they fail to
forecast. Forecasting involves trying to estimate how a condition will
be in the future. Forecasting takes advantage of input from others,
gives sequence in activity, and protects an organization against
undesirable changes.

With changes in technology, payment structures, and resource
availability, the manager who is unwilling or unable to forecast
accurately impedes the organization’s efficiency and the unit’s
effectiveness. Increased competition, changes in government
reimbursement, and decreased hospital revenues have reduced

intuitive managerial decision making. To avoid disastrous outcomes
when making future professional and financial plans, managers need
to stay well informed about the legal, political, and socioeconomic
factors affecting health care.

Managers who are uninformed about the legal, political,
economic, and social factors affecting health care make
planning errors that may have disastrous implications for
their professional development and the financial viability
of the organization.

Strategic Planning at the Organizational Level
Planning also has many dimensions. Two of these dimensions are
time span and complexity or comprehensiveness. Generally,
complex organizational plans that involve a long period (usually 3 to
7 years) are referred to as long-range or strategic plans. However,
strategic planning may be done once or twice a year in an
organization that changes rapidly. At the unit level, any planning that
is at least 6 months in the future may be considered long-range

Dumaine and Useem (2018) note that external pressures often
compel top-level organization leaders to focus heavily on short-term
goals and expectations. Although this is important, it is equally—if
not more—important to emphasize longer term objectives. Leader-
managers who adopt long-term strategies eventually help their
organizations become more profitable and have happier employees
and shareholders.

Strategic planning at the organizational level then must consider
both the short- and long-term goals and needs of the organization. In
doing this, strategic planning can forecast the future success of an
organization by matching and aligning an organization’s capabilities

with its external opportunities. For instance, an organization could
develop a strategic plan for dealing with a nursing shortage,
preparing succession managers in the organization, developing a
marketing plan, redesigning workload, developing partnerships, or
simply planning for organizational success.

Strategic planning typically examines an organization’s
purpose, mission, philosophy, and goals in the context of
its external environment.

Some experts suggest, however, that the need for increased
operational efficiencies has required a reconfiguration of how
strategic planning is done in most health-care organizations. Instead
of focusing on the external environment and the marketplace, health-
care organizations will need to look closely at their competencies
and weaknesses, examine their readiness for change, and identify
those factors critical to achieving future goals and objectives.

This assessment should begin with gathering data related to
financial performance, human resources, strategy, and service
offerings as well as outcomes and results. Feedback from senior
leadership, the medical staff, and the board is then needed so that
consensus can be obtained from stakeholders regarding the
organization’s strengths and weaknesses. Then, an action plan can
be created that strengthens the organization’s infrastructure. The
assessment concludes with an evaluation of how well the
organization is achieving its goals and objectives and the process
begins once again.

SWOT Analysis
There are many effective tools that assist organizations in strategic
planning. One of the most commonly used in health-care
organizations is SWOT analysis (identification of strengths,

weaknesses, opportunities, and threats) (Display 7.3). SWOT
analysis, also known as TOWS analysis, was developed by Albert
Humphrey at Stanford University in the 1960s and 1970s.


Strengths are those internal attributes that help an organization to
achieve its objectives.

Weaknesses are those internal attributes that pose barriers to an
organization achieving its objectives.

Opportunities are external conditions that promote achievement of
organizational objectives.

Threats are external conditions that challenge or threaten the
achievement of organizational objectives.

The first step in SWOT analysis is to define the desired end state
or objective. After the desired objective is defined, the SWOTs are
discovered and listed. Decision makers must then decide if the
objective can be achieved in view of the SWOTs. If the decision is
no, a different objective is selected and the process repeats. An
example of an abbreviated SWOT process is shown in Display 7.4.


Desired End State or Objective: Hospital Z wishes to increase
the number of nurses with baccalaureate and graduate degrees in
the staffing mix.

1. Local schools of nursing offer online baccalaureate and

master’s degrees at affordable costs for working nurses.
2. Hospital Z offers generous professional development funding

opportunities for staff.
3. This objective is in alignment with recommendations cited in

the Institute of Medicine’s report, The Future of Nursing:
Leading Change, Advancing Health, that 80% of registered
nurses should have baccalaureate or higher degrees by 2020.

1. Recent high turnover rates have resulted in tight staffing, and

requests by nurses for reduced workloads to return to school
would be difficult to honor.

2. At present, there is no role differentiation for nurses at Hospital
Z based on a nurse’s educational level.

3. At present, Hospital Z does not offer a salary differential to
nurses with baccalaureate or higher degrees, but another
hospital in the immediate area does.

1. Current research evidence suggests that increasing the

number of nurses with baccalaureate or higher degrees in the
staffing mix would positively impact quality of care.

2. Hospital Z could consider application for Magnet status if more
nurses held higher degrees.

3. Increasing the number of nurses with baccalaureate and
graduate degrees better prepares them to assume new and
emerging professional roles in an increasingly complex health-
care environment.

4. A review of the literature suggests that nurses with graduate
degrees are more likely to report being extremely satisfied with
their jobs compared with nurses who hold associate degrees.

1. Local schools of nursing have impacted enrollments, so not all

nurses who want to return to school can be accepted.
2. An impending national nursing shortage could further

exacerbate current staffing shortages.
3. Not all nurses are inherently motivated to return to school.

Performed correctly, SWOT analysis allows strategic planners to
identify those issues most likely to impact a particular organization or
situation in the future and then to develop an appropriate plan for
action. Marketing Teacher (Friesner, 2016), however, warns that
several simple rules must be followed for SWOT analysis to be
successful, and these are shown in Display 7.5. In essence, they
suggest that honesty, specificity, simplicity, and self-awareness are
integral to successful SWOT analysis.


Be realistic about the strengths and weaknesses of your

Be clear about how the present organization differs from what
might be possible in the future.

Be specific about what you want to accomplish.
Always apply SWOT analysis in relation to your competitors.
Keep SWOT analysis short and simple.
Remember that SWOT analysis is subjective.

Source: Adapted from Friesner, T. (2016). SWOT analysis. Retrieved August 2,
2018, from

Balanced Scorecard
Balanced scorecard, developed by Robert Kaplan and David Norton
in the early 1990s, is another tool that is highly assistive in strategic
planning. Strategic planners using a balanced scorecard develop
metrics (performance measurement indicators), collect data, and
analyze that data from four organizational perspectives: financial,
customers, internal business processes (or simply processes), and
learning and growth. Because all the measures are considered to be
related and because all of the measures are assumed to eventually
lead to outcomes, an overemphasis on financial measures is
avoided. The scorecard then is “balanced” in that outcomes are in

Balanced scorecards also allow organizations to align their
strategic activities with the strategic plan. The best balanced
scorecards are not a static set of measurements but instead reflect
the dynamic nature of the organizational environment. Because the
balanced scorecard is able to translate strategy into action, it is an
effective tool for translating an organization’s strategic vision into
clear and realistic objectives.

Strategic Planning as a Management Process
Although SWOT analysis and balanced scorecard are different, they
are also similar in that they can help organizations assess what they
do well and what they need to do to continue to be effective and
financially sound. Many other strategic planning tools exist as well,
although they are not discussed in this text. Regardless of the tool(s)
used, strategic planning as a management process generally
includes the following steps:

1. Clearly define the purpose of the organization.
2. Establish realistic goals and objectives consistent with the

mission of the organization.
3. Identify the organization’s external constituencies or

stakeholders and then determine their assessment of the
organization’s purposes and operations.

4. Clearly communicate the goals and objectives to the
organization’s constituents.

5. Develop a sense of ownership of the plan.
6. Develop strategies to achieve the goals.
7. Ensure that the most effective use is made of the organization’s

8. Provide a base from which progress can be measured.
9. Provide a mechanism for informed change as needed.

10. Build a consensus about where the organization is going.

It should be noted, though, that some critics argue that strategic
planning is rarely this linear or is it static. Strategic planning instead
involves various actions and reactions that are partially planned and
partially unplanned. As such, strategic plans must be adaptable and
flexible, so they can respond to changes in both internal and external

Who Should Be Involved in Strategic Planning?

Long-range planning for health-care organizations historically was
accomplished by top-level managers and the board of directors, with
limited input from middle-level managers. More contemporary
strategies suggest, however, the need to seek input from
subordinates from all organizational levels to give the strategic plan
meaning and to increase the likelihood of its successful
implementation. Indeed, Beckham (2017) suggests that leaders can
cascade ownership in the strategic plan by widely articulating vision
and driving strategies and then expanding the number of people
invited to consider how best to do that.


Making a Long-Term Plan

The human resource manager in the facility where you
are a supervisor has just completed a survey of the
potential retirement plans of the nursing staff and found
that within 5 years, 45% of the staff will probably be
retiring. You know that past and present available
statistics show that you normally replace 10% to 15% of
your staff each year with new hires. You are concerned
as you do not know how you will be able to handle this
new increase in your need for staff.


Make a 5-year, long-term plan that will increase the
likelihood of you being able to meet this new
demand. Remember that other units within your
facility and other health-care organizations in your
region may also be facing the same problem.

All organizations should establish annual strategic planning
conferences, involving all departments and levels of the hierarchy;
this action should promote increased effectiveness of nursing staff;
better communication between all levels of personnel; a cooperative
spirit relative to solving problems; and a pervasive feeling that the
departments are unified, goal directed, and doing their part to help
the organization accomplish its mission.

Organizational Planning: The Planning Hierarchy
There are many types of planning; in most organizations, these
plans form a hierarchy, with the plans at the top influencing all the
plans that follow. As depicted in the pyramid in Figure 7.1, the
hierarchy broadens at lower levels, representing an increase in the
number of planning components. In addition, planning components
at the top of the hierarchy are more general, and lower components
are more specific.

FIGURE 7.1 The planning hierarchy.

Vision and Mission Statements
Vision statements are used to describe future goals or aims of an
organization. It is a description in words that conjures up a picture for
all group members of what they want to accomplish together.
Prichard (2018) notes that the most consequential leaders
throughout history were able to both communicate their vision
skillfully and personify it. “At the summit of influence, their every
action, gesture or word moves into service of their greater cause.
This is at once an extraordinary accomplishment, opportunity and
burden. It requires a unity of life and work, of thought and action, an
overarching integrity” (para. 17). It is critical, then, that organization
leaders recognize that the organization will never be greater than the
vision that guides it.

An appropriate vision statement for a hospital is shown in Display


County Hospital will be the leading center for trauma care in the

An organization will never be greater than the vision that
guides it.

The purpose or mission statement is a brief statement (typically no
more than three or four sentences) identifying the reason that an
organization exists. The mission statement identifies the
organization’s constituency and addresses its position regarding
ethics, principles, and standards of practice.

A well-written mission statement will identify what is unique about
the organization. For example, all hospitals want to have high-
quality, patient-centered, cost-effective care, but mission statements
that include only this verbiage do not differentiate between
organizations. The mission statement should clearly drive action if it
is to be a template of purpose for the organization. In addition, it can
be challenging to meet an ambitious mission in an era of cost cutting
and limited resources; hence, the often-stated adage, “No margin, no

An example of a mission statement for County Hospital, a teaching
hospital, is shown in Display 7.7.


County Hospital is a tertiary care facility that provides
comprehensive, holistic care to all state residents who seek
treatment. The purpose of County Hospital is to combine high-
quality, evidence-based care with the provision of learning
opportunities for students in medicine, nursing, and allied health

The mission statement is of highest priority in the planning
hierarchy because it influences the development of an organization’s
philosophy, goals, objectives, policies, procedures, and rules.
Managers employed by County Hospital would have two primary
goals to guide their planning: (a) to provide high-quality, evidence-
based care and (b) to provide learning opportunities for students in
medicine, nursing, and other allied health sciences. To meet these
goals, adequate fiscal and human resources would have to be
allocated for preceptorships and clinical research. In addition, an
employee’s performance appraisal would examine the worker’s
performance in terms of organizational and unit goals.

Mission statements then have value, only if they truly guide the
organization. Indeed, actions taken at all levels of the organization
should be congruent with the stated organization mission. Therefore,
involving individuals from all levels of the organization in crafting
mission statements is so important.

Potential employees should review the mission statement of
potential employers and consider what it tells them about the
organization’s stakeholders and what beliefs and values are
espoused. Only then can the potential employee determine whether
this is an organization they want to work for.

An organization must truly believe and act on its mission
statement; otherwise, the statement has no value.


No Margin, No Mission? (Marquis &
Huston, 2012)

You are a nurse team leader in Jamestown Hospital, an
acute care, for-profit hospital. The mission statement for
Jamestown Hospital states that the hospital has two
primary purposes: (a) to provide the highest possible
quality of care for its clients and (b) to maximize the
efficiency and cost-effectiveness of resource utilization in
recognition of its obligation to internal and external

Recently, you have become increasingly concerned
regarding what you perceive to be the economically
motivated, premature discharge of patients with chronic
diseases. You know that some diabetic or asthmatic
patients yield little, if any, profit for the organization. You
are well acquainted with the discharge planner on the
unit, and both of you have discussed your concerns with
each other, but neither of you have taken any action.


Do you feel the dual goal mission statement is in
conflict? As a registered nurse, do you feel you can
influence the discharge process? How do you plan
on handling the conflict you are beginning to feel
regarding these early discharges? What
alternatives are available to you in deciding what, if
anything, to do?

Organizational Philosophy
The philosophy flows from the purpose or mission statement and
delineates the set of values and beliefs that guide all actions of the
organization. It is the foundation that directs all further planning
toward that mission. A statement of philosophy can usually be found
in policy manuals at the institution or is available upon request. A
philosophy that might be generated from County Hospital’s mission
statement is shown in Display 7.8.


The board of directors, medical and nursing staff, and
administrators of County Hospital believe that human beings are
unique due to different genetic endowments; personal
experiences in social and physical environments; and the ability to
adapt to biophysical, psychosocial, and spiritual stressors. Thus,
each patient is considered a unique individual with unique needs.
Identifying outcomes and goals, setting priorities, prescribing
strategy options, and selecting an optimal evidence-based
strategy for care will be negotiated by the patient, physician, and
health-care team.

As unique individuals, patients provide medical, nursing, and
allied health students invaluable diverse learning opportunities.
Because the board of directors, medical and nursing staff, and
administrators believe that the quality of health care provided
directly reflects the quality of the education of its future health-
care providers, students are welcomed and encouraged to seek
out as many learning opportunities as possible. Because high-
quality health care is defined by and depends on technological
advances and scientific discovery, County Hospital encourages
research as a means of scientific inquiry.

The organizational philosophy provides the basis for developing
nursing philosophies at the unit level and for nursing service as a
whole. Written in conjunction with the organizational philosophy, the
nursing service philosophy should address fundamental beliefs
about nursing and nursing care; the quality, quantity, and scope of
nursing services; and how nursing specifically will meet
organizational goals. Frequently, the nursing service philosophy
draws on the concepts of holistic care, education, and research. The
nursing service philosophy in Display 7.9 builds on County Hospital’s
mission statement and organizational philosophy.


The philosophy of nursing at County Hospital is based on respect
for the individual’s dignity and worth. We believe that all patients
have the right to receive effective, evidence-based nursing care.
This care is a personal service that is based on patients’ needs
and their clinical diseases or conditions.

Recognizing the obligation of nursing to help restore patients to
the best possible state of physical, mental, and emotional health
and to maintain patients’ sense of spiritual and social well-being,
we pledge intelligent cooperation in coordinating nursing service
with the medical and allied professional practitioners.
Understanding the importance of research and teaching for
improving patient care, the nursing department will support,
promote, and participate in these activities. Using knowledge of
human behavior, we shall strive for mutual trust and
understanding between nursing service and nursing employees to
provide an atmosphere for developing the fullest possible potential
of each member of the nursing team. We believe that nursing
personnel are individually accountable to patients and their
families for the quality and compassion of the patient care
rendered and for upholding the standards of care as delineated by
the nursing staff.

The unit philosophy, adapted from the nursing service philosophy,
specifies how nursing care provided on the unit will correspond with
nursing service and organizational goals. This congruence in
philosophy, goals, and objectives among the organization, nursing
service, and unit is shown in Figure 7.2.

FIGURE 7.2 Philosophical congruence in the planning hierarchy.

Although unit-level managers have limited opportunity to help
develop the organizational philosophy, they are active in
determining, implementing, and evaluating the unit philosophy. In
formulating this philosophy, the unit manager incorporates
knowledge of the unit’s internal and external environments and an
understanding of the unit’s role in meeting organizational goals. The
manager must understand the planning hierarchy and be able to
articulate ideas both verbally and in writing. Leader-managers also
must be visionary, innovative, and creative in identifying unit

purposes or goals so that the philosophy not only reflects current
practice but also incorporates a view of the future.

Like the mission statement, statements of philosophy in general
can be helpful only if they truly direct the work of the organization
toward a specific purpose. A department’s decisions, priorities, and
accomplishments reflect its working philosophy.

A working philosophy is evident in a department’s
decisions, in its priorities, and in its accomplishments.

A person should be able to identify exactly how the organization is
implementing its stated philosophy by observing members of the
staff, reviewing the budgetary priorities, and talking to consumers of
health care. The decisions made in an organization make the
philosophy visible to all—no matter what is espoused on paper. A
philosophy that is not or cannot be implemented is useless.


Developing a Philosophy Statement

Recover Inc., a fictitious for-profit home health agency,
provides complete nursing and supportive services for in-
home care. Services include skilled nursing, bathing,
shopping, physical therapy, occupational therapy, meal
preparation, housekeeping, speech therapy, and social
work. The agency provides around-the-clock care, 7 days
a week, to a primarily underserved rural area in Northern
California. The brochure the company publishes says that

it is committed to satisfying the needs of the rural
community and that it is dedicated to excellence.


Based on this limited information, develop a brief
philosophy statement that might be appropriate for
Recover Inc. Be creative and embellish information
if appropriate.

Societal Philosophies and Values Related to
Health Care
Societies and organizations have philosophies or sets of beliefs that
guide their behavior. These beliefs that guide behavior are called
values. Values have an intrinsic worth for a society or an individual.
Some strongly held American values are individualism, capitalism,
and competition. These values profoundly affected health-care policy
formation and implementation with the result being a US health-care
system that historically promoted structured inequalities. Passage of
the Affordable Care Act in 2010 reduced the number of uninsured in
the United States and made care more accessible and affordable for
many Americans, but numerous health-care disparities still exist.
Despite the highest spending as a percentage of gross domestic
product, American consumers continue to experience less than
desired outcomes.

Although values seem to be of central importance for health-care
policy development and analysis, public discussion of this crucial
variable is often neglected. Instead, health-care policy makers tend
to focus on technology, cost–benefit analysis, and cost-
effectiveness. Although this type of evaluation is important, it does

not address the underlying values in the United States that have led
to unequal access to health care.

Individual Philosophies and Values
As discussed in Chapter 1, values have a tremendous impact on the
decisions that people make. For the individual, personal beliefs and
values are shaped by that person’s experiences. All people should
carefully examine their value system and recognize the role that it
plays in how they make decisions and resolve conflicts and even
how they perceive things. Therefore, the leader-manager must be
self-aware and provide subordinates with learning opportunities or
experiences that foster increased self-awareness.

At times, it is difficult to assess whether something is a true value.
McNally’s (1980) classic work identified the following four
characteristics that determine a true value:

1. It must be freely chosen from among alternatives only after due

2. It must be prized and cherished.
3. It is consciously and consistently repeated (part of a pattern).
4. It is positively affirmed and enacted.

If a value does not meet all four criteria, it is a value indicator.
Most people have many value indicators but few true values. For
example, many nurses assert that they value their national nursing
organization; yet, they do not pay dues or participate in the
organization. True values require that the person take action,
whereas value indicators do not. Thus, the value ascribed to the
national nursing organization is a value indicator for these nurses
and not a true value.

In addition, because our values change with time, periodic
clarification is necessary to determine how our values may have
changed. Values clarification includes examining values, assigning

priorities to those values, and determining how they influence
behavior so that one’s lifestyle is consistent with prioritized values.
Sometimes, values change as a result of life experiences or newly
acquired knowledge. Most of the values we have as children reflect
our parents’ values. Later, our values are modified by peers and role
models. Although they are learned, values cannot be forced on a
person because they must be internalized. However, restricted
exposure to other viewpoints also limits the number of value choices
a person is able to generate. Therefore, becoming more worldly
increases our awareness of alternatives from which we select our


Reflecting on Your Values

Using what you have learned about values, value
indicators, and value clarifications, answer the following
questions. Take time to reflect on your values before
answering. This may be used as a writing exercise.

1. List three or four of your basic beliefs about nursing.
2. Knowing what you know now, ask yourself, “Do I value

nursing? Was it freely chosen from among alternatives
after appropriate reflection? Do I prize and cherish
nursing? If I had a choice to do it over, would I still
choose nursing as a career?”

3. Are your personal and professional values congruent?
Are there any values espoused by the nursing
profession that are inconsistent with your personal
values? How will you resolve resultant conflicts?

Elliot and Corey (2018) suggest that leaders need to be role
models for the values of the organizations they work in. They need to
take every opportunity to communicate and apply the organization’s
values, incorporating them to guide and help make better decisions.

Occasionally, however, individual values conflict with those of the
organization. Because the philosophy of an organization determines
its priorities in goal selection and distribution of resources, nurses
need to understand the organization’s philosophy. For example,
assume that a nurse is employed by County Hospital, which clearly
states in its philosophy that teaching is a primary purpose for the
hospital’s existence. Consequently, medical students are allowed to
practice endotracheal intubation on all people who die in the
hospital, allowing the students to gain needed experience in
emergency medicine. This practice disturbs the nurse a great deal; it
is not consistent with his or her own set of values and thus creates
great personal conflict.

Nurses who frequently make decisions that conflict with their
personal values may experience confusion and anxiety. This
intrapersonal struggle ultimately will lead to job stress and
dissatisfaction, especially for the novice nurse who comes to the
organization with inadequate values clarification. The choices that
nurses make about client care are not merely strategic options; they
are moral choices. Internal conflict and burnout may result when
personal and organizational values do not mesh.

When a nurse experiences cognitive dissonance between
personal and organizational values, the result may be
intrapersonal conflict and burnout.

As part of the leadership role, the manager should encourage all
potential employees to read and think about the organization’s

mission statement or philosophy before accepting the job. The
manager should give a copy of the philosophy to the prospective
applicant before the hiring interview. The applicant also should be
encouraged to speak to employees in various positions within the
organization regarding how the philosophy is implemented at their
job level. For example, a potential employee may want to determine
how the organization feels about cultural diversity and what policies
they have in place to ensure that patients from diverse cultures and
languages have a mechanism for translation as needed. Finally, new
employees should be encouraged to speak to community members
about the institution’s reputation for care. New employees who
understand the organizational philosophy will not only have clearer
expectations about the institution’s purposes and goals but also have
a better understanding of how they fit into the organization.

Although all nurses should have a philosophy comparable with
that of their employer, it is especially important for the new manager
to have a value system consistent with that of the organization.
Institutional changes that closely align with the value system of the
nurse-manager will receive more effort and higher priority than those
that are not true values or that conflict with the nurse-manager’s
value system. Managers who take a position with the idea that they
can change the organization’s philosophy to more closely agree with
their own philosophy are likely to be disappointed.

It is unrealistic for managers to accept a position under
the assumption that they can change the organization’s
philosophy to more closely match their personal

Such a change will require extraordinary energy and precipitate
inevitable conflict because the organization’s philosophy reflects the
institution’s historical development and the beliefs of those people

who were vital in the institution’s development. Nursing managers
must recognize that closely held values may be challenged by
current social and economic constraints and that philosophy
statements must be continually reviewed and revised to ensure
ongoing accuracy of beliefs.

Goals and Objectives
Goals and objectives are the ends toward which the organization is
working. All philosophies must be translated into specific goals and
objectives if they are to result in action. Thus, goals and objectives
“operationalize” the philosophy.

A goal may be defined as the desired result toward which effort is
directed; it is the aim of the philosophy. Although institutional goals
are usually determined by the organization’s highest administrative
levels, there is increasing emphasis on including workers in setting
organizational goals. Goals, much like philosophies and values,
change with time and require periodic reevaluation and prioritization.

Goals, although somewhat global in nature, should be measurable
and ambitious but realistic. Goals also should clearly delineate the
desired end product. When goals are not clear, simple
misunderstandings may compound, and communication may break
down. Organizations usually set long- and short-term goals for
services rendered; economics; use of resources, including people,
funds, and facilities; innovations; and social responsibilities. Display
7.10 lists sample goal statements.


All nursing staff will recognize the patient’s need for
independence and right to privacy and will assess the patient’s
level of readiness to learn in relation to his or her illness.

The nursing staff will provide effective patient care relative to
patient needs insofar as the hospital and community facilities
permit through the use of care plans, individual patient care,
and discharge planning, including follow-up contact.

An ongoing effort will be made to create an atmosphere that is
conducive to favorable patient and employee morale and that
fosters personal growth.

The performance of all employees in the nursing department will
be evaluated in a manner that produces growth in the employee
and upgrades nursing standards.

All nursing units within County Hospital will work cooperatively
with other departments within the hospital to further the mission,
philosophy, and goals of the institution.

