Miami Dade County Public Schools Health Patient Compliance Discusion

  

Instructions:

Review Learning

Exercise 8.3 – Using Change Strategies to Increase Sam’s Compliance

(located in Chapter 8 of the textbook)

Answer the following questions:

What change strategy or combination thereof (rational-empirical, normative-reedeucative or 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?

Your resume should be:

Typed according to APA style for margins, formatting and spacing standards.

Typed into a Microsoft Word document

Link to exercise 8.3

Senior Acquisitions Editor: Christina C. Burns
Director of Product Development: Jennifer K. Forestieri
Senior Development Editor: Roxanne Halpine Ward
Editorial Assistant: Hilari Bowman
Production Project Manager: Marian Bellus
Design Coordinator: Steven Druding
Illustration Coordinator: Jennifer Clements
Manufacturing Coordinator: Karin Duffield
Prepress Vendor: Absolute Service, Inc.
9th edition
Copyright © 2017 Wolters Kluwer..
Copyright © 2015 and 2012 by Wolters Kluwer Health | Lippincott Williams & Wilkins.
Copyright © 2009, 2006, 2003, and 2000 by Lippincott Williams & Wilkins. Copyright © 1996 by
Lippincott-Raven Publishers. Copyright © 1992 by J. B. Lippincott Company. All rights reserved. This
book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by
any means, including as photocopies or scanned-in or other electronic copies, or utilized by any
information storage and retrieval system without written permission from the copyright owner, except for
brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by
individuals as part of their offi cial duties as U.S. government employees are not covered by the abovementioned copyright. To request permission, please contact Lippincott Williams & Wilkins at Two
Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via e-mail at permissions@lww.com, or
via our website at lww.com (products and services).
987654321
Printed in China
Library of Congress Cataloging-in-Publication Data
Names: Marquis, Bessie L., author. | Huston, Carol Jorgensen, author.
Title: Leadership roles and management functions in nursing : theory and
application / Bessie L. Marquis, Carol J. Huston.
Description: Ninth edition. | Philadelphia : Wolters Kluwer Health, [2017] |
Includes bibliographical references and index.
Identifi ers: LCCN 2016046163 | ISBN 9781496349798
Subjects: | MESH: Nursing, Supervisory | Leadership | Nurse Administrators |
Nursing—organization & administration
Classifi cation: LCC RT89 | NLM WY 105 | DDC 362.17/3068—dc23
LC record available at https://lccn.loc.gov/2016046163
Care has been taken to confirm the accuracy of the information presented and to 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.
The author(s), editors, and publisher have exerted every effort to ensure that drug selection and dosage
set forth in this text are in accordance with the current recommendations and practice at the time of
publication. However, in view of ongoing research, changes in government regulations, and the constant
flow of information relating to drug therapy and drug reactions, the reader is urged to check the package
insert for each drug for any change in indications and dosage and for added warnings and precautions.
This is particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration
(FDA) clearance for limited use in restricted research settings. It is the responsibility of the health-care
provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice.
LWW.com
I dedicate this book to the two most important
partnerships in my life: my husband, Don Marquis,
and my colleague, Carol Huston.
Bessie L. Marquis
I dedicate this book to my husband Tom,
who has stood by my side for almost 45 years. I love you.
Carol Jorgensen Huston
REVIEWERS
Carol Amann, PhD, RN-BC, FNGNA
Nursing Instructor
Villa Maria School of Nursing
Gannon University
Erie, Pennsylvania
Andrea Archer, EdD, ARNP
Undergraduate Nursing Department
Florida International University
Miami, Florida
Cynthia Banks, PhD
Program Director, RN to BSN
Department of Nursing
Sentara College of Health Sciences
Chesapeake, Virginia
Dana Botz, MSN
Faculty, Department of Nursing
North Hennepin Community College
Brooklyn Park, Minnesota
Sharon Bradley, DNP
Clinical Assistant Professor
Director of Student Success
College of Nursing
University of Florida
Gainesville, Florida
Carolyn Brose, EdD, MSN
Associate Professor
MSN Program Director
Missouri Western State University
St. Joseph, Missouri
Beryl Broughton, MSN, CRNP, CS, CNE
Nursing Instructor, Nursing Education
Aria Health School of Nursing
Trevose, Pennsylvania
Suzette Cardin, PhD
Adjunct Associate Professor
School of Nursing
University of California, Los Angeles
Los Angeles, California
Fran Cherkis, DHSc
Associate Professor
Department of Nursing
Farmingdale State College
Farmingdale, New York
Alice Colwell, MSN
Assistant Professor
Department of Nursing
Kent State University Trumbull Campus
Warren, Ohio
Laura Crouch, EdD, MSN
Associate Clinical Professor
School of Nursing
Northern Arizona University
Flagstaff, Arizona
Karen Davis, DNP
Assistant Professor
College of Nursing
University of Arkansas for Medical Sciences
Little Rock, Arkansas
Karen Estridge, DNP, RN
Assistant Professor
Department of Nursing
Ashland University
Mansfield, Ohio