Although goals may direct and maintain the behavior of an
organization, there are several dangers in using goal evaluation as
the primary means of assessing organizational effectiveness. The
first danger is that goals may conflict with each other, creating
confusion for employees and consumers. For example, the need for
profit maximization in health-care facilities today may conflict with
some stated patient goals or quality goals. The second danger with
the goal approach is that publicly stated goals may not truly reflect
organizational goals. In addition, some organizational goals may be
developed simply as a conduit for individual or personal goals. The
final danger is that because goals are global, it is often difficult to
determine whether they have been obtained.

Objectives are like goals in that they motivate people to a specific
end and are explicit, measurable, observable or retrievable, and
obtainable. Objectives, however, are more specific and measurable
than goals because they identify how and when the goal is to be

Goals usually have multiple objectives that are each accompanied
by a targeted completion date. The more specific the objectives for a
goal can be, the easier for all involved in goal attainment to
understand and carry out specific role behaviors. This is especially
important for the nurse-manager to remember when writing job
descriptions; if there is little ambiguity in the job description, there will
be little role confusion or distortion. Clearly written goals and
objectives must be communicated to all those in the organization
responsible for their attainment. This is a critical leadership role for
the nurse-manager.

Objectives can focus on either the desired process or the desired
result. Process objectives are written in terms of the method to be
used, whereas result-focused objectives specify the desired
outcome. An example of a process objective might be “100% of staff
nurses will orient new patients to the call-light system, within 30
minutes of their admission, by first demonstrating its appropriate use
and then asking the patient to repeat said demonstration.” An
example of a result-focused objective might be “95% postoperative
patients will perceive a decrease in their pain levels following the
administration of parenteral pain medication.” Writing good
objectives requires time and practice.

For the objectives to be measurable, they should have certain
criteria. There should be a specific time frame in which the objectives
are to be completed, and the objectives should be stated in
behavioral terms, be objectively evaluated, and identify positive
outcomes rather than negative outcomes.

As a sample objective, one of the goals at Mercy Hospital is that
“all RNs will be proficient in the administration of intravenous fluids.”

Objectives for Mercy Hospital might include the following:

All RNs will complete Mercy Hospital’s course “IV Therapy
Certification” within 1 month of beginning employment. The
hospital will bear the cost of this program.

RNs who score less than 90% on a comprehensive examination
in “IV Therapy Certification” must attend the remedial 4-hour
course “Review of Basic IV Principles” not more than 2 weeks
after the completion of “IV Therapy Certification.”

RNs who achieve a score of 90% or better on the
comprehensive examination for “IV Therapy Certification” after
completing “Review of Basic IV Principles” will be allowed to
perform IV therapy on patients. The unit manager will establish
individualized plans of remediation for employees who fail to
achieve this score on the examination.

The leader-manager clearly must be skilled in determining and
documenting goals and objectives. Prudent managers assess the
unit’s constraints and assets and determine available resources
before developing goals and objectives. The leader must then be
creative and futuristic in identifying how goals might best be
translated into objectives and thus implemented. The willingness to
be receptive to new and varied ideas is a critical leadership skill. In
addition, well-developed interpersonal skills allow the leader to
involve and inspire subordinates in goal setting. The final step in the
process involves clearly writing the identified goals and objectives,
communicating changes to subordinates, and periodically evaluating
and revising goals and objectives as needed.


Writing Goals and Objectives


Practice writing goals and objectives for County
Hospital based on the mission and philosophy
statements in this chapter. Identify three goals and
three objectives to operationalize each of these

Policies and Procedures
Policies are plans reduced to statements or instructions that direct
organizations in their decision making. These comprehensive
statements, derived from the organization’s philosophy, goals, and
objectives, explain how goals will be met and guide the general
course and scope of organizational activities. Thus, policies direct
individual behavior toward the organization’s mission and define
broad limits and desired outcomes of commonly recurring situations
while leaving some discretion and initiative to those who must carry
out that policy. Although some policies are required by accrediting
agencies, many policies are specific to the individual institution, thus
providing management with a means of internal control.

Policies also can be implied or expressed. Implied policies, neither
written nor expressed verbally, have usually developed over time
and follow a precedent. For example, a hospital may have an implied
policy that employees should be encouraged and supported in their
activity in community, regional, and national health-care
organizations. Another example might be that nurses who limit their
maternity leave to 3 months can return to their former jobs and shifts
with no status change.

Expressed policies are delineated verbally or in writing. Most
organizations have many written policies that are readily available to
all people and promote consistency of action. Expressed policies

may include a formal dress code, policy for sick leave or vacation
time, and disciplinary procedures.

All organizations need to develop facility-wide policies and
procedures to guide workers in their actions. These policies and
procedures are ideally developed with input from all levels of the
organization. Unfortunately, in many health-care organizations, this
function falls to isolated policy and procedure committees. Involving
more individuals in the process, as in a shared governance
approach, should increase the quality of the end product and the
likelihood that procedures will be implemented as desired.

Although top-level management is more involved in setting
organizational policies (usually by policy committees), unit managers
must determine how those policies will be implemented on their
units. Input from subordinates in forming, implementing, and
reviewing policy allows the leader-manager to develop guidelines
that all employees will support and follow. Even if unit-level
employees are not directly involved in policy setting, their feedback
is crucial to its successful implementation. Having uniform policies
and procedures developed through collaboration is critical.

In addition, policies and procedures should be evidence based.
The addition of evidence to policies and procedures, however,
requires the development of a process that ensures consistency,
rigor, and safe nursing practice. Unfortunately, many policies
continue to be driven by tradition or regulatory requirements and
inadequate evidence exists to guide best practices in policy

After policy has been formulated, the leadership role of managers
includes the responsibility for communicating that policy to all who
may be affected by it. This information should be transmitted in
writing and verbally. A policy’s perceived value often depends on
how it is communicated.

Procedures are plans that establish customary or acceptable ways
of accomplishing a specific task and delineate a sequence of steps

of required action. Established procedures save staff time, facilitate
delegation, reduce cost, increase productivity, and provide a means
of control. Procedures identify the process or steps needed to
implement a policy and are generally found in manuals at the unit
level of the organization.

The manager also has a responsibility to review and revise
policies and procedure statements to ensure currency and
applicability. Given the current explosion of evidence-based research
as well as new regulations, technology, and drugs, keeping policies
and procedures current and relevant is a tremendous management
challenge. In addition, because most units are in constant flux, the
needs of the unit and the most appropriate means of meeting those
needs constantly change. For example, the unit manager is
responsible for seeing that a clearly written policy regarding holiday
and vacation time exists and that it is communicated to all those it
affects. The unit manager must also provide a clearly written
procedural statement regarding how to request vacation or holiday
time on that specific unit. The unit manager would assess any long-
term change in patient census or availability of human resources and
revise the policy and procedural statements accordingly.

Because procedural instructions involve elements of organizing,
some textbooks place the development of procedures in the
organizing phase of the management process. Regardless of where
procedural development is formulated, there must be a close
relationship with planning—the foundation for all procedures.

Rules and regulations are plans that define specific action or
nonaction. Generally included as part of policy and procedure
statements, rules describe situations that allow only one choice of
action. Rules are fairly inflexible, so the fewer rules, the better.
Existing rules, however, should be enforced to keep morale from

breaking down and to allow organizational structure. Chapter 25, on
discipline, includes a more detailed discussion of rules and

Overcoming Barriers to Planning
Benefits of effective planning include timely accomplishment of
higher quality work and the best possible use of capital and human
resources. Because planning is essential, managers must be able to
overcome barriers that impede planning. For successful
organizational planning, the manager must remember several points:

The organization can be more effective if movement within it is
directed at specified goals and objectives. Unfortunately, the
novice manager frequently omits establishing a goal or
objective. Setting a goal for a plan keeps managers focused on
the bigger picture and saves them from getting lost in the minute
details of planning. Just as the nursing care plan establishes
patient care goals before delineating problems and
interventions, managers must establish goals for their planning
strategies that are congruent with goals established at higher

Because a plan is a guide to reach a goal, it must be flexible and
allow for readjustment as unexpected events occur. This
flexibility is a necessary attribute for the manager in all planning
phases and the management process.

The manager should include in the planning process all people
and units that could be affected by a plan. Although time
consuming, employee involvement in how things are done and
by whom increases commitment to goal achievement. Although
not everyone will want to contribute to unit or organizational
planning, all should be invited. The manager also needs to
communicate clearly the goals and specific individual

responsibilities to all those responsible for carrying out the plans
so that work is coordinated.

Plans should be specific, simple, and realistic. A vague plan is
impossible to implement. A plan that is too global or unrealistic
discourages rather than motivates employees. If a plan is
unclear, the nurse-leader must restate the plan in another
manner or use group process to clarify common goals.

Know when to plan and when not to plan. Some people devote
excessive time to arranging details that might be better left to
those who will carry out the plan. Other times, managers
erroneously assume that people and events will naturally fall
into some desired and efficient method of production.

Good plans have built-in evaluation checkpoints so that there
can be a midcourse correction if unexpected events occur. A
final evaluation should always occur at the end of the plan. If
goals were not met, the plan should be examined to determine
why it failed. This evaluation process assists the manager in
future planning.

Integrating Leadership Roles and Management
Functions in Planning
Planning requires managerial expertise in health-care economics,
human resource management, political and legislative issues
affecting health care, and planning theory. Planning also requires the
leadership skills of being sensitive to the environment, being able to
appraise accurately the social and political climate, and being willing
to take risks.

Clearly, the leader-manager must be skilled in determining,
implementing, documenting, and evaluating all types of planning in
the hierarchy because an organization’s leaders are integral to
realizing the mission of the organization. Managers then must draw
on the philosophy and goals established at the organizational and

nursing service levels in implementing planning at the unit level.
Initially, managers must assess the unit’s constraints and assets and
determine its resources available for planning. The manager then
draws on his or her leadership skills in creativity, innovation, and
futuristic thinking to problem solve how philosophies can be
translated into goals, goals into objectives, and so on down the
planning hierarchy. The wise manager will develop the interpersonal
leadership skills needed to inspire and involve subordinates in this
planning hierarchy. The manager also must demonstrate the
leadership skill of being receptive to new and varied ideas.

The final step in the process involves articulating identified goals
and objectives clearly; this learned management skill is critical to the
success of the planning. If the unit manager lacks management or
leadership skills, the planning hierarchy fails.

Key Concepts

■ The planning phase of the management process is critical
and precedes all other functions.

■ Planning is a proactive function required of all nurses.
■ A plan is a guide for action in reaching a goal and must be

■ Plans should be specific, simple, and realistic.
■ All planning must include an evaluation step and requires

periodic reevaluation and prioritization.
■ All people and organizational units affected by a plan should

be included in the planning.
■ Plans must have a time for evaluation built into them so that

there can be a midcourse correction if necessary.
■ New paradigms and trends emerge continuously, requiring

leader-managers to be observant and proactive in

organizational strategic planning.
■ Because of rapidly changing technology, increasing

government regulatory involvement in health care, changing
population demographics, and reducing provider autonomy,
health-care organizations are finding it increasingly difficult to
appropriately identify long-term needs and plan accordingly.

■ Organizations and planners tend to use one of the four
planning modes: reactive, inactivism, preactivism, or
proactive. A proactive planning style is always the goal.

■ Strategic planning tools such as SWOT analysis and
balanced scorecard help planners to identify those issues
most likely to impact a particular organization or situation in
the future and then to develop an appropriate plan for action.

■ All planning in the organizational hierarchy must flow from
and be congruent with planning done at higher levels in the

■ Planning in the organizational hierarchy typically includes the
development of organizational vision and mission statements,
philosophies, goals, objectives, policies, procedures, and

■ An organizational philosophy that is not or cannot be
implemented is useless.

■ To avoid ongoing intrapersonal values conflicts, employees
should have a philosophy compatible with that of their

■ Policies and procedures should be evidence based.
■ Rules are fairly inflexible, so the fewer rules, the better.

Existing rules, however, should be enforced to keep morale
from breaking down and to provide organizational structure.

Additional Learning Exercises and Applications


Exploring the Impact of Philosophy on
Management Action

Susan is the supervisor of the 22-bed oncology unit at
Memorial Hospital, a 150-bed hospital. Unit morale and
job satisfaction are high, despite a unit occupancy rate of
less than 50% in the last 6 months. Patient satisfaction
on this unit is as high as or higher than that of any other
unit in the hospital.

Susan’s personal philosophy is that oncology patients
have physical, social, and spiritual needs that are
different from other patients. Both the unit and nursing
service philosophy reflect this belief. Thus, nurses
working in the oncology unit receive additional education,
orientation, and socialization regarding their unique roles
and responsibilities in working with oncology patients.

At this morning’s regularly scheduled department head
meeting, the chief nursing officer suggests that because
of extreme budget shortfalls and continuing low census,
the oncology unit should be closed, and its patients
merged with the general medical–surgical patient
population. The oncology nursing staff would be
reassigned to the medical–surgical unit, with Susan as
the unit’s cosupervisor.

The idea receives immediate support from the
medical–surgical supervisor because of the current
staffing shortage on her unit. Susan, startled by the
proposal, immediately voices her disapproval and asks

for 2 weeks to prepare her argument. Her request is


What values or beliefs are guiding Susan, the chief
nursing officer, and the medical–surgical unit
supervisor? Determine an appropriate plan of action
for Susan. What impact does a unit or nursing
service philosophy have on the actions of
management and employees?


Incremental Goal Setting

Assume that your career goal is to become a nurse-
lawyer. You are currently a registered nurse in an acute
care facility in a large, metropolitan city. You have your
Bachelor of Science in Nursing degree but will need to
take at least 12 units of prerequisite classes for
acceptance into law school. A law school within
commuting distance of your home offers evening classes
that would allow you to continue your current day job at
least part-time. Quitting your job entirely would be
financially unfeasible.


Identify at least four objectives that you need to set
to achieve your career goal. Be sure that these
objectives are explicit, measurable, observable or
retrievable, and obtainable. Then identify at least
three actions for each objective that delineate how
you will achieve them.


Current Events and Planning

You are a manager in a public health agency. In reading
the morning paper before going to work today, you
peruse an article about the influx of Hispanic families in
your county. This population has increased 10% in the
last year alone, and is expected to continue to rise. You

ponder how this will affect your client population and your

You decide to gather your staff together and develop a
strategic plan for dealing with the problems and
opportunities that this change in client demographics


In examining the 10 steps listed in development of
strategic plans, what are the things that you can
personally influence, and what other individuals in
the organization should be involved with the
strategic plan? Make a list of 10 to 12 strategies
that will assist you in planning for this new client
population. What other information or data will you
need to help you plan? What are some other future
developments in your county that could have a
positive or negative influence on your plan?

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Planned Change
. . . The nature of leadership is resistance and change.
—Scott Mabry

. . . I can’t understand why people are frightened of new
ideas. I’m frightened of old ones.—John Cage

. . . If you want to make enemies, try to change
something.—Woodrow Wilson


This chapter addresses:

BSN Essential II: Basic organizational and systems leadership
for quality care and patient safety

BSN Essential III: Scholarship for evidence-based practice
BSN Essential VI: Interprofessional communication and
collaboration for improving patient health outcomes

MSN Essential II: Organizational and systems leadership
MSN Essential IV: Translating and integrating scholarship into

MSN Essential VII: Interprofessional collaboration for improving
patient and population health outcomes

MSN Essential IX: Master’s level nursing practice
AONL Nurse Executive Competency I: Communication and
relationship building

AONL Nurse Executive Competency II: A knowledge of the
health-care environment

AONL Nurse Executive Competency III: Leadership
AONL Nurse Executive Competency V: Business skills
ANA Standard of Professional Performance 9:

ANA Standard of Professional Performance 10:

ANA Standard of Professional Performance 11: Leadership
ANA Standard of Professional Performance 13: Evidence-
based practice and research

ANA Standard of Professional Performance 14: Quality of

ANA Standard of Professional Performance 16: Resource

QSEN Competency: Teamwork and collaboration


The learner will:

differentiate between planned change and change by drift
identify the responsibilities of a change agent
develop strategies for unfreezing, movement, and refreezing
assess driving and restraining forces for change in given

apply rational–empirical, normative–reeducative, and power–
coercive strategies for effecting change

describe resistance as a natural and expected response to

identify and implement strategies to manage resistance to

involve all those who may be affected by a change in planning
for that change whenever possible

identify characteristics of aged organizations as well as
strategies to keep them ever-renewing

identify critical features of complex adaptive systems change

describe the impact of chaos and the butterfly effect on both
short- and long-term planning

plan at least one desired personal change

Larson (2015) notes that effectively dealing with rapid change while
leading ever more complex organizations was identified as a top
challenge and critical leadership competency in her interview of
more than 50 leaders. These leaders also suggested the need for
leaders to develop strategic thinking skills. Larson suggests the two
go hand in hand and that strategy is nothing more or less than
“planned change” (Larson, 2015, para. 1).

Some of the forces driving change in contemporary health care
include rising health-care costs, declining reimbursement, new
quality imperatives, workforce shortages, emerging technologies, the
dynamic nature of knowledge, and a growing elderly population.
Contemporary health-care agencies then must continually institute
change to upgrade their structure, promote greater quality, and keep
their workers. In fact, most health-care organizations find themselves
undergoing continual change directed at organizational restructuring,
quality improvement, and employee retention.

In most cases, these changes are planned. Planned change, in
contrast to accidental change or change by drift, results from a well-
thought-out and deliberate effort to make something happen.
Planned change is the deliberate application of knowledge and skills

to bring about a change. Successful leader-managers must be well
grounded in change theories and be able to apply such theories

Most business leaders today would agree on two things:
(a) Organizational change is constant, and (b) leading
change is one of the most difficult burdens of a leader’s
command (Gleeson, 2018).

Many change attempts fail because the approach used to
implement the change lacks structure or planning. Indeed, what
often differentiates a successful change effort from an unsuccessful
one is the ability of the change agent—a person skilled in the theory
and implementation of planned change—to deal appropriately with
conflicted human emotions and to connect and balance all aspects
of the organization that will be affected by that change. In
organizational planned change, the manager is often the change

In some large organizations today, however, multidisciplinary
teams of individuals, representing all key stakeholders in the
organization, are assigned the responsibility for managing the
change process. In such organizations, this team manages the
communication between the people leading the change effort and
those who are expected to implement the new strategies. In addition,
this team manages the organizational context in which change
occurs and the emotional connections essential for any

But having a skilled change agent alone is not enough. Change is
never easy, and regardless of the type of change, all major change
brings feelings of achievement and pride as well as loss and stress.
The leader then must use developmental, political, and relational
expertise to ensure that needed change is not sabotaged.

In addition, many good ideas are never realized because of poor
timing or a lack of power on the part of the change agent. For
example, both organizations and individuals tend to reject outsiders
as change agents because they are perceived as having inadequate
knowledge or expertise about the current status and their motives
often are not trusted. Therefore, there is more widespread resistance
if the change agent is an outsider. The outside change agent,
however, tends to be more objective in his or her assessment,
whereas the inside change agent is often influenced by a personal
bias regarding how the organization functions.

Likewise, some greatly needed changes are never implemented
because the change agent lacks sensitivity to timing. If the
organization or the people within that organization have recently
undergone a great deal of change or stress (change fatigue), any
other change should wait until group resistance decreases.

For effective change to occur, the change agent needs to have
made a thorough and accurate assessment of the extent of and
interest in change, the nature and depth of motivation, and the
environment in which the change will occur. In addition, because
human beings have little control over many changes in their lives,
the change agent must remember that people need a balance
between stability and change in the workplace. Change for change’s
sake subjects employees to unnecessary stress and manipulation.

Change should be implemented only for good reasons.

Initiating and coordinating change then requires well-developed
leadership and management skills. Leading organizational change
always starts with a bit of mindset transformation because time,
budget, and resources must typically be pulled from one important
area to invest in another (Gleeson, 2018). It also requires vision and
expert planning skills because a vision is not the same as a plan.

The failure to reassess goals proactively and to initiate these
changes results in misdirected and poorly used fiscal and human
resources. Leader-managers must be visionary in identifying where
change is needed in the organization, and they must be flexible in
adapting to change they directly initiated as well as change that has
indirectly affected them. Display 8.1 delineates selected leadership
roles and management functions necessary for leader-managers
acting either in the change agent role or as a coordinator of the
planned change team.


Leadership Roles
1. Is visionary in identifying areas of needed change in the

organization and the health-care system
2. Demonstrates risk taking in assuming the role of change

3. Demonstrates flexibility in goal setting in a rapidly changing

health-care system
4. Anticipates, recognizes, and creatively problem solves

resistance to change
5. Serves as a role model to followers during planned change by

viewing change as a challenge and opportunity for growth
6. Is a role model for high-level interpersonal communication

skills in providing support for followers undergoing rapid or
difficult change

7. Demonstrates creativity in identifying alternatives to problems
8. Demonstrates sensitivity to timing in proposing planned

9. Takes steps to prevent aging in the organization and to keep

current with the new realities of nursing practice
10. Supports and reinforces the individual adaptive efforts of

those affected by change

Management Functions
1. Forecasts unit needs with an understanding of the

organization’s and unit’s legal, political, economic, social, and
legislative climate

2. Recognizes the need for planned change and identifies the
options and resources available to implement that change

3. Appropriately assesses and responds to the driving and
restraining forces when planning for change

4. Identifies and implements appropriate strategies to minimize
or overcome resistance to change

5. Seeks subordinates’ input in planned change and provides
them with adequate information during the change process to
give them some feeling of control

6. Supports and reinforces the individual efforts of subordinates
during the change process

7. Identifies and uses appropriate change strategies to modify
the behavior of subordinates as needed

8. Periodically assesses the unit/department for signs of
organizational aging and plans renewal strategies

9. Continues to be actively involved in the refreezing process
until the change becomes part of the new status quo

Lewin’s Change Theory of Unfreezing, Movement,
and Refreezing
Most of the current research on change builds on the classic change
theories developed by Kurt Lewin in the mid-20th century. Lewin
(1951) identified three phases through which the change agent must
proceed before a planned change becomes part of the system:
unfreezing, movement, and refreezing.

Unfreezing occurs when the change agent convinces members of
the group to change or when guilt, anxiety, or concern can be
elicited. Thus, people become discontent and aware of a need to
change. Zenger and Folkman (2015) note that one of Newton’s laws
of thermodynamics is that a body at rest tends to stay at rest:
“Slowing down, stopping, and staying at rest does not require effort.
It happens very naturally. Many change efforts are not successful

because they become one of a hundred priorities” (para. 16). To
make a change effort successful, the leader must clear away the
competing priorities and shine a spotlight on the need for a change
to happen.

Rockwell (2015) suggests, however, that sometimes people are
afraid of discontent (unfreezing) and thus put significant energy into
simply comforting those experiencing stress related to possible
change. This simply prolongs the problem because motivation
declines when discomfort is removed. Instead, Rockwell argues that
before soothing someone’s discomfort related to change, leaders
should ask, “What would you like to do about that?” In doing so, the
leader encourages transformational conversations instead of
avoiding the real issue or problem. Indeed, Rockwell notes that
successful leaders often bring up issues others avoid. Discomfort
with discomfort invites a person to ignore issues that should be

Leaders create pull. Successful leaders run forward more
than they run away. The difference is push versus pull
(Rockwell, 2015).

The second phase of planned change is movement. In movement,
the change agent identifies, plans, and implements appropriate
strategies, ensuring that driving forces exceed restraining forces.
Because change is such a complex process, it requires a great deal
of planning and intricate timing. Recognizing, addressing, and
overcoming resistance may be a lengthy process, and whenever
possible, change should be implemented gradually. Any change of
human behavior, or the perceptions, attitudes, and values underlying
that behavior, takes time.

Indeed, addressing and responding appropriately to stress caused
by change is a high-level leadership skill. Research by Zenger and
Folkman (2015) suggested that helping others to change is not just
about being nice or nagging; instead, inspiration, goal setting,
building trust, and making change a priority are what matter. These
strategies and others identified by Zenger and Folkman are detailed
in Display 8.2.


1. Inspiring others: Working with individuals to set aspirational
goals, exploring alternative avenues to reach objectives, and
seeking other’s ideas for the best methods to use going

2. Noticing problems: Recognizing problems (to see situations
where change is needed and to anticipate potential snares in

3. Providing a clear goal: Fixing everyone’s sight on the same
goal. Therefore, the most productive discussions about any
change being proposed are those that start with the strategy
that it serves.

4. Challenging standard approaches: Challenging standard
approaches and finding ways to maneuver around old practices
and policies—even sacred cows. Leaders who excel at driving
change will challenge even the rules that seem carved in stone.

5. Building trust in your judgment: Actually improving your
judgment and improving others’ perceptions of it.

6. Having courage: A great deal of what leaders do, and
especially their change efforts, demands willingness to live in

7. Making change a top priority: Clear away the competing
priorities and shine a spotlight on this one change effort.
Leaders who do this well have a daily focus on the change
effort, track its progress carefully, and encourage others.

Source: Zenger, J., & Folkman, J. (2015). 7 Things leaders do to help people
change. Retrieved August 8, 2018, from

Hinshaw (2015b) emphasized that change movement, however,
should not be delayed solely because of fear of the unknown or

because some ambiguity exists. She notes that a 2010 study of
more than 42 organizations found that “top performing leadership
teams spent more time in project implementation than they did on
project analysis. These organizations did not have different
circumstances; all were presented with complex challenges and
ever-changing times. The key difference between top performing and
low performing teams was speed to action and the ‘we can make this
work’ confidence to move quickly into implementation” (Hinshaw,
2015b, para. 7).

The last phase is refreezing. During the refreezing phase, the
change agent assists in stabilizing the system change so that it
becomes integrated into the status quo. If refreezing is incomplete,
the change will be ineffective and the prechange behaviors will be
resumed. For refreezing to occur, the change agent must be
supportive and reinforce the individual adaptive efforts of those
affected by the change. Because change needs at least 3 to 6
months before it will be accepted as part of the system, the change
agent must be sure that he or she will remain involved until the
change is completed.

Change agents must be patient and open to new
opportunities during refreezing, as complex change takes
time and several different attempts may be needed before
desired outcomes are achieved.

It is important to remember, though, that refreezing does not
eliminate the possibility of further improvements to the change.
Indeed, measuring the impact of change should always be a part of
refreezing. Display 8.3 illustrates the change agent’s responsibilities
during the various stages of planned change.


Stage 1—Unfreezing
1. Gather data.
2. Accurately diagnose the problem.
3. Decide if change is needed.
4. Make others aware of the need for change; often involves

deliberate tactics to raise the group’s discontent level; do not
proceed to Stage 2 until the status quo has been disrupted
and the need for change is perceived by the others.

Stage 2—Movement
1. Develop a plan.
2. Set goals and objectives.
3. Identify areas of support and resistance.
4. Include everyone who will be affected by the change in its

5. Set target dates.
6. Develop appropriate strategies.
7. Implement the change.
8. Be available to support others and offer encouragement

through the change.
9. Use strategies for overcoming resistance to change.
10. Evaluate the change.
11. Modify the change, if necessary.

Stage 3—Refreezing
Support others so that the change continues.

Lewin’s Change Theory of Driving and
Restraining Forces

Lewin (1951) also theorized that people maintain a state of status
quo or equilibrium by the simultaneous occurrence of both driving
forces (facilitators) and restraining forces (barriers) operating within
any field. Driving forces advance a system toward change;
restraining forces impede change.

The forces that push the system toward change are
driving forces, whereas the forces that pull the system
away from change are restraining forces.

Examples of driving forces might include a desire to please one’s
boss, to eliminate a problem, to get a pay raise, or to receive
recognition. Restraining forces include conformity to norms, an
unwillingness to take risks, and a fear of the unknown. Lewin’s
(1951) model suggested that people like feeling safe, comfortable,
and in control of their environment. For change to occur then, driving
forces must be increased or restraining forces decreased.

In Figure 8.1, the person wishing to return to school must reduce
the restraining forces or increase the driving forces to alter the
present state of equilibrium. There will be no change or action until
this occurs. Therefore, creating an imbalance within the system by
increasing the driving forces or decreasing the restraining forces is
one of the tasks required of a change agent.

FIGURE 8.1 Driving and restraining forces.

A Contemporary Adaptation of Lewin’s Model
Burrowes and Needs (2009) shared an adaptation of Lewin’s model
in their discussion of a five-step stages of change model (SCM). In
this model, the first stage is precontemplation. During this stage, the
individual “has no intention to change his or her behavior in the
foreseeable future” (Burrowes & Needs, 2009, p. 41). Next comes
the contemplation stage at which point the individual considers
making a change but has not yet made a commitment to take action.
This would be the phase in which unfreezing would occur according
to Lewin.

A transition from unfreezing to movement begins in the
preparation stage, as the individual intends to take action in the
short-term future. The action stage then occurs (movement) in which
the individual actively modifies his or her behavior. Finally, the
process ends with the maintenance stage at which point the
individual works to maintain changes made during the action stage
and prevent relapse. This stage would be synonymous with
refreezing. Table 8.1 illustrates the steps of the SCM.


Stage 1:

No current intention to change

Stage 2:

Individual considers making a change.

Stage 3:

There is intent to make a change in the near

Stage 4: Action Individual modifies his or her behavior.
Stage 5:

Change is maintained and relapse is

Source: Burrowes, N., & Needs, A. (2009). Time to contemplate change? A
framework for assessing readiness to change with offenders. Aggression & Violent
Behavior, 14(1), 39–49.

Classic Change Strategies
In addition to being aware of the stages of change, the change agent
must be highly skilled in the use of behavioral strategies to prompt
change in others. Three such classic strategies for effecting change
were described by Bennis, Benne, and Chinn (1969), with the most
appropriate strategy for any situation depending on the power of the
change agent and the amount of resistance expected from the


Making Change Possible

Identify a change that you would like to make in your
personal life (such as losing weight, exercising daily, and
stopping smoking). List the restraining forces keeping you
from making this change. List the driving forces that
make you want to change. Determine how you might be
able to change the status quo and make the change

One of these strategies is to give current research as evidence to
support the change. This group of strategies is often referred to as
rational–empirical strategies. The change agent using this set of
strategies assumes that resistance to change comes from a lack of
knowledge and that humans are rational beings who will change
when given information documenting the need for change. This type
of strategy is used when there is little anticipated resistance to the
change or when the change is perceived as reasonable. An example
of research evidence being used to promote a successful planned
change is shown in Examining the Evidence 8.1.

Source: McAllen, E. R., Stephens, K., Biearman, B.
S., Kerr, K., & Whiteman, K. (2018). Moving shift
report to the bedside: An evidence-based quality
improvement project. Online Journal of Issues in
Nursing, 23(2), 1.

Moving Shift Report to the Bedside: A
Planned Change
A Midwestern, 532-bed, acute-care, tertiary,
Magnet-designated teaching hospital identified
concerns about fall rates and patient and nurse
satisfaction scores. Because evidence
suggests that the implementation of bedside
report (BSR) increases patient safety and
patient and nurse satisfaction, the
implementation of BSR was planned and
implemented over a 4-month time on three
nursing units.

The team completed a gap analysis to
determine evidence-based best practices for
shift report as compared to the current practice.
At baseline, shift report was done in a
conference room, at the desk, or in the
hallways. BSR was not a practice on any of the
units. Report was not standardized, although
all nurses had some preferred form of

An organizational assessment completed
using the strengths, weaknesses,
opportunities, threats (SWOT) format revealed
that the practice change to BSR was feasible
and congruent with the hospital’s nursing

model. Tests of change in plan, do, study, act
(PDSA) cycles were used to evaluate the
practice change in real time and make
necessary adjustments throughout
implementation. Scripted reports were created
with input and consensus of staff, using on the
introduction, situation, background,
assessment, recommendation, question
(ISBARQ) format. In addition, all nursing staff
members (n = 67) completed education prior to
implementation of BSR.

Performance audits revealed a combined
compliance rate of 94% (n = 157). There was
no statistically significant difference between
mean time for report before and after
implementation of BSR. Patient falls, however,
decreased by 24% in the 4 months after BSR
implementation compared to
preimplementation falls. The orthopedic unit
experienced the greatest reduction in the
number of falls at 55.6%, followed by the
neuroscience unit at 16.9%, and the general
surgery unit at a 6.9% reduction.

Patient satisfaction also increased after
implementation of BSR with the average Press
Ganey score for the eight questions producing
a result that increased the average score from
87.7% to 91.6%. Hospital Consumer
Assessment of Healthcare Providers and
Systems (HCAHPS) showed improvement, but
the changes were not statistically significant.

The researchers also found that sharing
success stories (such as the “good catch” of a

patient who had deteriorated on rounds or
improving fall rates) helped to encourage
continued participation in BSR but noted the
need for nursing leadership to continue to
monitor performance and reinforce consistent
expectations for refreezing to occur.

In contrast, normative–reeducative strategies use group norms
and peer pressure to socialize and influence people so that change
will occur. The change agent assumes that humans are social
creatures, more easily influenced by others than by facts. This
strategy does not require the change agent to have a legitimate
power base. Instead, he or she gains power by skill in interpersonal
relationships, focusing on noncognitive determinants of behavior,
such as people’s roles and relationships, perceptual orientations,
attitudes, and feelings, to increase acceptance of change.


Using Change Strategies to Increase
Sam’s Compliance

You are a staff nurse in a home health agency. One of
your patients, Sam Little, is a 38-year-old man with type 1
diabetes. He has developed some loss of vision and had
to have two toes amputated as consequences of his
disease process. Sam’s compliance with four-times-daily
blood glucose monitoring and sliding-scale insulin
administration has never been particularly good, but he

has been worse than usual lately. Sam refuses to use an
insulin pump; however, he has been willing to follow a
prescribed diabetic diet and has kept his weight to a
desired level.

Sam’s wife called you at the agency yesterday and
asked you to work with her in developing a plan to
increase Sam’s compliance with his blood glucose
monitoring and insulin administration. She said that Sam,
although believing it “probably won’t help,” has agreed to
meet with you to discuss such a plan. He does not want,
however, “to feel pressured into doing something he
doesn’t want to do.”


What change strategy or combination thereof
(rational–empirical, normative–reeducative, and
power–coercive) do you believe has the greatest
likelihood of increasing Sam’s compliance? How
could you use this strategy? Who would be involved
in this change effort? What efforts might you
undertake to increase the unfreezing so that Sam is
more willing to actively participate in such a planned
change effort?

The third group of strategies, power–coercive strategies, features
the application of power by legitimate authority, economic sanctions,
or the political clout of the change agent. These strategies include
influencing the enactment of new laws and using group power for
strikes or sit-ins. Using authority inherent in an individual position to
effect change is another example of a power–coercive strategy.
These strategies assume that people often are set in their ways and
will change only when rewarded for the change or when they are
forced by some other power–coercive method. Resistance is
handled by authority measures; the individual must accept it or

Often, the change agent uses strategies from each of these three
groups. An example may be reflected in the change agent who
wants someone to stop smoking. The change agent might present
the person with the latest research on cancer and smoking (the
rational–empirical approach); at the same time, the change agent
might have friends and family encourage the person socially to quit
(normative–reeducative approach). The change agent also might
refuse to ride in the smoker’s car if the person smokes while driving
(power–coercive approach). By selecting from each set of strategies,
the change agent increases the chance of successful change.

Resistance: The Expected Response to Change
Even though change is inevitable, it creates instability in our lives,
and some conflict should always be expected. Indeed, Heathfield
(2018) suggests that even the most cooperative, supportive
employees may experience resistance because change alters the
balance of a group.

Hinshaw (2015a) suggests that the level of resistance often
depends on two things: whether the change is mandated and if the
change is proactive. Proactive change is generally less emotional
than mandated change; yet, the lines often blur between the two
because proactive change launched by one group may be perceived
as mandated change by another.

The level of resistance also generally depends on the type of
change proposed. Technological changes encounter less resistance
than changes that are perceived as social or that are contrary to
established customs or norms. For example, nursing staff may be
more willing to accept a change in the type of intravenous (IV) pump
to be used than a change regarding who is able to administer certain
types of IV therapy. Nursing leaders also must recognize that
subordinates’ values, educational levels, cultural and social
backgrounds, and experiences with change (positive or negative) will
have a tremendous impact on the degree of resistance. It is also
much easier to change a person’s behavior than it is to change an
entire group’s behavior. Likewise, it is easier to change knowledge
levels than attitudes.

To eliminate resistance to change in the workplace, managers
historically used an autocratic leadership style with specific
guidelines for work, an excessive number of rules, and a coercive
approach to discipline. The resistance, which occurred anyway, was
both covert (such as delaying tactics and passive–aggressive
behavior) and overt (openly refusing to follow a direct command).

The result was wasted managerial energy and time and a high level
of frustration.

Because change disrupts the homeostasis or balance of
the group, resistance should always be expected.

Today, resistance is recognized as a natural and expected
response to change, and leader-managers must resist the impulse to
focus on blaming others when resistance to planned change occurs.
Instead, they should immerse themselves in identifying and
implementing strategies to minimize or manage this resistance to
change. One such strategy is to encourage subordinates to speak
openly so that options can be identified to overcome objections. In
addition, it is the leader’s role to see the vision of what the future
state will be like after the change has taken place and to share that
vision with his or her followers.


What Is Your Attitude Toward Change?

How do you typically respond to change? Do you
embrace it? Seek it out? Accept it reluctantly? Avoid it at
all cost? Is this behavior like your friends and that of your
family? Has your behavior always fit this pattern, or has
the pattern changed throughout your life? If so, what life
events have altered how you view and respond to

Try to remember a situation in your own life that
involved unnecessary change. Why do you think that the
change was unnecessary? What types of turmoil did it
cause? Were there things a change agent could have
done that would have increased unfreezing in this

Likewise, workers should be encouraged to talk about their
perceptions of the forces driving the planned change so that the
leader can accurately assess change support and resources. It takes
a strong leader to step up and engage when a change effort meets
with pushback.

Still, there are individual variations in terms of risk taking and
willingness to accept change. Some individuals, even at very early
ages, demonstrate more risk taking than others. Certainly,
temperament and personality play at least some role in this. Change
agents then should be aware of life history variables as well as risk-
taking propensity when assessing the likelihood of an individual or
group being willing to change. Early in a planned change then,
leader-managers should assess which workers will promote or resist
a specific change, by both observation and direct communication.
Then, the manager can collaborate with change promoters on how
best to convert those individuals more resistant to change.

Perhaps, the greatest factor contributing to the resistance
encountered with change, however, is a lack of trust between the
employee and the manager or the employee and the organization.
Workers want security and predictability. That is why trust erodes
when the ground rules change, as the assumed “contract” between
the worker and the organization is altered. Subordinates’ confidence
in the change agent’s ability to manage change depends on whether
they believe that they have adequate resources to cope with it. In
addition, the leader-manager must remember that subordinates in an
organization will generally focus more on how a specific change will

affect their personal lives and status than on how it will affect the
organization. Heathfield (2018) suggests then that the leader should
always help employees identify what’s in it for them to make the
change. A good portion of the normal resistance to change
disappears when employees are clear about the benefits the change
brings to them as individuals.

“True change in an organization often means that job
positions and titles also change, which means that roles
and responsibilities may shift as well. Resistance occurs
when employees don’t understand how they fit in with the
new way of doing things” (Quain, 2018, para. 4).

Planned Change as a Collaborative Process
Often, the change process begins with a few people who meet to
discuss their dissatisfaction with the status quo and an inadequate
effort is made to talk with anyone else in the organization. This
approach virtually guarantees that the change effort will fail. People
abhor “information vacuums,” and when there is no ongoing
conversation about the change process, gossip usually fills the void.
These rumors are generally much more negative than anything that
is actually happening. McQuerrey (2018) suggests that leaders
should quell this early discord by being as transparent as possible.
“Call a meeting or issue a companywide memo that sets the record
about imminent change. Even if the situation is still fluid,
acknowledge that change is on the horizon and announce you will
disseminate information as soon as it is available” (McQuerrey,
2018, para. 2).

Resistance to change can gain its initial footing in
unchecked gossip . . . People will speculate, make
assumptions, and otherwise develop their thought
patterns about what’s going on (McQuerrey, 2018).

In addition, as a general rule, anyone who will be affected by a
change should be included in planning it. When information and
decision making are shared, subordinates feel that they have played
a valuable role in the change. Change agents and the elements of
the system—the people or groups within it—must openly develop
goals and strategies together. All must have the opportunity to define
their interest in the change, their expectation of its outcome, and
their ideas on strategies for achieving change. Effective leaders
empower the early adopter change agents on his or her team to
sway the group (Hinshaw, 2015b).

It is not always easy, however, to attain grassroots involvement in
planning efforts. Even when managers communicate that change is
needed and subordinate feedback is wanted, the message often
goes unheeded. Some people in the organization may need to hear
a message repeatedly before they listen, understand, and believe
the message. If the message is one that they do not want to hear, it
may take even longer for them to come to terms with the anticipated

Whenever possible, all those who may be affected by a
change should be involved in planning for that change.

When change agents fail to communicate with the rest of the
organization, they prevent people from understanding the principles
that guided the change, what has been learned from prior
experience, and why compromises have been made. Likewise,
subordinates affected by the change should thoroughly understand

the change and the impacts that will likely result. Good, open
communication throughout the process can reduce resistance.
Leaders must ensure that group members share perceptions about
what change is to be undertaken, who is to be involved and in what
role, and how the change will directly and indirectly affect each
person in the organization.

The Leader-Manager as a Role Model During
Planned Change
Leader-managers must act as role models to subordinates during
the change process. Heathfield (2018) suggests it is critical that
leader-managers own the planned change, no matter where it
originated. In addition, the leader-manager must attempt to view
change positively and to impart this view to subordinates. Rather
than viewing change as a threat, managers should embrace it as a
challenge and the chance or opportunity to do something new and
innovative. Indeed, the leader has two responsibilities in facilitating
change in nursing practice. First, leader-managers must be actively
engaged in change in their own work and model this behavior to
staff. Second, leaders must be able to assist staff members in
making the needed change requirements in their work.

It is critical that managers not view change as a threat.

Managers must also believe that they can make a difference. This
feeling of control is probably the most important trait for thriving in a
changing environment. Unfortunately, many leader-managers lack
self-confidence in their ability to serve as an effective change agent.
When this occurs, there is a lack of engagement in the change
process and a role modeling to followers that the change may not be
worth the time and energy necessary to bring it to fruition.

Organizational Change Associated With
Nonlinear Dynamics
Most 21st-century organizations experience fairly brief periods of
stability followed by intense transformation. In fact, some later
organizational theorists feel that Lewin’s (1951) refreezing to
establish equilibrium should not be the focus of contemporary
organizational change because change is unforeseeable and ever
present. This is particularly true in health-care organizations, where
long-term outcomes are almost always unpredictable.

In the past, organizations looked at change and organizational
dynamics as linear, occurring both in steps and sequentially. More
contemporary theorists maintain that the world is so unpredictable
that such dynamics are truly nonlinear. As a result, nonlinear change
theories such as complex adaptive systems (CAS) theory and chaos
theory now influence the thinking of many organizational leaders.

Complexity and Complex Adaptive Systems
Change Theory
Complexity science has emerged from the exploration of the
subatomic world and quantum physics and suggests that the world is
complex as are the individuals who operate within it. Thus, control
and order are emergent rather than predetermined, and mechanistic
formulas do not provide the flexibility needed to predict what actions
will result in what outcomes.

CAS change theory, an outgrowth of complexity theory, suggests
that the relationship between elements and agents within any system
is nonlinear and that these elements are constantly in play to change
the environment or outcome.

For example, although an individual may have behaved one way
in the past, CAS theory suggests that future behavior may not
always be the same (not always predictable). This is because that

individual’s prior experience and past learning may change his or her
future choices. In addition, the rules or parameters of each situation
are different, even if these differences are subtle; even small
variations can dramatically alter choice of action. CAS theory also
suggests that the actions of any agent within the system affect all
other agents in the system; that is, that context and action are
interconnected. Finally, CAS theory suggests that there are always
hidden or unanticipated elements in systems that make linear
thinking almost impossible.

In their classic work on CAS, Olson and Eoyang (2001) suggest
that the self-organizing nature of human interactions in a complex
organization leads to surprising effects. Rather than focusing on the
macrolevel of the organization system, complexity theory suggests
that most powerful change processes occur at the microlevel, where
relationships, interactions, and simple rules shape emerging
patterns. The main features of the CAS approach are shown in
Display 8.4.


Change should be achieved through connections among
change agents instead of from the top-down.

There should be adaptation to uncertainty during the change
instead of trying to predict stages of development.

Goals, plans, and structures should be allowed to emerge
instead of depending on clear, detailed plans and goals.

Value differences should be amplified and explored instead of
focusing on consensus in change efforts.

Patterns in one part of the organization are often repeated in
another part. Thus, change does not need to begin at the top of
an organization to be successful. The goal instead is self-
similarity rather than differences in how change is implemented
in different parts of the organization.

Successful change fits with the current organizational
environment instead of with an ideal. This is what makes it

In applying CAS theory to planned change, it becomes clear that
the multidimensionality of health-care organizations, and the
individuals who work within them, results in significant challenges for
the change agent. Change agents then must carefully examine and
focus on the relationships between the elements and be careful not
to look at any one element in isolation from the others. It also
suggests that time and attention must be given to trying to
understand these relationships and interactions even before
unfreezing is attempted and that continual monitoring and adaptation
will likely be needed for movement and refreezing to be successful.

Chaos Theory
The roots of chaos theory, considered by some to be a subset of
complexity science, likely emerged from the early work of
meteorologist Edward Lorenz in the 1960s to improve weather
forecasting techniques (MIT News, 2008). Lorenz discovered that
even tiny changes in variables often dramatically affected outcomes.
Lorenz also discovered that even though these chaotic changes
appeared to be random, they were not. Instead, he found that there
were deterministic sequences and physical laws, which prevail in
nature, even if this does not appear to be the case.

Chaos theory is really about finding the underlying order
in apparently random data.

Determining this underlying order, however, is challenging, and the
order itself is constantly changing. This chaos makes it difficult to
predict the future. In addition, chaos theory suggests that even small
changes in conditions can drastically alter a system’s long-term
behavior (commonly known as the butterfly effect). Thus, changes in
outcomes are not proportional to the degree of change in the initial
condition. Because of this sensitivity, the behavior of a system
exhibiting chaos appears to be random, even though the system is
deterministic in the sense that it is well defined and contains no
random parameters.

Chaos and complexity theories have great application within the
health-care arena. For example, despite putting a great time of
energy and time into planning, many plans with sharply delivered
strategies and targets are often not effective. This is because hidden
variables are not explored, and general goals and boundaries are
not developed. For example, a single individual or unit can
undermine a planned organizational change, particularly if the
actions of that individual or unit to undermine the change are covert.

The change agent might inadvertently focus on the aftermath of the
subversive action without ever realizing the root cause of the

Elena Capella, a nurse educator at the University of San Francisco
School of Nursing and Health Professions, suggests that students
should receive training about chaos theory as a part of their nursing
education (Hall, 2017). She introduces chaos theory to her students
to help them handle the intense needs of the emergency room,
reaching a sense of calm in disaster situations. She notes there are
patients in the emergency department who don’t follow protocols,
there are patients who have different backgrounds and
understandings, there are miscommunications, and there are
problems with coordination. In such a disorganized and chaotic
setting, you need “someone to step in as a reorganization force,
someone who can redirect everyone’s attention and energy in an
efficient manner” (Hall, 2017, para. 6).

This is the same behavior that is needed of the change agent. It is
imperative then that change agents understand complexity theory
and chaos theory because the use of nonlinear theories to explain
organizational functioning and change is expected to increase in the
21st century.

Organizational Aging: Change as a Means of
Organizations progress through developmental stages, just as
people do—birth, youth, maturity, and aging. As organizations age,
structure increases to provide greater control and coordination. The
young organization is characterized by high energy, movement, and
virtually constant change and adaptation. Aged organizations have
established “turf boundaries,” function in an orderly and predictable
fashion, and are focused on rules and regulations. Change is limited.

Clearly, organizations must find a balance between stagnation and
chaos, between birth and death. In the process of maturing, workers
within the organization can become prisoners of procedures, forget
their original purposes, and allow means to become the ends.
Without change, the organization may stagnate and die.
Organizations need to keep foremost what they are going to do, not
what they have done.

For example, Gordon (2012) and Owarish (2013) shared insights
regarding Kodak, founded in 1880 by George Eastman, and one of
America’s most notable companies, helping establish the market for
camera film and then dominating the field. But it suffered from a
variety of problems over the last four decades—almost all related to
being an aged organization. Kodak’s top management never fully
grasped how the world around them was changing and they hung on
to obsolete assumptions (such as digital prints will never replace film
prints) long after they were no longer the case.

In addition, Kodak followed a pattern seen by many aged
organizations that face technological change. First, they tried to
ignore a new technology hoping it would go away by itself. Then they
openly put it down by using various justifications such as it is too
expensive, too slow, and too complicated. Then they tried to prolong
the life of the existing technology by attempting to create synergies
between the new technology and the old (such as photo CD). This
further delayed any serious commitment to the new order of things.

In the end, Kodak failed to realize its limitations, ignored the data,
and spent an additional 15 years in avoidance mode until it became
virtually irrelevant in the market. With only 1 full year of profit after
2004, Kodak ended up filing for bankruptcy in 2012, after 131 years
of being the pioneer in the film industry.

Philpot (2013) provides another example in her accounting of
Blackberry’s market plunge from having 40% of the smartphone
market in North America in 2010 to only 2% by the end of 2012.
Philpot suggests this death spiral occurred as the result of

accelerated obsolescence and notes that the “shelf life” of any
business model is shorter now than ever before. She concludes that
leaders today have to know how to “keep one foot in today and the
other in tomorrow. In other words, their responsibility is to
successfully execute their current business model while also
reinventing their company to compete in a market that they have not
yet seen” (Philpot, 2013, para. 4).


Young or Old Organization?

Reflect on the organization in which you work or the
nursing school you attend. Do you believe that this
organization has more characteristics of a young or aged
organization? Diagram on a continuum from birth to
death where you feel that this organization would fall.
What efforts has this organization taken to be dynamic
and innovative? What further efforts could be made? Do
you agree or disagree that most organizations change
unpredictably? Can you support your conclusions with
examples? If professions were classified in a manner like
organizations, do you believe that the nursing profession
would be classified as (a) an aging organization, (b) in
constant motion and ever renewing, or (c) a closed
system that does not respond well to change?