James Fell, MSN, MBA, BSN, BS
Associate Professor
Director
Department of Nursing
Baldwin Wallace University
Berea, Ohio
Rick García, PhD
Associate Professor
Faculty Fellow
Rory Meyers College of Nursing
New York University
New York, New York
Evalyn Gossett, MSN
Clinical Assistant Professor
School of Nursing
Indiana University Northwest
Gary, Indiana
Debra Grosskurth, PhD(c)
Assistant Chair
Department of Nursing
Salve Regina University
Newport, Rhode Island
Patricia Hanson, PhD
Professor
Department of Nursing
Madonna University
Livonia, Michigan
Tammy Henderson, MSN
Associate Director
Conemaugh School of Nursing
Conemaugh Memorial Medical Center
Johnstown, Pennsylvania
Barbara Hoerst, PhD, RN
Assistant Professor
Department of Nursing
La Salle University
Philadelphia, Pennsylvania
Brenda Kucirka, PhD, RN, PMHCNS-BC, CNE
Assistant Professor
Department of Nursing
Widener University
Chester, Pennsylvania
Coleen Kumar, PhD
College of Nursing
State University of New York Downstate Medical Center
Brooklyn, New York
Kathleen Lamaute, EdD
Professor
Department of Nursing
Molloy College
Rockville Centre, New York
Pamela Lapinski, MSN
Professor
Department of Nursing
Valencia College
Orlando, Florida
Jamie Lee, MSN, RN, CNL
Assistant Professor
Department of Nursing
James Madison University
Harrisonburg, Virginia
Carolyn Lewis, PhD
Assistant Professor
Department of Nursing
Angelo State University
San Angelo, Texas
Bette Mariani, PhD, RN
Assistant Professor
College of Nursing
Villanova University
Villanova, Pennsylvania
David Martin, MSN
Director
RN-BSN & Shared Curriculum Programs
School of Nursing
University of Kansas
Kansas City, Kansas
Donna McCabe, DNP, APRN-BC, GNP
Clinical Assistant Professor
Department of Nursing
Rory Meyers College of Nursing
New York University
New York, New York
Theresa Miller, PhD
Associate Professor, Nursing Education
OSF Saint Francis Medical Center College of Nursing
Peoria, Illinois
Donna Molyneaux, PhD
Associate Professor
Department of Nursing
Gwynedd Mercy University
Gwynedd Valley, Pennsylvania
LaDonna Northington, DNS
Professor, Traditional Undergraduate Nursing Program
University of Mississippi School of Nursing
Jackson, Mississippi
Sally Rappold, MSN, BSN
Assistant Teaching Professor
Department of Nursing
Montana State University
Missoula, Montana
Karen Ringl, MSN
Faculty
Department of Nursing
California State University, Fullerton
Fullerton, California
Joyce Shanty, PhD, RN
Associate Professor
Nursing and Allied Health Professions
Indiana University of Pennsylvania
Indiana, Pennsylvania
Jean Short, MSN
Assistant Professor
Division of Post-Licensure Nursing
School of Nursing
Indiana Wesleyan University
Marion, Indiana
Jennifer Sipe, MSN, CRNP
Assistant Professor
School of Nursing and Health Sciences
La Salle University
Philadelphia, Pennsylvania
Ana Stoehr, PhD, MSN
Faculty
Department of Nursing
George Mason University
Fairfax, Virginia
Patricia Thielemann, PhD
Professor
College of Nursing
St. Petersburg College
Pinellas Park, Florida
Charlene Thomas, PhD, MSN, BSN
Associate Professor
School of Nursing and Allied Health
Aurora University
Aurora, Illinois
Nina Trocky, DNP, RN
Assistant Professor
Department of Organizational Systems and Adult Health
School of Nursing
University of Maryland
Baltimore, Maryland
Brenda Tyczkowski, DNP, RN, RHIA
Assistant Professor
Professional Program in Nursing
University of Wisconsin Green Bay
Green Bay, Wisconsin
Dannielle White, MSN
Associate Professor
School of Nursing
Austin Peay State University
Clarksville, Tennessee
Mary Williams, MS
Associate Professor
School of Nursing and Health Science
Gordon State College
Barnesville, Georgia
Connie Wilson, EdD
Professor Emeritus
School of Nursing
University of Indianapolis
Indianapolis, Indiana
Kelly Wolgast, DNP
School of Nursing
Vanderbilt University
Nashville, Tennessee
Renee Wright, EdD
Assistant Professor
Department of Nursing
York College, City University of New York
New York, New York
Judith Young, DNP
Clinical Assistant Professor, Community and Health Systems
School of Nursing
Indiana University
Indianapolis, Indiana
PREFACE
Legacy of Leadership Roles and Management Functions in Nursing
This book’s philosophy has evolved over 35 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 nor 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 management.
The second concept that shaped this book was our commitment to developing critical thinking skills
through the use of experiential learning exercises. We propose that integrating leadership and management
can be accomplished through the use of learning exercises. The majority of 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
ninth 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.
Responding to reviewer recommendations, we have added and deleted content. In particular, we have
attempted to strengthen the leadership component of the book while maintaining a balance of management
content. We have also attempted to increase the focus on quality and safety as well as health-care finance,
and used outpatient/community settings as the location for more learning exercises.
We have also 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 ninth edition also includes
contemporary research and theory to ensure accuracy of the didactic material.