Integrating Leadership Roles and Management
Functions in Planned Change

Change and innovation are increasingly critical to organizational
survival as well as sustained success (Bligh, Kohles, & Yan, 2018).
Leadership and management skills are necessary, however, for
successful planned change to occur. The manager must understand
the planning process and planning standards and be able to apply
both to the work situation. The manager is also cognizant of the
specific driving and restraining forces within a specific environment
for change and can provide the tools or resources necessary to
implement that change. The manager, then, is the mechanic who
implements the planned change.

The leader, however, is the inventor or creator. Leaders today are
forced to plan in a chaotic health-care system that is changing at a
frenetic pace. Out of this chaos, leaders must identify trends and
changes that may affect their organizations and units and proactively
prepare for these changes. Thus, the leader must retain a big-picture
focus while dealing with each part of the system. In the inventor or
creator role, the leader displays such traits as flexibility, confidence,
tenacity, and the ability to articulate vision through insights and
versatile thinking. The leader also must constantly look for and
attempt to adapt to the changing and unpredictable interactions
between agents and environmental factors as outlined by the
complexity science theorists.

Both leadership and management skills then are necessary in
planned change. The change agent fulfills a management function
when identifying situations where change is necessary and
appropriate and when assessing the driving and restraining forces
affecting the plan for change. The leader is the role model in planned
change. He or she is open and receptive to change and views
change as a challenge and an opportunity for growth. Other critical
elements in successful planned change are the change agent’s
leadership skills—interpersonal communication, group management,
and problem-solving abilities.

Perhaps, there is no greater need for the leader, though, than to
be the catalyst for professional change as well as organizational
change. Many people attracted to nursing now find that their values
and traditional expectations no longer fit as they once did. It is the
leader’s role to help his or her followers turn around and confront the
opportunities and challenges of the realities of emerging nursing
practice; to create enthusiasm and passion for renewing the
profession; to embrace the change of locus of control, which now
belongs to the health-care consumer; and to engage a new social
context for nursing practice.

Key Concepts

■ Change should not be viewed as a threat but as a challenge
and a chance to do something new and innovative.

■ Change should be implemented only for good reason.
■ Because change disrupts the homeostasis or balance of the

group, resistance should be expected as a natural part of the
change process.

■ The level of resistance to change generally depends on the
type of change proposed. Technological changes encounter
less resistance than changes that are perceived as social or
that are contrary to established customs or norms.

■ Perhaps, the greatest factor contributing to the resistance
encountered with change is a lack of trust between the
employee and the manager or the employee and the

■ It is much easier to change a person’s behavior than it is to
change an entire group’s behavior. It is also easier to change
knowledge levels than attitudes.

■ Change should be planned and thus implemented gradually,
not sporadically or suddenly.

■ Those who may be affected by a change should be involved
in planning for it. Likewise, workers should thoroughly
understand the change and its effect on them.

■ The feeling of control is critical to thriving in a changing

■ Friends, family, and colleagues should be used as a network
of support during change.

■ The successful change agent has the leadership skills of
problem solving and decision making as well as good
interpersonal skills.

■ In contrast to planned change, change by drift is unplanned
or accidental.

■ Historically, many of the changes that have occurred in
nursing or have affected the profession are the results of
change by drift.

■ People maintain status quo or equilibrium when both driving
and restraining forces operating within any field
simultaneously occur. For change to happen, this balance of
driving and restraining forces must be altered.

■ Emerging theories such as complexity science suggest that
change is unpredictable, occurs at random, and is dependent
on rapidly changing relationships between agents and factors
in the system and that even small changes can affect an
entire organization.

■ Organizations are preserved by change and constant
renewal. Without change, the organization may stagnate and

Additional Learning Exercises and Applications


Implementing Planned Change in a
Family Planning Clinic

You are a Hispanic registered nurse who has recently
received a 2-year grant to establish a family planning
clinic in an impoverished, primarily Hispanic area of a
large city. The project will be evaluated at the end of the
grant to determine whether continued funding is
warranted. As project director, you have the funds to
choose and hire three health-care workers. You will
essentially be able to manage the clinic as you see fit.

The average age of your patients will be 14 years, and
many come from single-parent homes. In addition, the
population with which you will be working has high
unemployment, high crime and truancy levels, and great
suspicion and mistrust of authority figures. You are aware
that many restraining forces exist that will challenge you,
but you feel strongly committed to the cause. You believe
that the high teenage pregnancy rate and maternal and
infant morbidity can be reduced.


1. Identify the restraining and driving forces in this

2. Identify realistic short- and long-term goals for
implementing such a change. What can
realistically be accomplished in 2 years?

3. How might the project director use hiring
authority to increase the driving forces in this

4. Is refreezing of the planned change possible so
that changes will continue if the grant is not
funded again in 2 years?


Retain the Status Quo or Implement

Assume that morale and productivity are low on the unit
where you are the new manager. To identify the root of
the problem, you have been meeting informally with staff
to discuss their perceptions of unit functioning and to
identify sources of unrest on the unit. You believe that
one of the greatest factors leading to unrest is the limited
advancement opportunity for your staff nurses. You have
a fixed charge nurse on each shift. This is how the unit
has been managed for as long as everyone can
remember. You would like to rotate the charge nurse
position but are unsure of your staff’s feelings about the


Using the phases of change identified by Lewin
(1951), identify the actions you could take in
unfreezing, movement, and refreezing. What are
the greatest barriers to this change? What are the
strongest driving forces?


How Would You Handle This Response
to Change?

You are the unit manager of a cardiovascular surgical
unit. The workstation on the unit is small, dated, and
disorganized. The unit clerks have complained for some
time that the chart racks on the counter above their desk
are difficult to reach, that staff frequently impinge on the
clerks’ work space to discuss patients or to chart, that the
call-light system is antiquated, and that supplies and
forms need to be relocated. You ask all eight of your shift
unit clerks to make a “wish list” of how they would like the
workstation to be redesigned for optimum efficiency and

Construction is completed several months later. You
are pleased that the new workstation incorporates what
each unit clerk included in his or her top three priorities
for change. There is a new revolving chart rack in the
center of the workstation, with enhanced accessibility to
both staff and unit clerks. A new, state-of-the-art call-light
system has been installed. A small, quiet room has been
created for nurses to chart and conference, and new
cubbyholes and filing drawers now put forms within arm’s
reach of the charge nurse and unit clerk.

Almost immediately, you begin to be barraged with
complaints about the changes. Several of the unit clerks
find the new call-light system’s computerized response
system overwhelming and complain that patient lights are
now going unanswered. Others complain that with the
chart rack out of their immediate work area, charts can no
longer be monitored and are being removed from the unit
by physicians or left in the charting room by nurses. One
unit clerk has filed a complaint that she was injured by a
staff member who carelessly and rapidly turned the chart
rack. She refuses to work again until the old chart racks

are returned. The regular day-shift unit clerk complains
that all the forms are filed backward for left-handed
people and that after 20 years, she should have the right
to put them the way that she likes it. Several of the
nurses are complaining that the workstation is “now the
domain of the unit clerk” and that access to the
telephones and desk supplies is limited by the unit clerks.
There have been some rumblings that several staff
members believe that you favored the requests of some
employees over others.

Today, when you make rounds at change of shift, you
find the day-shift unit clerk and charge nurse involved in a
heated conversation with the evening-shift unit clerk and
charge nurse. Each evening, the charge nurse and unit
clerk reorganize the workstation in the manner that they
believe is most effective, and each morning, the charge
nurse and unit clerk put things back the way they had
been the prior day. Both believe that the other shift is
undermining their efforts to “fix” the workstation
organization and that their method of organization is the
best. Both groups of workers turn to you and demand that
you “make the other shift stop sabotaging our efforts to
change things for the better.”


Despite your intent to include subordinate input into
this planned change, resistance is high and worker
morale is decreasing. Is the level of resistance a
normal and anticipated response to planned
change? If so, would you intervene in this conflict?
How? Was it possible to have reduced the
likelihood of such a high degree of resistance?


Overcoming Resistance to a Needed

You are the charge nurse of a medical/surgical unit.
Recently, your hospital spent millions of dollars to
implement a bedside medication verification (BMV)
system to reduce medication errors and to promote a
culture of patient safety. In this system, the nurse, using a
handheld device, scans the drug he or she is planning to
give against the patient’s medication record to make sure
that the right drug, at the right dose, is being given at the
right time to the right patient. The nurse then scans the
patient’s name band/arm band to assure the right patient
is receiving the drug and finally scans his or her own
name badge to document who is administering the drug
to the patient. If any of the codes do not match, a signal
goes off, alerting the nurse of the discrepancy.

It has come to your attention, however, that some
nurses are overriding the safety features built into the bar
coding system. For example, some nurses are reluctant
to wake sleeping patients to scan his or her bar code
before they administer an intravenous push medication
and instead simply scan the chart label. Some nurses
have overridden the bar code warning, assuming it was
some kind of technological glitch. Some nurses have
administered drugs to patients despite having name

bands that have become smudged or torn and no longer
scan well. Still, other nurses are carrying multiple
prescanned pills on one tray or charting that drugs have
been given, even though they were left at the bedside.
Finally, you learned that one nurse even affixed extra
copies of her patient’s bar codes to her clipboard, so that
they could be scanned more quickly.


Despite thorough orientation and training regarding
BMV, some staff have developed “work-arounds” to
the bar coding system, increasing the risk of
medication errors and patient harm. Your staff
suggests that although they understand BMV
reduces risks to patients, the equipment does not
always work and performing the additional safety
checks often takes them more time than how they
did it in the past, ultimately delaying medications to
patients who need them. The staff states they will
try to be more careful in implementing the BMV
procedures, but you continue to sense resistance
on their part. What strategies could you employ now
to foster refreezing of the new system? Would
rational–empirical, power–coercive, or normative–
reeducative strategies be more effective? Provide a
rationale for your choice.


Promoting Evidence-Based Practice

In recent years, the implementation of evidence-based
practice has been identified as a priority across nearly
every nursing specialty (Prevost & Ford, 2020). In
addition, nurses are increasingly accepted as essential
members, and often as leaders, of the interdisciplinary
health-care teams. To effectively participate and lead a
health-care team, nurses must have knowledge of the

most effective and reliable evidence-based approaches
to care, increase their expertise in critiquing research,
and apply the evidence of their findings to select optimal
interventions for their patients (Prevost & Ford, 2020).


Identify at least five things you might do to increase
your knowledge and use of evidence in your
practice. What are the most significant driving and
restraining forces to make this change? Would you
anticipate (overt or covert) resistance to your
efforts? Will you need to enlist support from others
or acquire additional resources for this planned
change to occur? (Examples might be
administrative support, access to scholarly journals,
or mentoring.)

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Time Management
. . . nothing is particularly hard if you divide it into small
jobs.—Henry Ford

. . . things which matter most must never be at the
mercy of things that matter least.—Johann Wolfgang
von Goethe

. . . The bad news is time flies. The good news is you’re
the pilot.—Michael Altshuler


This chapter addresses:

BSN Essential II: Basic organizational and systems leadership
for quality care and patient safety

BSN Essential VI: Interprofessional communication and
collaboration for improving patient health outcomes

MSN Essential II: Organizational and systems leadership
AONL Nurse Executive Competency I: Communication and
relationship building

AONL Nurse Executive Competency II: A knowledge of the
health-care environment

ANA Standard of Professional Performance 9:

ANA Standard of Professional Performance 10:

ANA Standard of Professional Performance 11: Leadership
ANA Standard of Professional Performance 14: Quality of

ANA Standard of Professional Performance 16: Resource

QSEN Competency: Safety
QSEN Competency: Teamwork and collaboration


The learner will:

analyze how time is managed both personally and at the unit
level of the organization

describe the importance of allowing adequate time for daily
planning and priority setting

describe how planning fallacies influence the perception of the
time needed to complete a task

complete tasks according to the priority level they have been
assigned whenever possible

build evaluation steps into planning so that reprioritization can

identify common internal and external time wasters as well as
interventions that can be taken to reduce their impact

complete a time inventory to increase self-awareness regarding
personal priority setting and time management

identify how technology applications such as e-mail, the
Internet, telecommunications, and social networking can both
facilitate and hinder personal time management

involve subordinates and followers in maximizing time use and
guiding work to its successful implementation and conclusion

Another part of the planning process is short-term planning. This
operational planning focuses on achieving specific tasks. Short-term
plans involve a period of 1 hour to 3 years and are usually less
complex than strategic or long-range plans. Short-term planning may
be done annually, quarterly, monthly, weekly, daily, or even hourly.

Previous chapters examined the need for prudent planning of
resources, such as money, equipment, supplies, and labor. Time is
an equally important resource. Indeed, the Latin for “I waste time” is
“tempus tero,” which literally means the rubbing away or gradual
unrecognized loss of a valuable commodity (Stone & Treolar, 2015).

“From crossing things off our to-do lists, to achieving long-term
goals, it feels good to get things done” (Doyle, 2018, para. 2). Mental
health often improves when we can take some action to resolve the
challenges facing us. When we lack the time to resolve those
challenges, we feel overwhelmed, and this can lead to increased
errors, the omission of important tasks, and general feelings of
stress and ineffectiveness. If leaders are to empower others to
achieve personal and shared goals, they need to become experts in
the planning and implementation of goal attainment. If managers are
to direct employees effectively and maximize other resources, they
must first be able to find the time to do so. In other words, both must
become experts at time management.

Time management can be defined as making optimal use of
available time. Many people argue that there is not enough time in
the day to do everything that must be done. Yet, everyone has the
same amount of time in a day, but some people consistently get
much more done than others. The problem then may be how the
time available is being used.

Optimizing time management must include priority setting,
managing and controlling crises, and balancing work and personal

time. All these activities require some degree of both leadership
skills and management functions. Leadership roles and management
functions needed for effective time management are included in
Display 9.1.


Leadership Roles
1. Is self-aware regarding personal blocks and barriers to efficient

time management
2. Recognizes how one’s own value system influences his or her

use of time and the expectations of followers
3. Functions as a role model, supporter, and resource person to

others in setting priorities for goal attainment
4. Assists followers in working cooperatively to maximize time use
5. Prevents and/or filters interruptions that prevent effective time

6. Role models flexibility in working cooperatively with other

people whose primary time management style is different
7. Presents a calm and reassuring demeanor during periods of

high unit activity
8. Prioritizes conflicting and overlapping requests for time
9. Appropriately determines the quality of work needed in tasks to

be completed

Management Functions
1. Appropriately prioritizes day-to-day planning to meet short-term

and long-term unit goals
2. Builds time for planning into the work schedule
3. Analyzes how time is managed on the unit level by using job

analysis and time-and-motion studies
4. Eliminates environmental barriers to effective time

management for workers
5. Handles paperwork promptly and efficiently and maintains a

neat work area
6. Breaks down large tasks into smaller ones that can more easily

be accomplished by unit members

7. Utilizes appropriate technology to facilitate timely
communication and documentation

8. Discriminates between inadequate staffing and inefficient use
of time when time resources are inadequate to complete
assigned tasks

Good time management skills allow an individual to
spend time on things that matter.

Three Basic Steps to Time Management
There are three basic steps to time management (Fig. 9.1). The first
step requires that time be set aside for planning and establishing
priorities. The second step entails completing the highest priority
task (as determined in step 1) whenever possible and finishing one
task before beginning another. In the final step, the person must
reprioritize what tasks will be accomplished based on new
information received. Because this is a cyclic process, all three steps
must be accomplished sequentially.

FIGURE 9.1 The three basic steps in time management.

Taking Time to Plan and Establishing Priorities
Planning is essential if an individual is to manage by efficiency rather
than by crisis, and the adage “fail to plan—plan to fail” is timeless.
Planning occurs first in the management process because the ability
to be organized develops from good planning. During planning, there
should be time to think about how plans will be translated into action.
The planner must pause and decide how people, activities, and
materials are going to be put together to carry out the objectives.

Many individuals believe that they are unproductive if they take
time out early in their day to design a plan for action rather than
immediately beginning work on tasks. Without adequate planning,
however, the individual finds it difficult to get started and begins to

manage by crisis. In addition, there can be no sense of achievement
at day’s end if the goals for the day are not clearly delineated.
Managers who are new to time management may underestimate the
importance of regular planning and fail to allot enough time for it.

In addition, many individuals repeatedly fail to complete planned
tasks because they don’t allow adequate resources (time, energy,
human or physical resources, etc.) for task completion. For example,
the student who carries home a full backpack every night with the
expectation that every assignment or task contained within the
backpack will always be completed, is likely to be disappointed.
Interruptions occur, life events happen, and most people can only
sustain high levels of attention to tasks for limited periods of time.
Most people simply want to believe that tasks will always go well and
that no problems will arise. This unrealistic assumption leads to
serious planning errors and poor time management.

Unfortunately, two mistakes common in planning are
underestimating the importance of a daily plan and not
allowing adequate time for planning.

Similarly, many students fail to establish a plan for completing their
learning activities. Sometimes, this is because they are unclear
about what the finished product must look like. Other times, they are
unsure when assignments are due or how to break large
assignments down into workable subcomponents. In all these cases,
the result is that the student’s ability to achieve the desired outcome,
within the required timeline, is threatened. Tips college students can
use to improve their time management effectiveness are shown in
Display 9.2.


1. List everything that must be done (school, work, and personal
tasks that must be completed).

2. Create a life schedule (use a time management tool if that is

3. Be flexible but realistic about how much you can accomplish in
a day (typically not more than 8 to 10 hours of dedicated time).

4. Allow time for planning to avoid repetition.
5. Avoid procrastination and distraction. Study in environments

where you are most productive.
6. Exercise to clear your head in between study sessions.
7. Constantly review and reassess your schedule to see if

changes are needed or new priorities have emerged.

Source: 7 Time management tips for students. (2017). Retrieved September 4,
2018, from

In addition, many new electronic apps exist for students who want
to better manage their time, whether it is taking notes more
efficiently, scheduling workflow better, or sticking to assignment
deadlines. Some of these time management and productivity apps
are previewed in Display 9.3.


Time Doctor: tracks other people’s schedules and offers screen
monitoring software, a tool to monitor internet usage, website
application monitoring, and more.

Roadmap: balances the schedules of multiple people and
provides insights as to how project goals are lining up with the
realities of available resources so that adjustments can be
made accordingly.

Basecamp: organizes all important tasks into three categories
and displays them on one convenient dashboard. In addition,
there is a “project” section where members of different teams
can work together to finish a project. Here people can share
tasks and see every step of the project from start to completion.

Asana: a project management app that breaks down tasks into
either a list or a calendar. This allows users to see when they
have something due on a calendar, and to address them in an
orderly fashion. This app also emails notifications about
upcoming due dates.

Float: a project management task software with a click and
drop scheduler that helps users visualize team work load,
assign tasks, and make updates. Also helps make task
assignments, mark milestones, group projects, and add tasks

ProofHub: project management software that helps to plan
what needs to be done, discusses ideas, organizes documents,
and delivers projects of all sizes.

I Done This: productivity app that is essentially a to-do list.
When tasks are accomplished, an incomplete red “x” turns to a
green completed check mark.

Todoist: productivity app to list tasks to be accomplished. Tasks
are labeled, assigned a due date, and then filtered by priority.

Dropbox: cloud storage app for file sharing.
Google Drive: cloud storage app for file sharing, collaboration,

editing, commenting on documents, and more.
Google Hangouts: video meeting software that allows

meetings and chat through a voice or video call.
Skype: communication platform that allows easy messaging,

voice calls, screen sharing, and video conference calls across
all desktop, iOS, and Android devices. communication system to organize meetings. Includes
free conference calling capabilities, video conferencing, screen
sharing, and chat (through Slack), but also offers additional
benefits like webinar training services and a mobile whiteboard.

Slack: chat tool for quick group or one-on-one communications.
Workplace by Facebook: a joint Facebook account for all

individuals involved in a project. This allows members to hold
group discussions, post updates about projects, comment and
offer suggestions on posts, and also participate in voice and
video calling.

Source: 16 Best time management apps to skyrocket productivity in 2019. (2019).
Retrieved July 26, 2019, from


Making Big Projects Manageable

Think of the last major paper you wrote for a class. Did
you set short-term and intermediate deadlines? Did you
break the task down into smaller tasks to eliminate a last-

minute crisis? What short-term and intermediate
deadlines have you set to accomplish major projects that
have been assigned to you this quarter or semester? Are
you realistic about the time that will be required to
complete the task or are you likely to experience planning

The Time-Efficient Work Environment
Whether you are a student, a manager, or a staff nurse, planning
takes time; it requires the ability to think, analyze data, envision
alternatives, and make decisions. Examples of the types of plans a
charge nurse might make in day-to-day planning include staffing
schedules, patient care assignments, coordination of lunch- and
work-break schedules, and interdisciplinary coordination of patient
care. Examples of an acute care staff nurse’s day-to-day planning
might include determining how handoff reports will be given and
received; the timing and method used for initial patient assessments;
the coordination of medication administration, treatments, and
procedures; and the organization of documentation of the day’s

Some staff nurses, however, appear disorganized in their efforts to
care for patients. This may be the result of poor planning or it may be
a symptom of a work environment that is not conducive to efficient
time management. The following suggestions, using industrial
engineering principles, may assist the staff nurse in planning work
activities, especially when the environment poses obstacles to time

Gather all the supplies and equipment that will be needed before
starting an activity. Breaking a job down mentally into parts
before beginning the activity may help the staff nurse identify

what supplies and equipment will be needed to complete the

Get organized. Rampton (2018) notes that the average
American spends 2.5 days each year looking for misplaced
items. Have a home for everything and make sure that items are
put back where they belong. Rampton also suggests single-
tasking because most people cite multitasking as the main
culprit for misplacing items.

Group activities that are in the same location. If you have walked
a long distance down a hallway, attempt to do several things
there before going back to the nurses’ station. If you are a home
health nurse, group patient visits geographically when possible
to minimize travel time and maximize time with patients.

Use time estimates. For example, if you know an intermittent
intravenous medication (IV piggyback) will take 30 minutes to
complete, then use that time estimate for planning some other
activity that can be completed in that 30-minute window of time.

Document your nursing interventions as soon as possible after
an activity is completed. Waiting until the end of the workday to
complete necessary documentation increases the risk of
inaccuracies and incomplete documentation.

Always strive to end the workday on time. Although this is not
always possible, delegating appropriately to others and making
sure that the workload goal for any given day is reasonable are
two strategies that will accomplish this goal.

Like staff nurses, unit managers need to coordinate how their
duties will be carried out and devise methods to make work simpler
and more efficient. Often, this includes simple tasks such as
organizing how supplies are stored or determining the most efficient
lunch and break schedules for staff. In addition, it is the manager’s
responsibility to see that units are appropriately stocked with the

equipment nurses need to do their work. This reduces the time spent
in trying to locate needed supplies.

Daily planning actions that may help the unit manager identify and
utilize time as a resource most efficiently might include the following:

At the start of each workday, identify key priorities to be
accomplished that day. Identify what specific actions need to be
taken to accomplish those priorities and in what order they
should be done. Also, identify specific actions that should be
taken to meet ongoing, long-term goals.

Determine the level of achievement that you expect for each
prioritized task. Is a maximizing or “satisficing” approach more
appropriate or more reasonable for each of the goals you have

Assess the staff assigned to work with you. Assign work that
must be delegated to staff members who are both capable and
willing to accomplish the priority task that you have identified. Be
sure that you have clearly expressed any expectations you may
have about how and when a delegated task must be completed.
(Delegation is discussed further in Chapter 20.)

Review the short- and long-term plans of the unit regularly.
Include colleagues and subordinates in identifying unit problems
or concerns so that they can be fully involved in planning for
needed change.

Plan ahead for meetings. Prepare and distribute agendas in

Allow time at several points throughout the day and at the end of
the day to assess progress in meeting established daily goals
and to determine if unanticipated events have occurred or if new
information has been received that may have altered your
original plan. Ongoing realities for the unit manager include work
situations that are constantly changing, and with them, setting
new priorities and adjusting older ones.

Take regularly scheduled breaks. Planning for periodic breaks
from work during the workday is an integral part of an
individual’s time and task management. These work breaks
allow both managers and staff to refresh physically and

Using an electronic calendar to organize your day can help
make a day feel less chaotic. It can also help you identify
pockets of spare time that you could use for breaks.

Setting new priorities or adjusting priorities to reflect
ever-changing work situations is an ongoing reality for
the manager.


Setting Daily Priorities

Assume that you are the registered nurse-leader of a
team with one licensed vocational nurse and one nursing
assistant on the 7 AM to 3 PM shift at an acute care
hospital. The three of you are responsible for providing

total care to 10 patients. Prioritize the following list of 10
things that you need to accomplish this morning. Use a
“1” for the first thing you will do and a “10” for the last. Be
prepared to provide rationale for your priorities.

____ Check medication cards/sheets against the patient
medication record.

____ Listen to night shift handoff.
____ Take brief walking rounds to assess the night shift

report and to introduce yourself to patients.
____ Hang four 9:00 AM intravenous medications.
____ Set up the schedule for breaks and lunch among

your team members.
____ Give 8:45 AM preoperative on patient going to

surgery at 9:00 AM.
____ Pass 8:30 AM breakfast trays.
____ Meet with team members to plan the schedule for

the day and to clarify roles.
____ Read charts of patients who are new to you.
____ Check 6:00 AM blood glucose laboratory results for

7:30 AM insulin administration.

Priority Setting and Procrastination
Because most individuals are inundated with requests for their time
and energy, the next step in time management is prioritizing, which
may well be the key to good time management. Unfortunately, some
individuals lack self-awareness about what is important and
therefore how to spend their time.

Priority setting is perhaps the most critical skill in good
time management because all actions we take have some
type of relative importance.

One simple means of prioritizing what needs to be accomplished
is to divide all requests into three categories: “don’t do,” “do later,”
and “do now” (Display 9.4). The don’t do items probably reflect
problems that will take care of themselves, are already outdated, or
are better accomplished by someone else. The individual either
throws away the unnecessary information or passes it on to the
appropriate person in a timely fashion. In either case, the individual
removes unneeded clutter from his or her work area.


1. “Don’t do”
2. “Do later”
3. “Do now”

Before setting “do later” items aside, the leader-manager must be
sure that large projects have been broken down into smaller projects
and that a specific timeline and plan for implementation are in place.
The plan should include short-term, intermediate, and final
deadlines. Likewise, one cannot ignore items without immediate time
limits forever and must make a definite time commitment soon to
address these requests.

The do now requests most commonly reflect a unit’s day-to-day
operational needs. These requests may include daily staffing needs,
dealing with equipment shortages, meeting schedules, conducting
hiring interviews, and giving performance appraisals. Do now
requests also may represent items that had been put off earlier.

Some do later items reflect trivial problems or those that do not
have immediate deadlines; thus, they may be procrastinated. To
procrastinate means to put off something until a future time, to
postpone, or to delay needlessly. Procrastination can be
appropriately justified if it is more important to something of greater
importance now, but it should not be used to avoid a task because it
is overwhelming or unpleasant.

More often, procrastination is a barrier to effective time
management. Price (2018) agrees, noting that procrastination offers
only an illusion of freedom because it tricks us into believing we have
countless hours, only to rob us of them later. Hendriksen (2018)
concurs, noting that when we procrastinate, we typically regret the
time wasted as deadlines approach, time runs out, and opportunity
slips through our fingers. The key in procrastination then is to use it
appropriately and selectively.

Procrastination, however, is a difficult problem to solve because it
rarely results from a single cause and can involve a combination of
dysfunctional attitudes, rationalizations, and resentment. For
example, sometimes, procrastination is caused by perfectionism.
Price (2018) suggests perfectionists may postpone starting a project
because he or she feels overwhelmed by the sheer amount of
energy it will take to do something perfectly. Taibbi (2018) suggests
another cause is emotionality driving behavior rather than rationality.
For individuals driven by emotionality, the impulsive brain overrides
the rational one and the result is a delay in action.

New research even suggests that procrastination may have
neurobiological causes. Hendriksen (2018) notes that the tendency
to procrastinate runs in families and is linked on the genetic level to
impulsivity, creating a catchall of difficulty regulating our own
behavior. In addition, a team of German researchers found a relation
between the gray matter volume of the amygdala in the brain and
difficulties in initiating action. Theoretically, this is known as decision-
related action orientation. Individuals who tend to hesitate or

procrastinate show higher amygdala volume, providing a neural
signature referred to as an “amygdala hijack” (Pychyl, 2018). This
neural signature of action suggests that procrastination is a problem
with emotion regulation (see Examining the Evidence 9.1).

Source: Pychyl, T. A. (2018). The neural signature of
procrastination. Retrieved September 3, 2018, from

Is Procrastination a Function of Neural
A team of researchers from Ruhr-University
Bochum, Bochum, Germany, took a rare
neuroscientific approach to the study of action
control and procrastination. Using a sample of
264 young adults, they conducted functional
magnetic resonance imaging brain scans to
explore the neural correlates of the ability to
initiate and sustain action.
The researchers found a relation between the
gray matter volume of the amygdala and
difficulties in initiating action; individuals who
tend to hesitate or procrastinate show higher
amygdala volume. Because the amygdala is a
neuroanatomical hub for fear-motivation
behavior (“fight or flight” center of the brain),
individuals with a larger amygdala volume
evaluate future actions and their possible
consequences more extensively. This, in turn,
may lead to greater concern and hesitation.

The researchers did note, however, that
biology is not destiny because our brains can
change. For example, other research has
shown that mindfulness meditation can shrink
the volume of the amygdala. In addition,
individuals can learn skills to better regulate

their emotional response to the tasks in their

Making Lists
In prioritizing all the do now items, the leader-manager may find
preparing a written list helpful. Remember, however, that a list is a
plan, not a product, and that the creation of the list is not the final
goal. The list is a planning tool.


Targeting Personal Procrastination

Spend a few moments reflecting on the last 2 weeks of
your life. What are the things you put off doing? Do these
things form a pattern? For instance, do you always put off
writing a school paper until the last minute? Do you wait
to do certain tasks at work until you cannot avoid the task
any longer? What things do you do when you really do
not want to do something? Do you eat? Play video
games? Watch TV? Read?


Write a one-page essay on at least two things that
you procrastinate and then develop two strategies
for breaking each of these habits.

Although the individual may use monthly or weekly lists, a list also
can assist in coordinating daily operations. This daily list, however,
should not be longer than what can be realistically accomplished in 1
day; otherwise, it demotivates instead of assists.

In addition, although the leader-manager must be cognizant of and
plan for routine tasks, it is not always necessary to place them on the
list because they may only distract attention from other priority tasks.
Lists should allow adequate time for each task and have blocks of
time built in for the unexpected. In addition, individuals who use lists
to help them organize their day must be careful not to confuse
importance and urgency.

Not all important things are urgent, and not all urgent
things are important. This is especially true when the
urgency is coming from an external source.

In addition, the individual should periodically review lists from
previous days to see what was not accomplished or completed. If a
task appears on a list for several successive days, the manager
must reexamine it and assess why it was not accomplished.
Sometimes, tasks just need to be removed from the list. This occurs
when a task has low priority or when it is better done by someone
else. Other times, undone tasks on the list should be discarded
because they are duplicative or unimportant.

Sometimes, however, items on the list remain unaccomplished
because they are not divided into steps or tasks that can be
completed. Breaking a big job down into smaller parts can make the
task seem more manageable. Doyle (2018) agrees, suggesting that
when people feel stressed by a big job, they should ask themselves
what one thing could be done in the next 24 hours to help make
progress on that item. It does not need to be resolved entirely. For
example, many well-meaning people begin thinking about

completing their tax returns in early January but feel overwhelmed by
a project that cannot be accomplished in 1 day. If preparing a tax
return is not broken down into several smaller tasks with
intermediate deadlines, it may be almost perpetually procrastinated.

Some projects are not accomplished because they are
not broken down into manageable tasks.

The last step in time management is reprioritizing. Often, one’s
priorities or list will change during a day, week, or longer because
new information is received. If the individual does not take time to
reprioritize after each major task is accomplished, other priorities set
earlier may no longer be accurate. In addition, despite outstanding
planning, an occasional crisis may erupt.

No amount of planning can prevent an occasional crisis.

If a crisis does occur, the individual may need to set aside the
original priorities for the day and reorganize, communicate, and
delegate a new plan reflecting the new priorities associated with the
unexpected event causing the crisis.

Dealing With Interruptions
All managers experience interruptions, but lower level managers
typically experience the most. This occurs in part because first- and
middle-level managers are more involved in daily planning than
higher level managers and thus directly interact with a greater
number of subordinates. In addition, many lower level managers do
not have a quiet workspace or clerical help to filter interruptions.


Creating Planning Lists

Do you make a daily plan to organize what needs to be
done? Mentally or on paper, develop a list of five items
that must be accomplished today. Prioritize that list. Now
make a list of five items that must be done this week.
Prioritize that list as well.

Interruptions can cause a great deal of time wasting because
attention is continually diverted from the task at hand. All managers
need protected time to respond to time-sensitive phone calls or e-
mails, and it is important not to be disturbed during these times
unless there is an urgent request for an answer or guidance on
dealing with an emergency.

Frequent work interruptions also result in situational stress and
lowered job satisfaction. That’s because interruptions cause us to
split our attention between what we should be doing and addressing
the new demands. James Clear suggests the result of this divided
attention is “half–work,” work that takes twice as long to accomplish

half as much (Rampton, 2018). Managers then need to develop skill
in preventing interruptions that threaten effective time management.

Lower level managers experience more interruptions than
higher level managers.

Dealing with interruptions also requires leadership skills. Leaders
role model flexibility and the ability to regroup when new information
or tasks emerge as priorities. Followers often look to see how their
leaders are coping with change and even crisis, and their reactions
often mirror those of their leaders. That is often why a staff nurse
who feels harried or out of control typically finds these same feelings
reflected in the individuals he or she is assigned to work with.

Time Wasters
There are many time wasters, and the time wasters that are used
most often vary by the individual. Four time wasters warrant special
attention here (Display 9.5). The first of these surprisingly is
technology, which generally has been promoted as a time saver for
most people. Indeed, technology can and does save time. E-mail
now makes instantaneous, asynchronous communication to multiple
parties possible simultaneously, and the Internet provides virtually
unlimited access to emerging, state of the science knowledge
globally. In addition, social networks such as Facebook, Pinterest,
and Twitter have created new opportunities for communicating in real
time to vast networks of users.


1. Technology (Internet, gaming, e-mail, and social media sites)
2. Socializing
3. Paperwork overload
4. A poor filing system
5. Interruptions

Yet, this same technology increasingly consumes more and more
of our time. Many individuals find themselves randomly searching
the Internet or playing online games to distract themselves from the
tasks at hand. In addition, the need to check and respond to so
many different communication mediums (e-mail, blackberries, voice
mail, pagers, and social networking sites) is time consuming in and
of itself.

Finally, all this technology can make it difficult to find an
appropriate balance between the need for virtual and face-to-face
interaction and between work and personal life. Staying plugged in
and checking e-mails nonstop throughout the day can waste time
and use significant energy. This causes boundaries between work
and personal life to blur.

A second time waster is socializing. Socializing with colleagues
during the workday can waste significant amounts of time in a
workday. Although socializing can help workers meet relationship
needs or build power, it can tremendously deter productivity. This is
especially true for managers with an open-door policy. Subordinates
can be discouraged from taking up a manager’s time with idle chatter
in several ways:

Do not make yourself overly accessible. Make it easy for people
to ignore you. Try not to “work” at the nursing station, if this is
possible. If charting is to be done, sit with your back to others. If
you have an office, close the door. Have people make

appointments to see you. All these behaviors will discourage
casual socializers.

Interrupt. When someone is rambling on without getting to the
point, break in and say gently, “Excuse me. Somehow I’m not
getting your message. What exactly are you saying?”

Avoid promoting socialization. Having several comfortable chairs
in your office, a full candy dish, and posters on your walls that
invite comments encourage socializing in your office.

Be brief. Watch your own long-winded comments and stand up
when you are finished. This will signal an end to the

Schedule long-winded pests. If someone has a pattern of
lengthy chatter and manages to corner you on rounds or at the
nurse’s station, say, “I can’t speak with you now, but I’m going to
have some free time at 11 AM. Why don’t you see me then?”
Unless the meeting is important, the person who just wishes to
chat will not bother to make a formal appointment. If you would
like to chat and have the time to do so, use coffee breaks and
lunch hours for socializing.

Other external time wasters that a manager must conquer are
paperwork overload and a poor filing system. Managers are
generally inundated with paper clutter, including organizational
memos, staffing requests, quality assurance reports, incident
reports, and patient evaluations. Because paperwork is often
redundant or unnecessary, the manager needs to become an expert
at handling it. Whenever possible, incoming correspondence should
be handled the day it arrives; it should either be thrown away or filed
according to the date to be completed. Try to address each piece of
correspondence only once.

An adequate filing system also is invaluable to handling paper
overload. Keeping correspondence organized in easily retrievable
files rather than disorganized stacks saves time when the manager

needs to find specific information. The manager also may want to
consider increased use of computerization and e-mail to reduce the
paper use and to increase response time in time-sensitive

Personal Time Management
Personal time management refers in part to self-knowledge. Self-
awareness is a leadership skill. For people who are not certain of
their own short- and long-term goals, time management, in general,
poses difficulties. These goals give structure to what should be
accomplished today, tomorrow, and in the future. However, goals
alone are not enough; a concrete plan with timelines is needed.
Plans outlined in manageable steps are clearer, more realistic, and
attainable. By being self-aware and setting goals accordingly, people
determine how their time will be spent. If goals are not set, others
often end up deciding how a person should spend his or her time.

Indeed, many college students often report feeling time challenged
and overwhelmed by their numerous academic, work, and personal
commitments. This may reflect a lack of priority or goal setting or it
may simply reflect too many things to be reasonably accomplished in
the time frame given. Indeed, Greene and Maggs (2015) note that
during college, class attendance is discretionary, clubs and
organizations vie for members, and employment becomes an
important strategy to offset tuition and living expenses. Students
must learn to navigate the demands of this new environment in order
to maximize their present and future well-being.

To better understand how college students allocate their time,
Greene and Maggs (2015) examined longitudinal diary data of
college students. They found that the amount of time college
students devote to employment and leisure has increased over the
past 40 years. They also found support for their hypothesis that
increasing time in one productive activity resulted in less time

available for other productive activities. On days when students
spent more time than average on employment, they spent less time
on academics. These findings suggested that students may be
trading academic time for more time in employment, and thus, their
time management is more focused on meeting short-term goals than
long-term goals.

Think for a moment about last week. Did you accomplish all that
you wanted to accomplish? How much time did you or others waste?
In your clinical practice, did you spend your time hunting for supplies
and medicines instead of teaching your patient about his or her
diabetes? Too often, irrelevant decisions and insignificant activities
take priority over real purposes. Clearly, work redesign, clarification
of job descriptions, or a change in the type of care delivery system
may alleviate some of these problems. However, the same general
principle holds: Individuals who are self-aware and have clearly
identified personal goals and priorities have greater control over how
they expend their energy and what they accomplish.

When individuals lack this self-awareness, they may find it difficult
to find a balance between time spent on personal and professional
priorities. Indeed, a study of more than 50,000 employees from a
variety of manufacturing and service organizations found that 2 out
of every 5 employees were dissatisfied with the balance between
their work and their personal lives (Hansen, 2018). Effective time
management then is an essential part of finding that balance
between work life and personal life.

Brans (2013), building on thinking done by Benjamin Franklin
more than 300 years ago, suggests that there are 12 habits that
should be nurtured for optimum personal time management. These
are shown in Display 9.6. All 12 habits are directed at being self-
aware regarding what is important to accomplish in one’s life, staying
focused on the things that matter, taking care of oneself, and
following through in a timely and consistent manner.


Habit 1: Strive to be authentic. Be honest with yourself about
what you want and why you do what you do.

Habit 2: Favor trusting relationships. Build relationships with
people you can trust and count on and make sure those same
people can trust and count on you.

Habit 3: Maintain a lifestyle that will give you maximum
energy. Exercise, eat well, and get enough sleep.

Habit 4: Listen to your biorhythms and organize your day
accordingly. Pay attention to regular fluctuations in your
physical and mental energy levels throughout the day and
schedule tasks accordingly.

Habit 5: Set very few priorities and stick to them. Select a
maximum of two things that are your highest priority and work
on them.

Habit 6: Turn down things that are inconsistent with your
priorities. Say no to other people when their request is not a
priority for you and you do not have the time to help.

Habit 7: Set aside time for focused effort. Schedule time
every day to work on just one thing.

Habit 8: Always look for ways of doing things better and
faster. Watch for tasks you do over and over again and look for
ways of improving how you do them.

Habit 9: Build solid processes. Set up processes that last and
that run without your attention.

Habit 10: Spot trouble ahead and solve problems
immediately. Set aside time to think about what lies ahead and
face all problems as soon as you can.

Habit 11: Break your goals into small units of work and
think only about one unit at a time. Spend most of your time

working on the task in front of you and avoid dreaming too
much about the big goal.

Habit 12: Finish what is important and stop doing what is
no longer worthwhile. Do not stop doing what you considered
worth starting unless there is a good reason to give it up.

Source: Adapted from Brans, P. (2013). Twelve time management habits to master
in 2013. Retrieved September 3, 2018, from

In addition to being self-aware regarding the values that influence
how people prioritize the use of their time, people must be self-aware
regarding their general tendency to complete tasks in isolation or in
combination. Some people prefer to do one thing at a time, whereas
others typically do two or more things simultaneously. Some
individuals begin and finish projects on time, have clean and
organized desks because of handling each piece of paperwork only
once, and are highly structured. Others tend to change plans, borrow
and lend things frequently, emphasize relationships rather than
tasks, and build longer term relationships. It is important to recognize
one’s own preferred time management style and to be self-aware
about how this orientation may affect one’s interaction with others in
the workplace. A significant part of personal time management
depends on self-awareness about how and when a person is most
productive. Everyone has ways to waste time or steer clear of certain

Everyone avoids certain types of work or has methods of
wasting time.

Likewise, each person works better at certain times of the day or
for certain lengths of time. Rampton (2018) suggests the biggest and

most challenging tasks should be addressed in the morning because
most people have the greatest amount of energy in the morning.
Accomplishing the most important tasks in the morning also provides
a sense of accomplishment the rest of the day. Mornings may not be
the most productive time, however, for everyone. Self-aware people
schedule complex or difficult tasks during the periods they are most
productive and simpler or routine tasks during less productive times.

Finally, each individual should be cognizant of how he or she
values the time of others. For example, being punctual goes beyond
common courtesy. Tardiness reflects some disregard for the value of
other people’s time.

A lack of punctuality suggests that you do not value
other people’s time.

Using a Time Inventory
Because most people have an inaccurate perception of the time they
spend on a specific task or the total amount of time they are
productive during the day, a time inventory (Display 9.7) may provide
insight. A time inventory allows you to compare what you planned to
do, as outlined by your appointments and “to-do” entries, with what
you actually did. Electronic time inventory apps such as
RescueTime, Toggl, or my app Calendar can track everything you do
for a week (Rampton, 2018).


5:00 AM

6:00 AM

6:30 AM

7:00 AM

7:30 AM

8:00 AM

8:30 AM

9:00 AM

9:30 AM

10:00 AM

10:30 AM

11:00 AM

11:30 AM

12:00 PM

12:30 PM

1:00 PM

1:30 PM

2:00 PM

2:30 PM

3:00 PM

3:30 PM

4:00 PM

4:30 PM

5:00 PM

5:30 PM

6:00 PM

6:30 PM

7:00 PM

7:30 PM

8:00 PM

8:30 PM

9:00 PM

9:30 PM

10:00 PM

11:00 PM

12:00 PM

1:00 AM

2:00 AM

3:00 AM

4:00 AM

Because the greatest benefit from a time inventory is being able to
objectively identify patterns of behavior, it may be necessary to
maintain the time inventory for several days or even several weeks.
It may also be helpful to repeat the time inventory annually to see if
long-term behavior changes have been noted. Remember, there is
no way to beg, borrow, or steal more hours in the day. If time is
habitually used ineffectively, managing time will be very stressful.


Writing a Personal Time Inventory

Use the time inventory shown in Display 9.7 to
identify your activities for a 24-hour period. Record
your activities on the time inventory on a regular
basis. Be specific. Do not trust your memory. Star
the periods of time when you were most productive.
Circle periods of time when you were least
productive. Do not include sleep time. Was this a
typical day for you? Could you have modified your
activity during your least productive time periods? If
so, how?

Integrating Leadership Roles and Management
Functions in Time Management
There is a close relationship between time management and stress.
Managing time appropriately reduces stress and increases
productivity. The current status of health care, the nursing shortage,
and decreasing reimbursements have resulted in many health-care
organizations trying to do more with less. The effective use of time
management tools, therefore, becomes even more important to
enable leader-managers to meet personal and professional goals.

The leadership skills needed to manage time resources draw
heavily on interpersonal communication skills. The leader is a
resource and role model to subordinates in how to manage time. As
has been stressed in other phases of the management process, the
leadership skill of self-awareness is also necessary in time
management. Leaders must understand their own value system,

which influences how they use time and how they expect
subordinates to use time.

The management functions inherent in using time resources
wisely are more related to productivity. The manager must be able to
prioritize activities of unit functioning to meet short- and long-term
unit needs. To do this, the leader-manager must initiate an analysis
of time management on the unit level, involve team members and
gain their cooperation in maximizing time use, and guide work to its
conclusion and successful implementation.

Successful leader-managers are able to integrate leadership skills
and management functions; they accomplish unit goals in a timely
and efficient manner in a concerted effort with subordinates. They
also recognize time as a valuable unit resource and share
responsibility for the use of that resource with subordinates. Perhaps
most important, the integrated leader-manager with well-developed,
time management skills can maintain greater control over time and
energy constraints in his or her personal and professional life.

Key Concepts

■ Because time is a finite and valuable resource, learning to
use it wisely is essential for effective management.

■ Time management can be reduced to three cyclic steps: (a)
allow time for planning and establish priorities; (b) complete
the highest priority task, and whenever possible, finish one
task before beginning another; and (c) reprioritize based on
remaining tasks and new information that may have been

■ Setting aside time at the beginning of each day to plan the
day allows the manager to spend appropriate time on high-
priority tasks.

■ Many individuals fall prey to planning fallacies, where they
are overly optimistic about the time it will take to complete a

■ Making lists is an appropriate tool to manage daily tasks. This
list should not be any longer than what can realistically be
accomplished in a day and must include adequate time to
accomplish each item on the list and time for the unexpected.

■ A common cause of procrastination is failure to break large
tasks down into smaller ones so that the manager can set
short-term, intermediate, and long-term goals.

■ Lower level managers have more interruptions in their work
than do higher level managers. This results in situational
stress and lowered job satisfaction.

■ Managers must learn strategies to cope with interruptions
from socializing.

■ Because so much paperwork is redundant or unnecessary,
the manager needs to develop expertise at prioritizing it and
eliminating unnecessary clutter at the work site.

■ An efficient filing system is invaluable to handling paper

■ Personal time management refers to “the knowing of self.”
Managing time is difficult if a person is unsure of his or her
priorities, including personal short-term, intermediate, and
long-term goals.

■ Being punctual implies that you value other people’s time and
creates an imperative for them to value your time as well.

■ Effective time management is an essential part of finding that
balance between work life and personal life.

■ Using a time inventory is one way to gain insight into how
and when a person is most productive. It also assists in
identifying internal time wasters.

Additional Learning Exercises and Applications


A Busy Day at the Public Health Agency

You work in a public health agency. It is the agency’s
policy that at least one public health nurse is available in
the office every day. Today is your turn to remain in the
office. From 1 PM to 5 PM, you will be the public health
nurse at the scheduled immunization clinic; you hope to
be able to spend some time finishing your end-of-month
reports, which are due at 5 PM. The office stays open

during lunch; you have a luncheon meeting with a Cancer
Society group from noon to 1 PM today. The registered
nurse in the office is to serve as a resource to the
receptionist and handle patient phone calls and drop-ins.
In addition to the receptionist, you may delegate
appropriately to a clerical worker. However, the clerical
worker also serves the other clinic nurses and is usually
fairly busy. While you are in the office today trying to
finish your reports, the following interruptions occur:

8:30 AM: Your supervisor, Anne, comes in and requests a
count of the diabetic and hypertensive patients seen in
the last month.

9:00 AM: An upset patient is waiting to see you about her
daughter who just found out that she is pregnant.

9:00 AM: Three drop-in patients are waiting to be
interviewed for possible referral to the chest clinic.

9:30 AM: The public health physician calls you and needs
someone to contact a family about a child’s

9:30 AM: The dental department drops off 20 referrals and
needs you to pull charts of these patients.

10:00 AM: A confused patient calls to find out what to do
about the bills that he has received.

10:45 AM: Six families have been waiting since 8:30 AM to
sign up for food vouchers.

11:45 AM: A patient calls about her drug use; she does
not know what to do. She has heard about Narcotics
Anonymous and wants more information now.


How would you handle each interruption? Justify
your decisions. Do not forget lunch for yourself and
the two office workers. Note: Attempt your own
solution before reading the possible solution
presented in the back of this book.


Realistic Priority Setting

You are a registered nurse providing total patient care
to four patients on an orthopedic unit during the 7 AM to 3
PM shift. Given the following patient information, prioritize
your activities for the shift in eight 1-hour blocks of time.
Be sure to include time for handoffs, planning your day’s
activities, breaks, and lunch. Be realistic about what you
can accomplish. What activities will you delegate to the
next shift? What overall goals have guided your time
management? What personal values or priorities were
factors in setting your goals?

101 A


84 years old. Fractured left hip,
secondary to fall at home. Disoriented
since admission, especially at night. Fall
precautions ordered. Moans frequently.
Being given IV pain medication every 2
hours prn. Vital signs and checks for
circulation, feeling, and movement in
toes ordered every 2 hours. Scheduled

for surgery at 10:30 AM. Preoperative
medications scheduled for 9:30 AM and
10:00 AM. Consent yet to be signed.
Family members will be here at 8:00 AM
and have expressed questions about
the surgery and recovery period. Patient
to return from surgery at approximately
2:30 PM. Will require postoperative vital
signs every 15 minutes.

101 B


26 years old. Compound fracture of the
femur with postoperative fat emboli, now
resolved. Ten-pound Buck’s traction.
Has been in the hospital 3 weeks. Very
bored and frustrated with prolonged
hospitalization. Upset about roommate
who calls out all night and keeps her
from sleeping. Wants to be moved to
new room. Has also requested to have
hair washed today. Has IV medication
running at 100 mL/hour. IV antibiotic
piggybacks at 8:00 AM and 12:00 PM.
Oral medications at 8:00 AM, 9:00 AM,
and 12:00 PM.