Additional content that has been added or expanded in this edition includes the following:
26 new learning exercises, further strengthening the problem-based element of this text.
Over 200 displays, figures, and tables (17 of which are new) help readers visualize important
concepts, whereas photographs of nurses in leadership and management situations help students
relate concepts to real-world practice.
An expanded focus on evidence-driven leadership and management decision making
Time management and productivity apps
Newer care delivery models focused on ambulatory care and outpatient settings (primary care nurse
coordinator in medical homes, nurse navigators, clinical nurse leaders [CNLs], leaders in patientcentered care)
Impact of the 2010 Patient Protection and Affordable Care Act (PPACA) on quality and health-care
finance in this country
The shifting in health-care reimbursement from volume to value
Personality testing as an employment selection tool
Electronic health records and meaningful use
Reflective practice and the assessment of continuing competency
Civility, healthy workplaces, and bullying
Interprofessional collaboration and workgroups
Working with diverse workforces and patient populations
Social media and organizational communication
New quality Initiatives put forth by the Centers for Medicare & Medicaid Services, The Joint
Commission, and other regulatory bodies
Sentinel events
Lean Six Sigma methodologies
Medication reconciliation
Self-appraisal, peer review, and 360-degree evaluation as performance appraisal tools
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 making.
Units III–VII are organized using the management processes of planning, organizing, staffing, directing,
and controlling.
Features of the Text
The ninth 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 chapter.
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 of Nurse
Executives (AONE) Nurse Executive Competencies (updated September 2015), and the Quality and
Safety Education for Nurses (QSEN) Competencies (2014). For this edition, the newly revised Standards
for Professional Performance from the American Nurses Association (ANA) Nursing Scope and
Standards of Practice (2015) have been included. This edition, then, attempts 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).
TABLE 1 AMERICAN ASSOCIATION OF COLLEGES OF NURSING
ESSENTIALS OF BACCALAUREATE EDUCATION FOR PROFESSIONAL
NURSING PRACTICE
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 environments
• 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 practice.
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 lifespan 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).
TABLE 2 AMERICAN ASSOCIATION OF COLLEGES OF NURSING
ESSENTIALS OF MASTER’S EDUCATION IN NURSING
Essential I: Background for practice from sciences and humanities
• 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 perspective.
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 practice
• 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 care.
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 of Nurse Executives Nurse Executive Competencies
In 2004 (updated in 2015), the AONE published a paper describing skills common to nurses in executive
practice regardless of their educational level or titles in different organizations. While these Nurse
Executive Competencies differ depending on the leader’s specific position in the organization, the AONE
suggested that managers at all levels must be competent in the five areas noted in Table 3 (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.
TABLE 3 AMERICAN ORGANIZATION OF NURSE EXECUTIVES NURSE
EXECUTIVE COMPETENCIES
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.
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 4).
TABLE 4 AMERICAN NURSES ASSOCIATION NURSING
ADMINISTRATION STANDARDS OF PROFESSIONAL PERFORMANCE
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 practice.
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 practice.
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 Competencies
Using the Institute of Medicine (2003) competencies for nursing, the QSEN Institute (2014; Cronenwett,
2007) 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, QSEN pursues strategies
to develop effective teaching approaches to assure that future graduates develop competencies in patientcentered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and
informatics.
TABLE 5 QUALITY AND SAFETY EDUCATION FOR NURSES
COMPETENCIES
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 care.
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 systems.
Safety
• Definition: Minimizes the risk of harm to patients and providers through
both system effectiveness and individual performance.
Informatics
• Definition: Use information and technology to communicate, manage
knowledge, mitigate error, and support decision making.
Leadership Roles and Management Functions in Nursing, ninth edition, has ancillary resources
designed with both students and instructors in mind, available on
web site.
Student Resources Available on
Glossary—Fully updated for the ninth edition, the glossary contains definitions of all important
terms in the text.
Journal Articles—25 full articles from Wolters Kluwer journals (one corresponding to each chapter)