102 A


47 years old. C5 quadriplegic due to
diving accident 14 years ago. Two days
postoperative above-knee amputation
due to osteomyelitis. Cultures show
methicillin-resistant Staphylococcus
aureus. Strict wound isolation. Has been
hospitalized for 2 weeks. Expressing
great deal of anger and frustration to
anyone who enters room. IV site red

and puffy. IV needs to be restarted.
Dressing change of operative site
ordered daily. Heat lamp treatments
ordered b.i.d. to small pressure sores on
coccyx. IV antibiotic piggybacks at 8:00
AM, 10:00 AM, 12:00 PM, and 2:00 PM.
Main IV bag to run out at 10:00 AM. 6:00
AM laboratory results to be called to
physician this morning. Needs total
assistance in performing activities of
daily living, such as bathing and feeding

103 A


19 years old. Severe tear of rotator cuff
in left shoulder while playing football.
One-day postoperative rotator cuff
repair. Very quiet and withdrawn.
Refusing pain medication, which has
been ordered every 2 hours prn. Says
he can handle pain and does not want
to “mess up his body with drugs.” He
wants to be recruited into professional
football after this semester. Nonverbal
signs of grimacing, moaning, and
inability to sleep suggest that moderate
pain is present. Physician states that
likelihood of Mr. Novak ever playing
football again is very low but has not yet
told the patient. Girlfriend frequently in
room at patient’s bedside. IV infusing at
150 mL/hour. IV antibiotics at 8:00 AM
and 2:00 PM. Has not had a sponge bath
since admission 2 days ago.


Creating a Shift Time Inventory

You are a 3 PM to 11 PM shift coordinator for a skilled
nursing facility. You are the only registered nurse on your
unit this shift. All the other personnel assigned to work
with you this evening are unlicensed. The unit census is
21. As the shift coordinator, your responsibility is to make
shift assignments, provide needed patient treatments,
administer medications, and coordinate the work of team
members. This evening, you will need to administer
treatments and/or medications to the following patients:

101 A


88 years old. Senile dementia. Resident
for 6 years. Confused—strikes out at
staff. Soft wrist restraints bilaterally. Has
small grade 2 pressure ulcer on coccyx,
which requires evaluation and dressing
change each shift.

102 B


64 years old. Diabetes. New resident.
Bilateral above-knee amputee. Right
amputation 2 weeks ago. Left
amputation performed 8 years ago.
Needs stump dressing on right
amputation site this shift. Has
developed methicillin-resistant
Staphylococcus aureus in wound site.
Wound isolation ordered. IV antibiotics
due at 4:00 PM and 10:00 PM tonight.
Blood glucose monitoring due at 4:30

PM and 9:00 PM with sliding-scale

106 A


26 years old. Closed head injury 5 years
ago. Resident since that time.
Decerebrate posturing only. Does not
follow commands. Percutaneous
endoscopic gastrostomy feeding tube
site red and inflamed; medical doctor
has not yet been notified. Needs
feeding solution bag change this PM.

107 A


93 years old. Functional decline.
Refusing to eat. Physician has written
an order not to resuscitate in the event
of cardiac or respiratory failure but
wants an IV line begun this PM to
minimize patient dehydration. Family
will also be here this PM and wants to
talk about their mother’s status.

109 C


89 years old. Admit from local hospital,
2 weeks postoperative left hip
replacement. Anticipated length of stay
—2 weeks. Arrives by ambulance at
3:30 PM. Needs to have admission
assessment and paperwork completed
and care plan started.

Oral Medications Schedule

Room 101 A—4 PM, 8 PM
Room 101 B—4 PM, 8 PM
Room 102 A—5 PM, 9 PM
Room 103 B—4 PM, 10 PM
Room 104 C—5 PM, 6 PM, 9 PM

Room 106 B—6 PM, 9 PM
Room 108 C—9 PM
Room 109 C—5 PM, 6 PM, 8 PM, 9 PM


Create a time inventory from 3:00 PM to 11:30 PM
using 1-hour blocks of time. Plan what activities you
will do during each 1-hour block. Be sure that you
start with the activities you have prioritized for the
shift. Also, remember that you will be in shift report
from 3:00 PM to 3:30 PM and from 11:00 PM to 11:30
PM and that you need to schedule a dinner break
for yourself. Allow adequate time for planning and
dealing with the unexpected. Compare the
inventory that you created with other students in
your class. Did you identify the same priorities?
Were you more focused on professional, technical,
or amenity care? Will your plan require
multitasking? Was the time inventory that you
created realistic? Is this a workload that you believe
you could handle?


Plan Your Day

It is October of your second year as nursing coordinator
for the surgical department. A copy of your appointment

calendar for Monday, October 27, follows.

Appointment Calendar for Monday, October 27


Arrive at work


Daily rounds with each head nurse in your area


Continuation of daily rounds with head nurses






Department head meeting


United Givers committee


United Givers committee continued



Noon Lunch



Weekly meeting with administrator—budget and
annual report due




Infection control meeting


Infection control meeting continued

3:00 Fire drill and critique of drill


Fire drill and critique of drill continued






Off duty

You will review your unfinished business from the
preceding Friday and look at the new items of business
that have arrived on your desk this morning. (The new
items follow the appointment calendar.) The unit ward
clerk is usually free in the afternoon to provide you with 1
hour of clerical assistance, and you have a charge nurse
on each shift to whom you may delegate.

1. Assign a priority to each item, with 1 being the most
important and 5 being the least important.

2. Decide when you will deal with each item, being
careful not to use more time than you have open on
your calendar.

3. If the problem is to be handled immediately, explain
how you will do this (e.g., delegated, phone call).

4. Explain the rationale for your decisions.

Item 1
From the desk of M. Jones, personnel manager
October 24
Dear Joan:

I am sending you the names of two new graduate
nurses who are interested in working in your area. I have
processed their applications; they seem well qualified.

Could you manage to see them as early as possible in
the week? I would hate to lose these prospective
employees, and they are anxious to obtain definite
confirmation of employment.

Item 2
From the desk of John Brown, purchasing agent
October 23

We really must get together this week and devise a
method to control supplies. Your area has used three
times the amount of thermometer covers as any other
area. Are you taking that many more temperatures? This
is just one of the supplies your area uses excessively. I’m
open to suggestions.

Item 3
Roger Johnson, MD, chief of surgical department
October 24
Ms. Kerr:

I know you have your budget ready to submit, but I just
remembered this week that I forgot to include an arterial
pressure monitor. Is there another item that we can leave
out? I’ll drop by Monday morning, and we’ll figure
something out.

Item 4
October 23
Ms. Kerr:

The following personnel are due for merit raises, and I
must have their completed and signed evaluations by
Tuesday afternoon: Mary Rocas, Jim Newman, Marge
M. Jones, personnel manager

Item 5
Roger Johnson, MD, chief of surgical department
October 23
Ms. Kerr:

The physicians are complaining about the availability of
nurses to accompany them on rounds. I believe you and I
need to sit down with the doctors and head nurses to
discuss this recurring problem. I have some free time
Monday afternoon.

Item 6
5 AM

Sally Knight (your regular night registered nurse)
requested a leave of absence due to her mother’s illness.
I told her it would be OK to take the next three nights off.
She is flying out of town on the 9 AM commuter flight to
San Francisco, so phone her right away if you don’t want
her to go. I felt I had no choice but to say yes.
Nancy Peters, night supervisor
P.S. You’ll need to find a replacement for her for the next
three nights.

Item 7
To: Ms. Kerr
From: Administrator
Re: Patient complaint
Date: October 23

Please investigate the following patient complaint. I
would like a report on this matter this afternoon.
Dear Sir:

My mother, Gertrude Boswich, was a patient in your
hospital, and I just want to tell you that no member of my

family will ever go there again.
She had an operation on Monday, and no one gave her

a bath for 3 days. Besides that, she didn’t get anything to
eat for 2 days, not even water. What kind of a hospital do
you run anyway?
Elmo Boswich

Item 8
To: Joan Kerr
From: Nancy Newton, RN, head nurse
Re: Problems with X-ray department
Date: October 23

We have been having problems getting diagnostic x-
ray procedures scheduled for patients. Many times,
patients have had to stay an extra day to get x-ray tests
done. I have talked to the radiology chief several times,
but the situation hasn’t improved. Can you do something
about this?

Item 9
To: All department heads
From: Storeroom
Re: Supplies
Date: October 23

The storeroom is out of the following items: toilet
tissue, paper clips, disposable diapers, and pencils. We
are expecting a shipment next week.

Telephone Messages
Item 10

Sam Surefoot, Superior Surgical Supplies, Inc.,
returned your call at 7:50 AM on October 27. He will be at
the hospital this afternoon to talk about problems with
defective equipment received.

Item 11
Donald Drinkley, Channel 32-TV, called at 8:10 AM on

October 27 to say he will be here at 11:30 AM to do a
feature story on the open-heart unit.

Item 12
Lila Green, director of nurses at St. Joan’s Hospital,

called at 8:05 AM on October 24 about a phone reference
on Jane Jones, RN. Ms. Jones has applied for a job
there. Isn’t that the one we fired last year?

Item 13
Betty Brownie, Bluebird Troop 35, called at 8 AM on

October 27 about the Bluebird Troop visit to patients on
Halloween with trick-or-treat candy. She will call again.


Avoiding Crises

Some people always seem to manage by crisis. The
following scenarios depict situations that likely could have
been avoided with better planning. Write down what
could have been done to prevent the crisis. Then outline
at least three alternatives to deal with the problem, as it
already exists.

It is the end of your 8-hour shift. Your team members
are ready to go home. You have not yet begun to chart
on any of your six patients. You have neither completed
your intake/output totals nor given patients the
medications that were due 1 hour ago. The arriving
shift asks you to give your handoff report now.

You need to use the home computer to write your
midterm essay, which is due tomorrow, but your mother
is online doing the family’s taxes, which must be mailed
by midnight. The taxes will likely take several additional

Your computer hard drive crashes when you try to print
your term paper, which is due tomorrow.

An elderly, frail patient pulls out her intravenous line.
You make six attempts, over a 1-hour period, to restart
the line but are unsuccessful. You have missed your
lunch break and, now, must choose between taking
time for lunch and finishing your shift on time.


The Need to Reprioritize (Marquis &
Huston, 2012)

You have just arrived home from a long day at school
(it’s 4 PM on Wednesday) and sit down to look at your to-
do list for the week. You have several major deadlines
looming and are aware that you have procrastinated their

completion far too long. Items on your list that must be
completed by week’s end include the following:

1. You have a 15-page term paper due in your leadership
class on Friday (9 AM), which you have not begun.
This will require 3 to 4 hours of literature review before
you can begin and likely 4 to 6 hours to write the
paper. There is a 10% loss of points for every day the
paper is late, including weekends.

2. You have to create clinical preparation sheets tonight
for the four medical/surgical patients you will be caring
for tomorrow (Thursday) at the hospital (7:00 AM to
3:30 PM). Each of these preparation sheets will take
approximately 30 minutes to complete. These
preparation sheets will be used to provide patient care
tomorrow and will be discussed at the postclinical
conference from 3:30 PM to 4:30 PM.

3. You have a test tomorrow night (Thursday) in your
political science class, which begins at 7 PM. You have
read the materials but want to review them one last
time because the test counts for 25% of your grade.

4. You need to finish writing your reflective journal
analysis, a weekly assignment for your clinical course.
The analysis is typically 4 to 6 pages and reflects what
you learned in your clinical experiences each week. It
is due by noon on Friday.

5. You are the maid of honor for your best friend’s
wedding and as such are responsible for hosting her
bridal shower on Saturday afternoon. You have not yet
purchased the food or bought the materials you need
for the activities you have planned. You also realize
that your apartment is a mess and that it needs
cleaned before guests arrive.

6. Your car is critically low on oil. The oil light has been
on for the last week, and you know that you are likely
to burn up the engine if you keep driving it. You must
take it in for an oil change immediately because the
campus and hospital are too far away to take your bike
and there is no public transportation system.

As you create your time inventory for the next 4 days,
you realize just how tight your schedule is. If you work
until at least midnight each night and get up just in time to
make it to clinical and class (6:00 AM), you should be able
to get everything done.

At 6 PM, the phone rings. It is one of your peers from
school. She has just broken up with her fiancé and is in a
crisis state. She asks that you come over right away and
stay with her as she does not want to be alone. In
addition, shortly after you hang up the phone, your
roommate knocks on your door and says she needs to
have a conversation with you about the “house rules” the
two of you set. She says the rules are not working and
that she has grown increasingly frustrated the last week.
She wants to resolve the conflict right now and is
threatening to move out. Finally, there is a knock at the
door. One of your neighbors tells you that he just saw
your dog running down the street. The gate must have
been left open when your roommate returned home.


How will you reprioritize your plans for this evening
as well as the rest of the week? Can any items be
eliminated from your list? Can any items be further
procrastinated? What satisficing choices will you
make regarding the items you will accomplish from
your to-do list for the week?

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Hansen, R. S. (2018). Is your life in balance? Work/life balance quiz.
A quintessential careers quiz. Retrieved September 3, 2018, from

Hendriksen, E. (2018). 5 Ways to finally stop procrastinating.
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Marquis, B., & Huston, C. (2012). Leadership and management tools
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Taibbi, R. (2018). Are you emotionally driven? Retrieved September
3, 2018, from


Fiscal Planning and Health-
Care Reimbursement

. . . nurses are practicing caring in an environment where
the economics and costs of health care permeate
discussions and impact decisions.—Marian C. Turkel

. . . the trouble with a budget is that it’s hard to fill up one
hole without digging another.—Dan Bennett

. . . Don’t tell me what you value, show me your budget,
and I’ll tell you what you value.—Joe Biden


This chapter addresses:

BSN Essential II: Basic organizational and systems leadership for
quality care and patient safety

BSN Essential V: Health-care policy, finance, and regulatory

MSN Essential II: Organizational and systems leadership
MSN Essential III: Quality improvement and safety
MSN Essential VI: Health policy and advocacy
AONL Nurse Executive Competency II: A knowledge of the
health-care environment

AONL Nurse Executive Competency V: Business skills
ANA Standard of Professional Performance 10: Collaboration
ANA Standard of Professional Performance 11: Leadership

ANA Standard of Professional Performance 14: Quality of

ANA Standard of Professional Performance 16: Resource

QSEN Competency: Quality improvement
QSEN Competency: Safety


The learner will:

define basic fiscal terminology
differentiate among the three major types of budgets (personnel,
operating, and capital) and the four most common budgeting
methods (incremental, zero-based, flexible, and new performance

identify the strengths and weaknesses of flexible budgets
recognize the need to involve subordinates and followers in fiscal
planning whenever possible

design a decision package to aid in fiscal priority setting
anticipate, recognize, and creatively problem solve budgetary

accurately compute the standard formula for calculating nursing
care hours per patient-day

describe the impetus for the development of diagnosis-related
groups, the prospective payment system, and other managed care

describe the resulting impact on cost and quality when health-care
reimbursement shifted from a health-care system dominated by
third-party, fee-for-service plans to capitated, managed care

describe the impact of the increasing shift in government and
private insurer reimbursement from volume to value based

recognize that rapidly changing federal and state reimbursement
policies make long-range budgeting and planning very difficult for
health-care organizations

discuss how spiraling health-care costs that had little relationship
to health-care outcomes led to comprehensive health-care reform
in the United States in 2010

describe key components of the Patient Protection and Affordable
Care Act (PPACA or ACA) as well as its implementation plan
between 2010 and 2014

consider how current legislative efforts to repeal the ACA and the
elimination of the “individual mandate” to have health insurance
may affect health care in the future

describe why nurses need to understand and actively be involved
in fiscal planning and health-care reform

For at least 30 years, health-care organizations have faced
unprecedented financial challenges because of shrinking
reimbursement and rising costs. Regulatory controls have tightened,
quality expectations have risen, and the public is increasingly
demanding more and higher quality services at little to no out-of-pocket

In addition, costs for health care have soared. In a recent Gallup poll,
Americans cited the high cost of health care as their number one
financial concern (Allen, 2017). The Kaiser Family Foundation (2017)
notes that the average annual premiums for employer-sponsored
health insurance in 2017 was $6,690 for single coverage and $18,764
for family coverage, an increase of 19% since 2012 and 55% since
2007, respectively. This translates into the “typical family” paying about
35% of their income for health care in 2016 (Moffit, 2016).

In addition, as we entered the second decade of the 21st century, 44
million people in the United States lacked any type of health insurance
and an even greater number were underinsured (Huston, 2020). Of the

millions of people who were too poor to afford health insurance, many
did not qualify for federally provided health insurance. In addition, small
businesses, in tough economic times, lacked the resources to provide
health insurance benefits to all employees (ObamaCare Facts, n.d.). All
these factors suggested a need for health-care reform that provided
universal health-care insurance coverage.

Comprehensive, systematic efforts to reform this clearly broken
health-care system achieved no real momentum, however, until late in
the first decade of the 21st century. Even then, convergence on
proposals for reform was limited, so the relatively swift passage of
controversial national health-care reform in the United States in March
2010 came as a surprise to many. This legislation the Patient
Protection and Affordable Care Act (PPACA), hereafter called the
Affordable Care Act (ACA), promised significant reductions in numbers
of uninsured, greater access to coverage for those with preexisting
conditions, and mandated health-care insurance provision by
employers. Provisions of the ACA are discussed later in this chapter.

In addition, health-care reform accelerated a shift in reimbursement
from volume to value to remove incentives for redundant and
inappropriate care. Unlike volume, which simply considers how much of
a product is purchased, value considers quality, efficiency, safety, and
cost. The ACA’s payment reform provisions included value-based
purchasing (VBP), accountable care organizations (ACOs), bundled
payments, the medical home, and the health insurance marketplace, all
of which are based on value and discussed later in this chapter.

Great change also occurred in fiscal planning at the organizational
level over the past three decades in terms of scope of responsibility
and accountability for cost and outcomes. Nurse leader-managers in
the 21st century are expected to be fiscally knowledgeable because
nursing budgets generally account for the greatest share of health-care
institutional expenses. Yet, shrinking resources and increasing
demands increasingly pose challenges for nursing managers.

Fiscal planning is not intuitive; it is a learned skill that
improves with practice.

Unfortunately, many nurses perceive fiscal planning to be the most
difficult type of planning. This is often the result of inadequate formal
education or training on budget preparation as well as forecasting
(making an educated budget estimate by using historical data). It is
important to remember that fiscal planning is an acquired skill that
improves with use; that’s because it requires vision; creativity; and a
thorough knowledge of the political, social, and economic forces that
shape health care. Fiscal planning, then, must be included in nursing
program curricula and in management preparation programs.

This chapter discusses the leader-manager’s role in fiscal planning,
identifies types of budgets, and delineates the budgetary process.
Learners will also examine health-care reimbursement concepts with
specific attention given to the recent change from volume-based
reimbursement to value-based reimbursement. The leadership roles
and management functions involved in fiscal planning are outlined in
Display 10.1.


Leadership Roles
1. Is visionary in identifying or forecasting short- and long-term unit

needs, thus inspiring proactive rather than reactive fiscal

2. Is knowledgeable about political, social, and economic factors
that shape fiscal planning and reimbursement in health care

3. Demonstrates flexibility in fiscal goal setting in a rapidly
changing system

4. Anticipates, recognizes, and creatively solves budgetary

5. Influences and inspires group members to become active in
short- and long-range fiscal planning

6. Recognizes when fiscal constraints have resulted in an inability
to meet organizational or unit goals and communicates this
insight effectively, following the chain of command

7. Ensures that patient safety is not jeopardized by cost

8. Role models leadership in needed health-care reform efforts
9. Proactively prepares followers for the plethora of changes in

health care associated with health-care reform and
implementation of the Patient Protection and Affordable Care Act

Management Functions
1. Identifies the importance of and develops short- and long-range

fiscal plans that reflect unit needs
2. Articulates and documents unit needs effectively to higher

administrative levels
3. Assesses the internal and external environment of the

organization in forecasting to identify driving forces and barriers
to fiscal planning

4. Demonstrates knowledge of budgeting and uses appropriate
techniques to budget effectively

5. Provides opportunities for subordinates to participate in relevant
fiscal planning

6. Coordinates unit-level fiscal planning to be congruent with
organizational goals and objectives

7. Accurately assesses personnel needs by using predetermined
standards or an established patient classification system

8. Coordinates the monitoring aspects of budget control
9. Ensures that documentation of patients’ need for services and

services rendered is clear and complete to facilitate
organizational reimbursement

10. Collaborates with other health-care administrators to proactively
determine how health-care reform initiatives such as value-
based purchasing, accountable care organizations, bundled
payments, the medical home, and the health insurance
marketplace may impact organizational viability and the provision
of services

Balancing Cost and Quality
Complicating fiscal planning in health-care organizations today are the
dual goals of cost containment and quality care. Cost containment
refers to the effective and efficient delivery of services while generating
needed revenues for operations. Cost containment is the responsibility
of every health-care provider, and the viability of most health-care
organizations today depends on their ability to use their fiscal resources

Being cost-effective, however, is not the same as being inexpensive;
cost-effective means producing good results for the money spent; in
other words, the product is worth the price (YourDictionary, 2018).
Expensive items can be cost-effective, and inexpensive items may not.
Cost-effectiveness then must consider factors such as anticipated

length of service, need for such a service, and availability of other

In addition, cost and quality do not necessarily have a linear
relationship in health care. Sometimes, high spending represents a
duplication of services, an overutilization of services, and the use of
technology that exceeds a specific patient’s needs. In fact, numerous
studies over the past decade have examined the relationship between
higher spending and the quality and outcomes of care and found that
higher spending does not necessarily result in better quality care.

Spending more does not always equate to better quality
health outcomes.

These findings are true on the macrolevel as well. The US health-
care system is the most expensive in the world, spending almost twice
as much on health care, as a percentage of its economy, in 2016, as
other advanced industrialized countries—totaling $3.3 trillion, or 17.9%
of gross domestic product (GDP) (Frakt & Carroll, 2018).Yet, our
outcomes in terms of teenage pregnancy rates, low-birth-weight infants,
and access to care are worse than many countries that spend
significantly less.

In addition, health-care costs are simply higher in the United States.
Frakt and Carroll (2018) agree, noting that Americans don’t consume
significantly more health care than citizens in other industrialized
countries; they’re just paying more for that care. For example, the
average cost of a magnetic resonance imaging (MRI) in the United
States in 2015 was $1,119, compared to $811 in New Zealand (Mack,
2017). An MRI in Spain averaged $130. Similarly, the average cost of
an appendectomy in the United States was $15,930, whereas it was
$8,009 in the United Kingdom and only $3,814 in Australia (Mack,
2017). Similarly, pharmaceuticals cost far more in the United States
because of government protected “monopoly” rights for drug
manufacturers. The problem then is not a scarcity of resources. The

problem is that we do not use the resources we have available in a
cost-effective manner.

Responsibility Accounting
An essential feature of fiscal planning is responsibility accounting,
which means that each of an organization’s revenues, expenses,
assets, and liabilities is someone’s responsibility. The leader-manager
at the unit level then should be an active participant in unit budgeting,
have a high degree of control over what is included in the unit budget,
receive regular data reports that compare actual expenses with
budgeted expenses, and be held accountable for the financial results of
the operating unit.

The unit manager also can best monitor and evaluate all aspects of a
unit’s budget control. Like other types of planning, the unit manager has
a responsibility to communicate budgetary planning goals to the staff.
The more the staff understands the budgetary goals and the plans to
carry out those goals, the more likely the goal attainment is. Sadly,
many nurses have little knowledge of the nursing budget model used
by their hospital system.

Budget Basics
A budget is a financial plan that includes estimated expenses as well
as income for a set period of time. Accuracy dictates the worth of a
budget; the more accurate the budget blueprint, the better the
institution can plan the most efficient use of its resources.

The budget’s value is directly related to its accuracy.

Because a budget is at best a prediction, a plan, and not a rule,
however, fiscal planning requires flexibility, ongoing evaluation, and
revision. In the budget, expenses are classified as fixed or variable and
either controllable or noncontrollable. Fixed expenses do not vary with

volume, whereas variable expenses do. Examples of fixed expenses
might be a building’s mortgage payment or a manager’s salary; variable
expenses might include the payroll of hourly wage employees and the
cost of supplies.

Controllable expenses can be controlled or varied by the manager,
whereas noncontrollable expenses cannot. For example, the unit
manager can control the number of personnel working on a certain shift
and the staffing mix; he or she cannot, however, control equipment
depreciation, the number and type of supplies needed by patients, or
overtime that occurs in response to an emergency. A list of the fiscal
terminology that a manager needs to know is shown in Display 10.2.


Accountable care organizations—groups of providers and
suppliers of service who work together to better coordinate care
for Medicare patients (does not include Medicare Advantage)
across care settings

Acuity index—weighted statistical measurement that refers to
severity of illness of patients for a given time. Patients are
classified according to acuity of illness, usually in one of four
categories. The acuity index is determined by taking a total of
acuities and then dividing by the number of patients.

Affordable Care Act—officially known as the Patient Protection and
Affordable Care Act, this act passed in March 2010 to provide
more Americans access to affordable health insurance

Assets—financial resources that a health-care organization
receives, such as accounts receivable

Baseline data—historical information on dollars spent, acuity level,
patient census, resources needed, hours of care, and so forth.
This information is used as basis on which future needs can be

Break-even point—point at which revenue covers costs. Most
health-care facilities have high fixed costs. Because per-unit fixed
costs in a noncapitated model decrease with volume, health-care
facilities under this model need to maintain a high volume to
decrease unit costs.

Bundled payment—a payment structure in which different health-
care providers who are treating a patient for the same or related
conditions are paid an overall sum for taking care of that
condition rather than being paid for each individual treatment,
test, or procedure. In doing so, providers are rewarded for
coordinating care, preventing complications and errors, and
reducing unnecessary or duplicative tests and treatments
(, n.d., para. 1).

Capitation—a prospective payment system (PPS) that pays health
plans or providers a fixed amount per enrollee per month for a
defined set of health services, regardless of how many (if any)
services are used

Case mix—type of patients served by an institution. A hospital’s
case mix is usually defined in such patient-related variables as
type of insurance, acuity levels, diagnosis, personal
characteristics, and patterns of treatment.

Cash flow—rate at which dollars are received and dispersed
Controllable costs—costs that can be controlled or that vary. An

example would be the number of personnel employed, the level
of skill required, wage levels, and quality of materials.

Cost–benefit ratio—numerical relationship between the value of an
activity or procedure in terms of benefits and the value of the
activity’s or procedure’s cost. The cost–benefit ratio is expressed
as a fraction.

Cost center—smallest functional unit for which cost control and
accountability can be assigned. A nursing unit is usually
considered a cost center, but there may be other cost centers
within a unit (orthopedics is a cost center, but often, the cast
room is considered a separate cost center within orthopedics).

Diagnosis-related groups (DRGs)—rate-setting PPS used by
Medicare to determine payment rates for an inpatient hospital
stay based on admission diagnosis. Each DRG represents a
case type for which Medicare provides a flat dollar amount of
reimbursement. This set rate may be higher or lower than the
cost of treating the patient in a particular hospital.

Direct costs—costs that can be attributed to a specific source, such
as medications and treatments; costs that are clearly identifiable
with goods or service

Fee-for-service (FFS) system—a reimbursement system whereby
insurance companies reimburse health-care providers a billed
amount for services after the services are delivered

Fixed budget—style of budgeting that is based on a fixed, annual
level of volume, such as number of patient-days or tests
performed, to arrive at an annual budget total. These totals are
then divided by 12 to arrive at the monthly average. The fixed
budget does not make provisions for monthly or seasonal

Fixed costs—costs that do not vary according to volume. Examples
of fixed costs are mortgage or loan payments.

For-profit organization—organization in which the providers of
funds have an ownership interest in the organization. These
providers own stocks in the for-profit organization and earn
dividends based on what is left when the cost of goods and of
carrying on the business is subtracted from the amount of money
taken in.

Full costs—total of all direct and indirect costs
Full-time equivalent (FTE)—number of hours of work for which a

full-time employee is scheduled for a weekly period. For example,
1.0 FTE = five 8-hour days of staffing, which equals 40 hours of
staffing per week. One FTE can be divided in different ways. For
example, two part-time employees, each working 20 hours per
week, would equal 1 FTE. If a position requires coverage for
more than 5 days or 40 hours per week, the FTE will be greater
than 1.0 for that position. Assume a position requires 7-day
coverage, or 56 hours, then the position requires 1.4 FTE
coverage (56 / 40 = 1.4). This means that more than one person
is needed to fill the FTE positions for a 7-day period.

Health maintenance organization—historically, a prepaid
organization that provided health care to voluntarily enrolled
members in return for a preset amount of money on a per-
person, per-month basis; often referred to as a managed care

Hours per patient-day (HPPD)—hours of nursing care provided per
patient per day by various levels of nursing personnel. HPPD are

determined by dividing total production hours by the number of

Indirect costs—costs that cannot be directly attributed to a specific
area. These are hidden costs and are usually spread among
different departments. Housekeeping services are considered
indirect costs.

International Classification of Disease (ICD) codes—coding used
to report the severity and treatment of patient diseases, illnesses,
and injuries to determine appropriate reimbursement; currently in
its 10th revision (ICD-10)

Managed care—term used to describe a variety of health-care plans
designed to contain the cost of health-care services delivered to
members while maintaining the quality of care

Medicaid—federally assisted and state-administered program to pay
for medical services on behalf of certain groups of low-income
individuals. Generally, these individuals are not covered by Social
Security. Certain groups of people (e.g., older adults, blind,
disabled, members of families with dependent children, and
certain other children and pregnant women) also qualify for
coverage if their incomes and resources are sufficiently low.

Medicare—nationwide health insurance program authorized under
Title 18 of the Social Security Act that provides benefits to people
aged 65 years or older. Medicare coverage also is available to
certain groups of people with catastrophic or chronic illness, such
as patients with renal failure requiring hemodialysis, regardless of

Noncontrollable costs—indirect expenses that cannot usually be
controlled or varied. Examples might be rent, lighting, and
depreciation of equipment.

Not-for-profit organization—this type of organization is financed by
funds that come from several sources, but the providers of these
funds do not have an ownership interest. Profits generated in the
not-for-profit organization are frequently funneled back into the
organization for expansion or capital acquisition.

Operating expenses—daily costs required to maintain a hospital or
health-care institution

Patient classification system—method of classifying patients.
Different criteria are used for different systems. In nursing,
patients are usually classified according to acuity of illness.

Pay for performance (also known as P4P) programs—incentives
are paid to providers to achieve a targeted threshold (typically a
process or outcome measure) of clinical performance, typically a
process or outcome measure associated with a specified patient

Pay for value programs—incentive payments that are linked to
both quality and efficiency improvements

Preferred provider organization (PPO)—health-care financing and
delivery program with a group of providers, such as physicians
and hospitals, who contract to give services on an FFS basis.
This provides financial incentives to consumers to use a select
group of preferred providers and pay less for services. Insurance
companies usually promise the PPO a certain volume of patients
and prompt payment in exchange for fee discounts.

Production hours—total amount of regular time, overtime, and
temporary time. This also may be referred to as actual hours.

Prospective payment system—a hospital payment system with
predetermined reimbursement ratio for services given

Revenue—source of income or the reward for providing a service to
a patient

Staffing mix—ratio of registered nurses (RNs), licensed vocational
nurses (LVNs)/licensed practical nurses (LPNs), and unlicensed
workers (e.g., a shift on one unit might have 40% RNs, 40%
LPNs/LVNs, and 20% others). Hospitals vary on their staffing mix

Third-party payment system—a system of health-care financing in
which providers deliver services to patients, and a third party, or
intermediary, usually an insurance company or a government
agency, pays the bill

Turnover ratio—rate at which employees leave their jobs for
reasons other than death or retirement. The rate is calculated by
dividing the number of employees leaving by the number of
workers employed in the unit during the year and then by
multiplying by 100.

Value-based purchasing—a payment methodology that rewards
quality of care through payment incentives

Variable costs—costs that vary with the volume. Payroll costs are
an example.

Workload units—in nursing, workloads are usually the same as
patient-days. For some areas, however, workload units might
refer to the number of procedures, tests, patient visits, injections,
and so forth.

Steps in the Budgetary Process
The nursing process provides a model for the steps in budget planning:

1. The first step is to assess what needs to be covered in the
budget. Generally, this determination should reflect input from all
levels of the organizational hierarchy because budgeting is most
effective when all personnel using the resources are involved in
the process.

2. The second step is diagnosis. In the case of budget planning, the
diagnosis would be the goal or what needs to be accomplished,
which is to create a cost-effective budget that maximizes the use
of available resources. Unfortunately, some managers artificially
inflate their department budgets as a cushion against budget cuts.
If several departments partake in this unsound practice, the entire
institutional budget may be ineffective. If a major change in the
budget is indicated, the entire budgeting process must be
repeated. Top-level managers must watch for and correct
unrealistic budget projections before they are implemented.

3. The third step is to develop a plan. The budget plan may be
developed in many ways. A budgeting cycle that is set for 12
months is called a fiscal-year budget. This fiscal year, which may
or may not coincide with the calendar year, is then usually broken
down into quarters or subdivided into monthly or semiannual

Most budgets are developed for a 1-year period, but a perpetual
budget may be done on a continual basis each month so that 12
months of future budget data are always available. Selecting the
optimal time frame for budgeting is also important. Errors are
more likely if the budget is projected too far in advance. If the
budget is shortsighted, compensating for unexpected major
expenses or purchasing capital equipment may be difficult.

4. The fourth step is implementation. In this step, ongoing monitoring
and analysis occur to avoid inadequate or excess funds at the end
of the fiscal year. In most health-care institutions, monthly
statements outline each department’s projected budget and
deviations from that budget.

5. The last step is evaluation. The budget must be reviewed
periodically and modified as needed throughout the fiscal year.
Each unit manager is accountable for budget deviations in his or
her unit. Most units can expect some change from the anticipated
budget, but large deviations must be examined for possible
causes and remedial action taken if necessary.

A budget that is predicted too far in advance has greater
probability for error.


Would You Accept This Gift?

You are the director of the education department in a 40-
bed, rural, critical access hospital. A simulation vendor has
offered to give you a 5-year-old, used, high-fidelity manikin
for staff development training purposes (cardiopulmonary
resuscitation, advanced cardiac life support, pediatric
advanced life support, annual skills updates). His only
request is that all supplies used with the manikin and the
maintenance contract be purchased through his company.
The chief nursing officer is very excited about the offer and
has asked all the unit directors to consider how the manikin
might be used for their staff training needs. The hospital
currently does not have the funds available to purchase a
new manikin.


1. Justify acceptance or rejection of the gift. What
influenced your choice?

2. What are the fixed and variable costs?
3. What are the controllable and noncontrollable

4. What factors determine whether this gift is cost-

5. Who will have control over how and when the

manikin is used?

Types of Budgets
Three major types of budgets that the nurse-manager may be directly
involved in with fiscal planning are personnel, operating, and capital

The Personnel Budget

The largest of the budget expenditures is the workforce or personnel
budget because health care is labor-intensive. To handle fluctuating
patient census and acuity, managers need to use historical data about
unit census fluctuations in forecasting short- and long-term personnel
needs. Likewise, a manager must monitor the personnel budget closely
to prevent understaffing or overstaffing. As patient-days or volume
decreases, managers must decrease personnel costs in relation to the
decrease in volume.

The largest of the budget expenditures is the workforce or
personnel budget because health care is labor-intensive.

In addition to numbers of staff, the manager must be cognizant of the
staffing mix. Staffing mix refers to the mix (percentages) of licensed
(registered nurse [RN] and licensed vocational nurse [LVN]) and
unlicensed assistive personnel (certified nursing assistant
[CNA]/nursing assistive personnel) working at a given time. The
manager must also be aware of the patient acuity so that the most
economical level of nursing care that will meet patient needs can be

Although Unit V discusses staffing, it is necessary to briefly discuss
here how staffing needs are expressed in the personnel budget. Most
staffing is based on a predetermined standard. This standard may be
addressed in hours per patient-day (HPPD) (medical units), visits per
month (home health agencies), or minutes per case (the operating
room). Because the patient census, number of visits, or cases per day
never remains constant, the manager must be ready to alter staffing
when volume increases or decreases.

The standard formula for calculating nursing care hours per patient-
day (NCH/PPD) is shown in Figure 10.1.

FIGURE 10.1 Standard formula for calculating nursing care hours per patient-day
(NCH/PPD). (Copyright © 2006 Lippincott Williams & Wilkins. Instructor’s Resource
CR-ROM to Accompany Leadership Roles and Management Functions in Nursing, by
Bessie L. Marquis and Carol J. Huston.)

A unit manager in an acute care facility might use this formula to
calculate daily staffing needs. For example, assume that your budgeted
NCH are 6 NCH/PPD. You are calculating the NCH/PPD for today,
January 31; at midnight, it will be February 1. The patient census at
midnight is 25 patients. In checking staffing, you find the following

Shift Staff on Duty Hours Worked

11:00 PM (1/30) to
7:00 AM (1/31)

2 RNs 8 h each

1 LVN 8 h
1 CNA 8 h

7:00 AM to 3:00 PM

3 RNs 8 h each

2 LVNs 8 h each
1 CNA 8 h
1 ward clerk 8 h

3:00 PM to 11:00 PM

2 RNs 8 h each

2 LVNs 8 h each
1 CNA 8 h
1 ward clerk 8 h

11:00 PM (1/31) to
7:00 AM (2/1)

2 RNs 8 h each

2 LVNs 8 h each
1 CNA 8 h

RNs, registered nurses; LVNs, licensed vocational nurses; CNA, certified nursing

Ideally, you would use 12 midnight to compute the NCH/PPD for
January 31, but most staffing calculations based on traditional 8-hour
shifts are made beginning at 11:00 PM and ending at 11:00 PM the
following night. Therefore, in this case, it would be acceptable to figure
the NCH/PPD for January 31 by using numerical data from the 11:00
PM to 7:00 AM shift last night and the 7:00 AM to 3:00 PM and 3:00 PM to
11:00 PM shifts today. The first step in this calculation requires a
computation of total NCH worked in 24 hours (including the ward clerk’s

hours). This can be calculated by multiplying the total number of staff
on duty each shift by the hours each worked in their shift. Each shift
total then is added together to get the total number of nursing hours
worked in all three shifts or 24 hours: The nursing hours worked in 24
hours are 136 hours.

The second step in solving NCH/PPD requires that you divide the
nursing hours worked in 24 hours by the patient census. The patient
census in this case is 25. Therefore, 136 / 25 = 5.44.

The NCH/PPD for January 31 was 5.44, which is less than your
budgeted NCH/PPD of 6.0. It would be possible to add up to 14
additional hours of nursing care in the next 24 hours and still maintain
the budgeted NCH standard. However, the unit manager must
remember that the standard is flexible and that patient acuity and
staffing mix may suggest the need for even more staff for February 1
than the budgeted NCH/PPD.

The personnel budget includes actual worked time (also called
productive time or salary expense) and time that the organization pays
the employee for not working (nonproductive or benefit time).
Nonproductive time includes the cost of benefits, new employee
orientation, employee turnover, sick and holiday time, and education
time. For example, the average 8.5-hour shift includes a 30-minute
lunch break and two 15-minute breaks. Thus, this employee would
work 7.5 productive hours and have 1.0 hours of nonproductive time.


Calculating Nursing Care Hours per

Calculate the nursing care hours per patient-day
(NCH/PPD) if the midnight census is 25, but use the

following as the number of hours worked:

12 midnight to 12
noon 2 RNs 12 h each

2 LVNs 12 h each
1 CNA 12 h
1 ward clerk 5 h

12 noon to 12
midnight 3 RNs 12 h each

2 LVNs 12 h each
1 CNA 12 h
1 ward clerk 12 h

Now, calculate the NCH/PPD if the following staff were

12 midnight to 12
noon 3 RNs 12 h each

1 LVN 12 h
12 noon to 12
midnight 2 RNs 12 h each

1 LVN 12 h
1 ward clerk 4 h

RNs, registered nurses; LVNs, licensed vocational nurses; CNA, certified
nursing assistant.

The Operating Budget
The operating budget is the second area of expenditure that involves
all managers. The operating budget reflects expenses that change in
response to the volume of service, such as the cost of electricity,

repairs and maintenance, and supplies. Although personnel costs lead
the hospital budget, the cost of supplies typically runs a close second.

Next to personnel costs, supplies are typically the second
most significant component in the hospital budget.

Effective unit managers should be alert to the types and quantities of
supplies used in their unit. They should also understand the
relationship between supply use and patient mix, occupancy rate,
technology requirements, and types of procedures performed on the
unit. Saving unused supplies from packs or trays, reducing obsolete
and slow-moving inventory, eliminating pilferage, and monitoring the
uncontrolled usage of supplies and giveaways all represent potential
cost savings. Other ways to cut supply costs might be in rental versus
facility-owned equipment, stocking products on consignment, and just-
in-time stockless inventory. Just-in-time ordering is a process whereby
inventory is delivered to the organization by suppliers only when it is
needed and immediately before it is to be used.

The Capital Budget
The third type of budget used by managers is the capital budget.
Capital budgets plan for the purchase of buildings or major equipment,
which include equipment that has a long life (usually greater than 5 to 7
years), is not used in daily operations, and is more expensive than
operating supplies. Examples of these types of capital expenditures
might include the acquisition of a positron emission tomography imager
or the renovation of a major wing in a hospital. The short-term
component of the capital budget includes equipment purchases within
the annual budget cycle, such as call-light systems, hospital beds, and
medication carts.

Often, the designation of capital equipment requires that the value of
the equipment exceed a certain dollar amount. That dollar amount will
vary from institution to institution, but $5,000 is common. Managers are

usually required to complete specific capital equipment request forms
to justify their request.

Budgeting Methods
Budgeting is frequently classified according to how often it occurs and
the base on which budgeting takes place. Four of the most common
budgeting methods are incremental budgeting (also called flat-
percentage increase budgeting), zero-based budgeting, flexible
budgeting, and performance budgeting.

Incremental Budgeting
Incremental or the flat-percentage increase method is the simplest
method for budgeting. By multiplying current-year expenses by a
certain figure, usually the inflation rate or consumer price index, the
budget for the coming year may be projected. Although this method is
simple and quick and requires little budgeting expertise on the part of
the manager, it is generally inefficient fiscally because there is no
motivation to contain costs and no need to prioritize programs and
services. Hospitals historically used incremental budgeting in fiscal


Missing Supplies

You are a unit manager in an acute care hospital. You are
aware that staff occasionally leave at the end of the shift
with forgotten hospital supplies in their pockets. You
remember how often as a staff nurse you would
unintentionally take home rolls of adhesive tape, syringes,

penlights, and bottles of lotion. Usually, you remembered to
return the items, but other times, you did not.

Recently, however, your budget has shown a dramatic
and unprecedented increase in missing supplies, including
gauze wraps, blood pressure cuffs, stethoscopes, surgical
instruments, and personal hygiene kits. Although this
increase represents only a fraction of your total operating
budget, you believe that it is necessary to identify the
source of their use. An audit of patient charts and charges
reveals that these items were not used in patient care.

When you ask your charge nurses for an explanation,
they reveal that a few employees have openly expressed
that taking a few small supplies is, in effect, an expected
and minor fringe benefit of employment. Your charge nurses
do not believe that the problem is widespread, and they
cannot objectively document which employees are involved
in pilfering supplies. The charge nurses suggest that you
ask all employees to document in writing when they see
other employees taking supplies and then turn in the
information to you anonymously for follow-up.


Because supplies are such a major part of the
operating budget, you believe that some action is
indicated. You must determine what that action should
be. Analyze your actions in terms of the desirable and
undesirable effects on the employees involved in
taking the supplies and those who are not. Is the
amount of the fiscal debit in this situation a critical
factor? Is it worth the time and energy that would be
required to truly eliminate this problem?

Zero-Based Budgeting
In comparison, managers who use zero-based budgeting must rejustify
their program or needs every budgeting cycle. This method does not
automatically assume that because a program has been funded in the

past, it should continue to be funded. Thus, this budgeting process is
labor-intensive for nurse-managers. The use of a decision package to
set funding priorities is a key feature of zero-based budgeting. Key
components of decision packages are shown in Display 10.3. Display
10.4 presents an example of an abbreviated decision package.


1. Listing of all current and proposed objectives or activities in the

2. Alternative plans for carrying out these activities
3. Costs for each alternative
4. Advantages and disadvantages of continuing or discontinuing an



Objective: To determine if annual mandatory flu vaccination is an
appropriate strategy for reducing the risk of flu transmission to
and from hospital employees

Driving forces: The Centers for Disease Control and Prevention
(CDC) recommend that all health-care workers receive an annual
flu vaccine, arguing it is one of the most important ways to
prevent transmission of influenza, not only in the hospital but also
in other health-care settings. Flu vaccines typically protect
against the three or four viruses (depending on vaccine) that
research suggests will be most common that year (CDC, 2018).
Individual hospitals and health systems have some latitude to
devise and implement policies based on their own strategies
within the bounds established by state laws.

Restraining forces: Porter (2018) suggests that mandatory flu
vaccine policies can push too far or fail to include proper
safeguards that could violate worker rights. In addition, it is not
possible to predict what any flu season will be like because the
timing, severity, and length of the season varies from one season
to another as does the efficacy of the vaccine.

Alternative 1: Require all workers to receive an annual flu
vaccination, at the hospital’s expense.

Advantage: There is no out-of-pocket expense to employees for the
vaccination. There is greater likelihood that employees will be
protected against the flu while working in a high-risk clinical

Disadvantage: The effectiveness of the vaccine varies from year to
year. Some employees may believe that requiring the vaccine
infringes on their right to control choices about their bodies. In
addition, mandatory vaccination policies may violate certain

employee’s religious beliefs or pose health risks. Employee
lawsuits arguing a violation of their rights are likely.

Alternative 2: Require all workers to be vaccinated, at the hospital’s
expense, unless an employee can show evidence that the
vaccination poses a health risk or violates religious beliefs.
Require workers who cannot have the flu vaccine, and are
approved for an exemption, wear masks during the flu season.
Educate employees about the importance of immunization.

Advantage: There is no out-of-pocket expense to employees for the
vaccination. Employees can refuse the vaccine for documented
medical or religious reasons.

Disadvantage: The effectiveness of the vaccine varies from year to
year. Resources will be needed to process requests for religious
and medical exemption as well as appeals. Some employees
may have less protection against the flu while working in a high-
risk clinical setting. Employee lawsuits arguing a violation of their
rights may occur.

Alternative 3: Encourage, but do not require, employees to have
annual flu vaccinations. Provide education about the value of flu
vaccination and provide incentives to workers who do agree to be
vaccinated. Require workers who choose not to have the flu
vaccine wear masks during the flu season.

Advantage: There is no out-of-pocket expense to employees for the
vaccination. Employees have a choice regarding whether to have
the vaccinations and assume the responsibility of protecting their
health themselves.

Disadvantage: The effectiveness of the vaccine varies from year to
year. Some employees may have less protection against the flu
while working in a high-risk clinical setting.

Decision packages and zero-based budgeting are advantageous
because they force managers to set priorities and to use resources
most efficiently. This rather lengthy and complex method also

encourages participative management because information from peers
and subordinates is needed to analyze adequately and prioritize the
activities of each unit.

Flexible Budgeting
Flexible budgets are budgets that flex up and down over the year
depending on volume. A flexible budget automatically calculates what
the expenses should be, given the volume that is occurring. This works
well in many health-care organizations because of changing census
and manpower needs that are difficult to predict despite historical
forecasting tools.

Performance Budgeting
The fourth method of budgeting, performance budgeting, emphasizes
outcomes and results instead of activities or outputs. Thus, the
manager would budget as needed to achieve specific outcomes and
would evaluate budgetary success accordingly. For example, a home
health agency would set and then measure a specific outcome in a
group, such as diabetic patients, as a means of establishing and
justifying a budget.


Developing a Decision Package

Given the following objective, develop a decision package
to aid you in fiscal priority setting.

Objective: To have reliable, economic, and convenient
transportation when you enter nursing school in 3 months

Additional information: You currently have no car and rely
on public transportation, which is inexpensive and reliable
but not very convenient. Your current financial resources are
limited, although you could probably qualify for a car loan if
your parents were willing to cosign the loan. Your nursing
school’s policy states that you must have a car available to
commute to clinical agencies outside the immediate area.
You know that this policy is not enforced and that some
students do carpool to clinical assignments.


Identify at least three alternatives that will meet your
objective. Choose the best alternative based on the
advantages and disadvantages that you identify. You
may embellish information presented in the case to
help your problem solving.

Critical Pathways and Variance Analysis
Critical pathways (also called clinical pathways and care pathways) are
a strategy for assessing, implementing, and evaluating the cost-
effectiveness of patient care. These pathways reflect relatively
standardized predictions of patients’ progress for a specific diagnosis or
procedure. For example, a critical pathway for a specific diagnosis
might suggest an average length of stay of 4 days, with certain
interventions completed by certain points on the pathway (much like a
program evaluation and review technique flow diagram; see Fig. 1.5).
Patient progress that differs from the critical pathway prompts a
variance analysis.

Critical pathways are predetermined courses of progress
that patients should make after admission for a specific
diagnosis or after a specific surgery.

The advantage of critical pathways is that they do provide some
means of standardizing care for patients with similar diagnoses. Their
weakness, however, is the difficulties they pose in accounting for and
accepting what are often justifiable differentiations between unique
patients who have deviated from their pathway. They also pose one
more paperwork and utilization review function in a system already
burdened with administrative costs. Despite these challenges, research
suggests that critical pathways can standardize care according to
evidence-based best practices, leading to improved patient outcomes
and lower costs.

Health-Care Reimbursement
Historically, health-care institutions used incremental budgeting and
placed little or no emphasis on budgeting. Because insurance carriers
reimbursed fully on virtually a limitless basis, there was little motivation
to save costs, and organizations found it unnecessary to justify
charges. Reimbursement was based on costs incurred to provide the
service plus profit (fee-for-service [FFS]), with no ceiling placed on the
total amount that could be charged. Indeed, under FFS, the more
services provided, the greater the amount that could be billed,
encouraging the overtreatment of clients. The end result of uncontrolled
FFS reimbursement was skyrocketing health-care costs with health
care increasingly assuming a greater percentage of GDP each year.
Few efforts to shift from FFS to more cost-effective reimbursement
models began before the late-1970s.