—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 on
Competency Maps pull together the mapping provided in the crosswalk feature for each chapter,
showing how the book content as a whole 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.
Learning Management System Course Cartridges
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: 7 and 14 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 over 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 Solutions
We are delighted to introduce an expanded suite of digital solutions to support instructors and students
using Leadership Roles and Management Functions in Nursing, ninth 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 http://www.nursingeducationsuccess.com/ 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 scenarios.
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 casebased learning for every student:
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 throughout.
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:
http://www.nursingeducationsuccess.com/coursepoint
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, ninth 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 application.
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 content.
To learn more about Lippincott RN to BSN Online, please visit
http://www.nursingeducationsuccess.com/nursing-education-solutions/lippincott-rn-bsn-online/
Closing Note
It is our hope and expectation that the content, style, and organization of this ninth 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
R E FE R E N C E S
American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for
professional nursing practice. Retrieved October 17, 2015, from
http://www.aacn.nche.edu/education-resources/baccessentials08.pdf
American Association of Colleges of Nursing. (2011). The essentials of master’s education in nursing.
Retrieved October 17, 2015, from http://www.aacn.nche.edu/educationresources/MastersEssentials11.pdf
American Nurses Association. (2015). Nursing: Scope & standards of practice (3rd ed.). Silver Spring,
MD: Author.
American Organization of Nurse Executives. (2015). The AONE nurse executive competencies.
Retrieved October 17, 2015, from http://www.aone.org/resources/nurse-leadercompetencies.shtml
Cronenwett, L., et al. (2007). Quality and safety education for nurses. Nursing Outlook 55(3), 122.
Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC:
National Academies Press.
Quality and Safety Education for Nurses Institute. (2014). Competencies. Retrieved October 17, 2015,
from http://qsen.org/competencies/
CONTENTS
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 Reasoning
Vicarious Learning to Increase Problem-Solving and Decision-Making Skills
Theoretical Approaches to Problem Solving and Decision Making
Critical Elements in Problem Solving and Decision Making
Individual Variations in Decision Making
Overcoming Individual Vulnerability in Decision Making
Decision Making in Organizations
Decision-Making Tools
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 Management
Managers
Leaders
Historical Development of Management Theory
Historical Development of Leadership Theory (1900 to Present)
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
Transition From Industrial Age Leadership to Relationship Age Leadership
Integrating Leadership Roles and Management Functions in the 21st Century
Key Concepts
Additional Learning Exercises and Applications
II
Foundation for Effective Leadership and Management Ethics, Law,
and Advocacy
4 Ethical Issues
Moral Issues Faced by Nurses
Ethical Frameworks for Decision Making
Principles of Ethical Reasoning
American Nurses Association Code of Ethics and Professional Standards
Ethical Problem Solving and Decision Making
The Moral Decision-Making Model
Working Toward Ethical Behavior as the Norm
Integrating Leadership Roles and Management Functions in Ethics
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
Avoiding Malpractice Claims
Extending the Liability
Incident Reports and Adverse Event Forms
Intentional Torts
Other Legal Responsibilities of the Manager
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 Rights
Subordinate and Workplace Advocacy
Whistleblowing as Advocacy
Professional Advocacy
Integrating Leadership Roles and Management Functions in Advocacy
Key Concepts
Additional Learning Exercises and Applications
III
Roles and Functions in Planning
7 Organizational Planning
Looking to the Future
Proactive Planning
Strategic Planning at the Organizational Level
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
Rules
Overcoming Barriers to Planning
Integrating Leadership Roles and Management Functions in Planning
Key Concepts
Additional Learning Exercises and Applications
8 Planned Change
Lewin’s Change Theory of Unfreezing, Movement, and Refreezing
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
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
Personal Time Management
Integrating Leadership Roles and Management Functions in Time Management
Key Concepts
Additional Learning Exercises and Applications
10 Fiscal Planning
Balancing Cost and Quality
Responsibility Accounting and Forecasting
Basics of Budgets
Steps in the Budgetary Process
Types of Budgets
Budgeting Methods
Critical Pathways
Health-Care Reimbursement
Medicare and Medicaid