Medicare and Medicaid

The US federal government became a major insurer of health care with
the advent of Medicare and Medicaid in the mid-1960s. Medicare is a
federally sponsored health insurance program for individuals older than
65 years and for certain groups of people with catastrophic or chronic
illness regardless of age. Medicare currently provides coverage for
items and services for 64 million beneficiaries, approximately 18% of
the US population (Kaiser Family Foundation, 2019b). Approximately
84% of enrollees are elderly, 16% are disabled, and less than 1% have
end-stage renal disease (Kaiser Family Foundation, 2019a). Medicare
enrollments are expected to increase dramatically in the coming years
as the result of the aging population.

Medicare Part A is the hospital insurance program. Medicare Part B
is the supplementary medical insurance program that pays for
outpatient care (including laboratory and X-ray services) and physician
(or other primary care provider) services. Medicare Part C (now called
Medicare Advantage) allows patients more choices for participating in
managed care plans. And the newest, Medicare Part D, which became
effective January 1, 2006, allows Medicare patients to purchase at least
limited prescription drug coverage, either through stand-alone
prescription drug plans or Medicare Advantage prescription drug (MA-
PD) plans. Approximately 22 million beneficiaries (34%) participated in
Medicare Advantage in 2019 (Kaiser Family Foundation, 2019c). Out-
of-pocket costs for Medicare beneficiaries as of 2018 are shown in
Table 10.1.


Medicare Insurance
Plan Cost

Part B premium $135.50 each month (or higher depending on
your income)

Part B deductible and

$185 per year. After the deductible is met,
patients typically pay 20% of the Medicare-
approved amount for most doctor services
(including most doctor services while a
hospital inpatient), outpatient therapy, and
durable medical equipment.

Part A premium Most people do not pay a monthly premium for
Part A. If you must buy Part A, the cost is up
to $437 each month.

Part A hospital
inpatient deductible
and coinsurance

Beneficiaries pay:
● $1,364 deductible for each benefit period
● Days 1–60: $0 coinsurance for each benefit

● Days 61–90: $341 coinsurance per day of

each benefit period in 2015
● Days 91 and beyond: $682 coinsurance per

each “lifetime reserve day” after day 90 for
each benefit period (up to 60 days over
your lifetime)

● Beyond lifetime reserve days: all costs
Part C Monthly premium varies by plan.
Part D Monthly premium varies by plan (higher

income consumers may pay more).
Source: (2019). Medicare costs at a glance. Retrieved July 28, 2019,

Medicaid is a federal-state cooperative health insurance plan created
primarily for low-income children and adults, although it also provides
medical and long-term care coverage for people with disabilities and
assistance with health and long-term care expenses for low-income
seniors. Over the past 20 years, Medicaid enrollment increased
substantially during two major recessions and again in 2015 with
implementation of the ACA. As a result, Medicaid provided coverage to
about one in five Americans, or about 74 million people as of June
2017 (Rudowitz & Valentine, 2017).

During economic downturns, when individuals lose their jobs and
incomes decline, more people qualify and enroll in Medicaid, which in
turn drives increases in total Medicaid spending. Both Medicare and
Medicaid are coordinated by the Centers for Medicare & Medicaid
Services (CMS).

The Prospective Payment System
With the advent of Medicare, Medicaid, and FFS reimbursement,
health-care costs skyrocketed as large segments of the population that
previously had no health insurance or inadequate coverage began
accessing services. In addition, health-care providers saw the
government as having “deep pockets,” which suggested almost
limitless reimbursement and began providing services accordingly.
Because of rapidly escalating costs, the government began
establishing regulations requiring organizations to justify the need for
services and to monitor the quality of services. Health-care providers
were forced for the first time to submit budgets and justify costs. This
new surveillance and existence of external controls had a tremendous
effect on the health-care industry.

The advent of diagnosis-related groups (DRGs) in the early 1980s
added to the need for monitoring cost containment. DRGs were
predetermined payment schedules that reflected historical costs for
treatment of specific patient conditions. Medicare Severity DRGs were
implemented in 2007 and have been updated annually since.

With DRGs, hospitals joined the prospective payment system (PPS),
whereby they receive a specified amount for each Medicare patient’s
admission regardless of the actual cost of care. Exceptions to this
occur when providers can demonstrate that a patient’s case is an
outlier, meaning that the cost of providing care for that patient justifies
extra payment. PPS and consequent cost-containment efforts lead to
decreased length of stays for most patients.

Because of the PPS and the need to contain costs, the
length of stay for most hospital admissions has decreased

Many argue that quality standards have been lowered because of the
PPS and that patients are being discharged before they are ready. It is
the nurse-leader’s responsibility to recognize when cost containment is
impinging on patient safety and to take appropriate action to guarantee
at least a minimum standard of care.

In addition, hospitals must use the International Classification of
Diseases (ICD) to code diseases, signs and symptoms, and abnormal
findings. Currently in its 10th revision, ICD-10 provides significantly
more coding options for treatment, reporting, and payment processes,
including more than 68,000 clinical modification codes as compared
with 15,000 in ICD-9 (CMS, 2018b).

The government again deeply affected health-care administration in
the United States in 1997 with the passage of the Balanced Budget Act
(BBA). This act contained numerous cost-containment measures,
including reductions in provider payments for traditional FFS Medicare
program participants. The bulk of the savings resulted from limiting the
growth rates for hospital and physician payments. A second major
source of savings derived from restructuring the payment methods for
rehabilitation hospitals, home health agencies, skilled nursing facilities,
and outpatient services. The BBA also, for the first time, authorized

payments to nurse practitioners for Medicare-provided services at 85%
of the physician-fee schedule.

The ever-increasing impact of the federal government on how health
care is delivered in the United States must be recognized.
Accompanying this funding is an increase in regulations for facilities
treating these patients and a system that rewards cost containment.
Health-care providers are encountering financial crises as they attempt
to meet unlimited health-care needs and services with limited fiscal
reimbursement. Competition has intensified, reimbursement levels
have declined, and utilization controls have increased. In addition,
rapidly changing federal and state reimbursement policies make long-
range budgeting and planning very difficult for health-care facilities.

Managed Care
Managed care has also been a significant factor affecting health-care
delivery and reimbursement since the early 1990s. Broadly defined,
managed care is a system that attempts to integrate efficiency of care,
access, and cost of care. Common denominators in managed care
include the use of primary care providers as “gatekeepers,” a focus on
prevention, a decreased emphasis on inpatient hospital care, the use of
clinical practice guidelines for providers, and selective contracting
(whereby providers agree to lower reimbursement levels in exchange
for patient population contracts). Managed care typically uses
formularies to manage pharmacy care and focuses on continuous
quality monitoring and improvement.

Utilization review is another common component of managed care.
Utilization review is a process used by insurance companies to assess
the need for medical care and to assure that payment will be provided
for the care. Utilization review typically includes precertification or
preauthorization for elective treatments, concurrent review, and, if
necessary, retrospective review for emergency cases.

Another frequent hallmark of managed care is capitation, whereby
providers receive a fixed monthly payment regardless of services used

by that patient during the month. If the cost to provide care to someone
is less than the capitated amount, the provider profits. If the cost is
greater than the capitated amount, the provider suffers a loss. The
goal, then, for capitated providers is to see that patients receive the
essential services to stay healthy or to keep from becoming ill but to
eliminate unnecessary use of health-care services. Critics of capitation
argue that this reimbursement strategy leads to undertreatment of
patients. A summary of managed care characteristics is found in
Display 10.5.


Represents a wide range of financing alternatives that focus on
managing the cost and quality of health care by
Using panels of selectively contracted providers
Limiting benefits to subscribers who use noncontracted

Implementing some type of authorization system
Focusing on primary care rather than specialists and inpatient

Emphasizing preventive health care
Relying on clinical practice guidelines for providers
Regularly reviewing the use of health-care resources
Continuously monitoring and improving the quality of health

Patients have less choice about the providers they can see and

services they can access, in exchange for small copayments and
no deductibles.

Managed care organizations often use primary care gatekeepers
Be sure that the provider-ordered services are needed and

See that patients are cared for in outpatient settings whenever

Ration care by queuing and wait times for authorizations
Encourage providers to follow more standardized care pathways

and clinical guidelines for treatment
Managed care is based on the concept of capitation, whereby

providers prospectively receive a fixed monthly payment,
regardless of what services are used by that patient during the
month. This encourages providers to treat less because their
potential profits decline as treatment increases.

Types of Managed Care Organizations
One of the most common types of managed care organizations (MCOs)
is the health maintenance organization (HMO). An HMO is a network of
providers funded by insurance premiums. The HMO’s physicians and
other professionals practice medicine within certain financial,
geographic, and professional limits to individuals and families who have
enrolled in the HMO. Although HMOs originated as an alternative to
traditional health insurance plans, some of the largest private insurers,
including Blue Cross and Blue Shield and Aetna, have created HMOs
within their organization while maintaining their traditional indemnity
plans. More than 70 million Americans have enrolled in HMOs since
their inception (National Conference of State Legislatures [NCSL],

In discussing HMOs, it is important to remember that there are
different types of HMOs as well as different types of plans within HMOs
to which members may subscribe. Several types of HMOs include (a)
staff, (b) independent practice association (IPA), (c) group, and (d)
network. In staff HMOs, physician providers are salaried by the HMO
and under direct control of the HMO. In IPA HMOs, the HMO contracts
with a group of physicians through an intermediary to provide services
for members of the HMO. In a group HMO, the HMO contracts directly
with one independent physician group. In network HMOs, the HMO
contracts with multiple independent physician group practices.

The types of plans available within HMOs typically vary according to
the degree of provider choice available to enrollees. Two such plans
include point-of-service (POS) and exclusive provider organization
(EPO) options. In POS plans, the patient has the option, at the time of
service, to select a provider outside the network but pays a higher
premium as well as a copayment (amount of money enrollees pay out
of their pocket at the time a service is provided) for the flexibility to do
so. In the EPO option, enrollees must seek care from the designated
HMO provider or pay all of the cost out of pocket.

Another common type of MCO is the preferred provider organization
(PPO). PPOs render services on an FFS basis but provide financial
incentives to consumers (they pay less) when the preferred provider is
used. Providers are motivated to become part of a PPO because it
ensures them an adequate population of patients. Almost 90 million
Americans have become a part of PPOs since their inception (NCSL,

Medicare and Medicaid Managed Care
Although Medicare and Medicaid patients historically were excluded
from managed care under the free choice of physician rule, these
restrictions were lifted in the 1970s and 1980s. As a result, Medicare
and Medicaid patients can now participate in private HMOs and other
types of managed care programs through Medicare Part C (formerly
the Medicare + Choice program and now known as Medicare
Advantage). To join a Medicare Advantage plan, patients must have
both Medicare Parts A and Part B. The payment system for these
programs (effective 1982) was to be prospective, and the HMO was at
risk for providing all benefits in return for the capitated payment.

MCOs receive reimbursement for Medicare-eligible patients based
on a formula established by the CMS, which looks at age, gender,
geographic region, and the average cost per patient at a given age.
Then, the government gives itself a 5% discount and gives the rest to
the MCO. The BBA of 1997 expanded the role of private plans under
Medicare + Choice to include PPOs, provider-sponsored organizations,
private FFS plans, and medical savings accounts, coupled with high-
deductible insurance plans.

The CMS is now the largest managed care buyer in the United

The CMS is now the largest purchaser of managed care in
the United States.

Proponents and Critics of Managed Care Speak Up
Proponents of managed care argue that prepaid health-care plans,
such as those offered by HMOs, decrease health-care costs, provide
broader benefits for patients than under the traditional FFS model,
appropriately shift care from inpatient to outpatient settings, result in
higher physician productivity, and have high enrollee satisfaction levels.

Critics, however, suggest that participation in MCOs may result in a
loss of existing physician–patient relationships, a limited choice of
physicians for consumers, a lower level of continuity of care, reduced
physician autonomy, longer wait times for care, and consumer
confusion about the many rules to be followed. A common complaint
heard from managed care subscribers is that services must be
preapproved or preauthorized by a gatekeeper or that second opinions
must be obtained before surgery. Although this loss of autonomy is
difficult for consumers accustomed to an FFS system with few limits on
choice and access, such utilization constraints are necessary due to
moral hazard, which is the risk that the insured will overuse services
just because the insurance will pay the costs. Because the copayment
is typically small for patients in managed care programs, the risk of
moral hazard rises.

Moral hazard refers to the propensity of insured patients to
use more medical services than necessary because their
insurance covers so much of the cost.

Another aspect complicating health-care reimbursement through the
PPS, an HMO, or a PPO is that clear and comprehensive
documentation of the need for services and actual services provided is
mandatory. Provision of service no longer guarantees reimbursement.
Thus, the fiscal accountability of nurses goes beyond planning and
implementing; it includes responsible recording and communication of

Provision of service no longer guarantees reimbursement.

Perhaps the most serious concern about the advancement of
managed care in this country is the change in relationships among
insurers, physicians, nurses, and patients. The full impact on clinical
judgment of tying physician and nursing salaries to bonuses,
incentives, and penalties designed to reduce utilization of services and
resources and increase profit is unknown. As a result, a need for self-
awareness regarding the values that guide individual professional
nursing practice has never been greater.


Providing Care With Limited

You are the manager at a home health agency. One of
your elderly patients has insulin-dependent diabetes. He
has no family support. He speaks limited English and has
little understanding of his disease. He lives alone. Your
reimbursement from a government agency pays $90 per
visit. Because this gentleman needs so much care, you find
that the actual cost to your agency is $130 for each visit to
him. What will be the impact to your agency if this patient is
seen twice a week for 3 months? How can you recover the
lost revenue? How can you make each visit less costly and
still meet the needs of the patient?

The Future of Managed Care
Managed care continues to change the face of health care in the
United States. The contractual complexity and the use of prospective
payment in managed care make it much more difficult for providers to
anticipate potential revenues and then to bill for and collect
reimbursement for services provided. Indeed, some critics of managed
care suggest that health-care practitioners and institutions now bear
much more of the financial risk for the cost of care than insurers.

Some declines in managed care participation have occurred in part
because these plans are no longer significantly less expensive for
consumers to purchase or for insurers to provide. In addition, providers
have grown increasingly frustrated with limited and delayed
reimbursement for services provided as well as the need to justify need
for services ordered. Indeed, some providers have filed lawsuits
against managed care insurers for delay of payment or nonpayment for
services provided. Even with this discontent, managed care is not going

to go away—at least not any time soon. It will, however, continue to
change. Certainly, in reviewing the health-care reimbursement
milestones of the past 75 years (Display 10.6), one can see that health-
care reimbursement has changed dramatically in a relatively short time
and that managed care is just one more reimbursement schema that
has changed the face of health care in the United States.


1929 First health maintenance organization (HMO), the Ross-Loos
Clinic, is established in Los Angeles.

1929 Origins of Blue Cross, when Baylor University Hospital agreed
to provide 1,500 school teachers up to 21 days of hospital care
for $6.00 per year.

1935 Passage of Social Security Act. This act originally included
compulsory health insurance for states that voluntarily chose to
participate, but the American Medical Association fought it and
the health insurance provisions were omitted from the act.

1942 First nationwide hospital insurance bill introduced into
Congress, but it failed to pass.

1946 Hill-Burton Act promoted hospital development and renovation
after World War II. Authorized $75 million yearly for 5 years to aid
in hospital construction.

1965 Passage of Medicare and Medicaid as part of Lyndon B.
Johnson’s Great Society. Resulted in 50% increase in the number
of medical schools in the United States.

1972 Professional standards review organizations established by
Congress to prevent excess hospitalization and utilization by
Medicare and Medicaid patients.

1973 The Health Maintenance Act authorized the spending of $375
million over 5 years to set up and evaluate HMOs in communities
across the country.

1974 The National Planning Act created a system of state and local
health planning agencies largely supported by federal funds. This
created health systems agencies to inventory each community’s
health-care resources and to issue Certificates of Need.

1974 The Employment Retirement Income Security Act (ERISA)
passed, generally preempting state regulation of self-insuring
employee benefit plans.

1983 Diagnosis-related groups established, which changed the
structure of Medicare payments from a retrospectively adjusted
cost-reimbursement system to a prospective, risk-based one.

1986 Consolidated Omnibus Budget Reconciliation Act (COBRA) of
1986 passed. Allowed terminated employees or those who lose
coverage because of reduced work hours to buy group coverage
for themselves and their families for limited periods of time (up to
60 days to decide).

1988 Medicare Catastrophic Coverage Act (MCCA) enacted, which
expanded Medicare benefits greatly to include a portion of out-of-
pocket drug and physician expenses.

1989 Medicare system of paying physician charges changed to a
resource-based relative value scale to be phased in starting in

1993 Former President William J. Clinton introduced the Health
Security Act, legislation assuring universal access to all
Americans. The act failed to pass.

1996 Health Insurance Portability and Accountability Act passed.
Created medical savings accounts and required the U.S.
Department of Health and Human Services to establish national
standards for electronic health-care transactions and national
identifiers for providers, health plans, and employers. It also
addressed the security and privacy of health data.

1997 Approximately one-quarter of Americans enrolled in HMOs.
Almost 6 million Medicare beneficiaries enrolled in HMOs.
Balanced Budget Act gives states the authority to implement
managed care programs without federal waivers.

1999 Health-care spending comprised approximately 15% of the
gross domestic product of the United States, exceeding $1 trillion
in annual health-care expenditures for the first time.
Approximately 37 million Americans were uninsured, and
between 50 and 70 million were inadequately insured.

2001 More than 1.5 million elderly Medicare HMO patients forced to
find new insurance arrangements as their HMOs pulled out of the

Medicare program after losing money on Medicare enrollees.
Increasing disenchantment noted with managed care.

2003 The Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 passed, providing a voluntary program
for prescription drug coverage under the Medicare program. It
also commissioned the Institute of Medicine to prioritize options
to align performance and payment in Medicare, supporting a “pay
for performance” (P4P) approach.

2009 Congressional committees began active debate of a
comprehensive health-care reform package. Former President
Barack Obama announced the release of nearly $600 million in
funding to strengthen community health centers that would serve
500,000 additional patients and use health information

2010 Former President Barack Obama’s Health Care Reform bill
Patient Protection and Affordable Care Act (PPACA) passed,
resulting in sweeping overhauls of the US health-care system
and the introduction of a new Patient’s Bill of Rights related to
insurance coverage. Provisions related to eliminating lifetime
limits on insurance coverage, extending coverage to young
adults, and providing new coverage to individuals who have been
uninsured for at least 6 months due to a preexisting condition
were implemented.

2011 PPACA provisions related to providing free preventive care to
seniors, the establishment of a Community-Based Care
Transitions Program, and the creation of a new Center for
Medicare & Medicaid Innovation were put into place.

2012 The PPACA established hospital value-based purchasing
programs in traditional Medicare to provide incentives for health-
care providers to work together to form accountable care
organizations as well as new, voluntary options for long-term care

2013 The PPACA provided new funding to state Medicaid programs
that chose to cover preventive services for patients at little or no

cost, expanded the authority to bundle payments, increased
medical payments for primary care doctors, and began open
enrollment in the Healthcare Insurance Marketplace.

2014 The final provisions of the PPACA were phased in, including
the implementation of the Healthcare Insurance Marketplace,
prohibition of discrimination due to preexisting conditions or
gender, the elimination of annual limits on insurance coverage,
and ensuring coverage for individuals participating in clinical

2015 The tax penalty for being uninsured increased. The 2015
penalty was the larger of 2% of income or $325 per person
($162.50 per child younger than 18 years). Businesses with 100
or more full-time equivalent (FTE) employees were required to
offer affordable coverage to full-time staff that offered the
essential benefits required under the Affordable Care Act (ACA).
In addition, these policies were required to cover full-time
employees’ dependent children up through age 26 years. If
businesses of this size chose not to offer insurance, they had to
pay a tax penalty to the government. This provision applied to
businesses with 50 or more full-time employees in 2016.

2016 Under the PPACA, all businesses with 100 or fewer FTE
employees were able to purchase insurance through the state
SHOP Exchange. A new program also began, allowing states to
form health-care choice compacts and allowing insurers to sell
policies in any state participating in the compact.

2017 Under the PPACA, a state’s ability to allow large employers
(with 100+ employees) to provide coverage through a SHOP
Exchange took effect.

2017 Multiple bills to repeal and replace the ACA were introduced
into either the House or the Senate in fall 2017, although
legislative consensus was not achieved. Although the bills were
different in some respects, the common theme was a reduction in
mandates for individuals and businesses to buy or provide health

insurance and a reduction of government subsidies for vulnerable
populations like the elderly and the poor.

2017 The Tax Cuts and Jobs Act (passed by Congress and signed
into law by President Donald Trump in late December 2017). This
made significant changes to the ACA, including eliminating the
penalty of the “individual mandate” to purchase health insurance
in 2018 and repealing the individual mandate in 2019. The
Congressional Budget Office estimated that repealing the
individual mandate will result in 4 million people losing coverage
in 2019 and 13 million losing coverage by 2027 (O’Brien, 2017).

2018 President Donald Trump revealed the American Patients First
plan. This plan sought to reform the rebates drug companies pay
to pharmacy benefit managers (PBMs), who negotiate prices
between drug manufacturers, pharmacies, and health insurance
companies. The rebates create incentives for PBMs to suggest
higher cost drugs. In addition, PBMs can charge insurers more
than they’re charging pharmacies (Huston, 2020).

2019 With legislative failure to repeal the ACA in 2017, a stalemate
is in place. The ACA is in place, but new laws continue to be
introduced to incrementally dismantle it (Huston, 2020).

Health-Care Reform Efforts: The Patient Protection
and Affordable Care Act. What Comes Next?
In March 2010, former President Barack Obama signed the ACA that
put in place comprehensive insurance reforms to be phased in over a
4-year period. The act included a new Patient’s Bill of Rights
implemented in 2010, a provision for Medicare beneficiaries to get
preventive services for free and discounts on brand name drugs for
some patients using Medicare Part D beginning in 2011 as well as the
introduction of “bundled payments,” the addition of ACOs and other
programs help doctors and health-care providers work together to
deliver better care in 2012, hospital VBP and open enrollment in the

Health Insurance Marketplace beginning in October 2013, and greater
access for most Americans to affordable health insurance options in
2014 (U.S. Department of Health and Human Services, 2017).

Bundled Payments
Passed in October 2011 and implemented in 2013, the Bundled
Payments for Care Improvement Initiative gave providers flexibility to
work together to coordinate care for patients over the course of a single
episode of an illness. There are four broadly defined models of bundled
care: Three of these models involve retrospective payment, and one is
prospective. In the retrospective payment models, CMS and providers
set a target payment amount for a defined episode of care. This target
amount would reflect a discount to total costs for a similar episode of
care as determined from historical data. Participants then would be
paid for their services under the original Medicare FFS system but at a
negotiated discount. Models 2 and 3 may include clinical laboratory
services and durable medical equipment (CMS, 2018a).

The prospective payment model differs in that CMS makes a single,
prospectively determined bundled payment to a hospital that would
encompass all services furnished during the inpatient stay by the
hospital, physicians, and other practitioners. Physicians and other
practitioners would be paid by the hospital out of the bundled payment.

Accountable Care Organizations
ACOs are groups of providers and suppliers of service who work
together to better coordinate care for Medicare patients (does not
include Medicare Advantage) across care settings. The goal of an ACO
is to deliver seamless, high-quality care in an environment that is truly
patient centered and where patients and providers are partners in
decision making.

Although patient and provider participation in ACOs is voluntary at
this time, the Medicare Shared Savings Program rewards ACOs that
lower growth in health-care costs while meeting performance standards

on quality of care and putting patients first (U.S. Department of Health
and Human Services, 2017). ACOs are entitled to these shared savings
when savings exceed the minimum sharing rate and if the ACO meets
or exceeds the quality performance standards. Additional shared
savings can be earned by ACOs that include beneficiaries who receive
services from a federally qualified health center or rural health clinic
during the performance year (U.S. Department of Health and Human
Services, 2017).

Hospital Value-Based Purchasing
Beginning in 2013, for the first time, the hospital VBP program paid
inpatient acute care services partially on care quality, not just on the
quantity of the services they provide. In VBP, providers are held
accountable for the quality and cost of the health-care services they
provide by a system of rewards and consequences. This requires the
reporting of standardized, comparable patient outcomes.

The Patient-Centered Medical Home
The patient-centered medical home (PCMH), also known as the
medical home, is a coordinated effort to meet patient needs through the
better coordination of quality care. The medical home uses a team of
providers—such as physicians, nurses, nutritionists, pharmacists, and
social workers—to integrate all aspects of health care, including
physical health, behavioral health, access to community-based social
services, and the management of chronic conditions. Communication
occurs through well-developed health information technology including
electronic health records.

Payment reform is also a critical part of the medical home initiative as
financial incentives are offered to providers to focus on the quality of
patient outcomes rather than the volume of services they provide.
Although the model is still evolving, national and state medical home
accreditation is available, facilitating payment from both public and
private payers.

Improved quality of care is also a critical goal for the PCMH. Multiple
researchers have compared the connection between medical homes
and reduced hospitalizations, reduced emergency department (ED)
visits, and lowered costs of care, with diff