The Prospective Payment System
Managed Care
Health-Care Reform and the Patient Protection and 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
Continued Competency as Part of Career Development
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
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
Limitations of Organization Charts
Types of Organizational Structures
Decision Making Within the Organizational Hierarchy
Stakeholders
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
Organizational Effectiveness
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
The Authority–Power Gap
Mobilizing the Power of the Nursing Profession
An Action Plan for Increasing Professional Power in Nursing
Strategies for Building a Personal Power Base
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 Modes of Organizing Patient Care
Disease Management
Selecting the Optimum Mode of Organizing Patient Care
New Roles for the Changing Health Care Arena: Nurse Navigators, Clinical Nurse Leaders, and
Leaders in Patient-Centered Care
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 Imminent?
Supply and Demand Factors Leading to a Potential Nursing Shortage
Recruitment
Interviewing as a Selection Tool
Tips for the Interviewee
Selection
Placement
Indoctrination
Integrating Leadership Roles and Management Functions in Employee Recruitment, Selection,
Placement, and Indoctrination
Key Concepts
Additional Learning Exercises and Applications
16 Socializing and Educating Staff in a Learning Organization
The Learning Organization
Staff Development
Learning Theories
Assessing Staff Development Needs
Evaluation of Staff Development Activities
Shared Responsibility for Implementing Evidence-Based Practice
Socialization and Resocialization
Overcoming Motivational Deficiencies
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 Organization
Key Concepts
Additional Learning Exercises and Applications
17 Staffing Needs and Scheduling Policies
Unit Manager’s Responsibilities in Meeting Staffing Needs
Centralized and Decentralized Staffing
Complying With Staffing Mandates
Staffing and Scheduling Options
Workload Measurement Tools
The Relationship Between Nursing Care Hours, Staffing Mix, and Quality of Care
Managing a Diverse Staff
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
Creating a Motivating Climate
Strategies for Creating a Motivating Climate
Promotion: A Motivational Tool
Promoting Self-Care
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
The Communication Process
Variables Affecting Organizational Communication
Organizational Communication Strategies
Communication Modes
Elements of Nonverbal Communication
Verbal Communication Skills
Listening Skills
Written Communication Within the Organization
Technology as a Tool in Contemporary Organizational Communication
Communication, Confidentiality, and Health Insurance Portability and Accountability Act
Electronic Health Records and Meaningful Use
Group Communication
Group Dynamics
Integrating Leadership and Management in Organizational, Interpersonal, and Group Communication
Key Concepts
Additional Learning Exercises and Applications
20 Delegation
Delegating Effectively
Common Delegation Errors
Delegation as a Function of Professional Nursing
Subordinate Resistance to Delegation
Delegating to a Multicultural Work Team
Integrating Leadership Roles and Management Functions in Delegation
Key Concepts
Additional Learning Exercises and Applications
21 Effective Conflict Resolution 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
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
Union Representation of Nurses
American Nurses Association and Collective Bargaining
Employee Motivation to Join or Reject 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
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
Defining Quality Health Care
Quality Control as a Process
The Development of Standards
Audits as a Quality Control Tool
Standardized Nursing Languages
Quality Improvement Models
Who Should Be Involved in Quality Control?
Quality Measurement as an Organizational Mandate
Professional Standards Review Organizations
The Joint Commission
Centers for Medicare & Medicaid Services
National Committee for Quality Assurance
National Database of Nursing Quality Indicators
Report Cards
Medical Errors: An Ongoing Threat to Quality of Care
The Leapfrog Group
Six Sigma Approach and Lean Manufacturing
Reforming the Medical Liability System
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 Appraisal
Performance Appraisal Tools
Planning the Performance Appraisal Interview
Overcoming Appraisal Interview Difficulties
Performance Management
Coaching: A Mechanism for Informal Performance Appraisal
When Employees Appraise Their Manager’s Performance
Using 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
Disciplining the Unionized Employee
The Disciplinary Conference
The Termination Conference
Grievance Procedures
Transferring Employees
The Marginal Employee
The Chemically Impaired Employee
Recognizing the Chemically Impaired Employee
Integrating Leadership Roles and Management Functions When Dealing With Problem Employees
Key Concepts
Additional Learning Exercises and Applications
Appendix Solutions to Selected Learning Exercises
Index
1
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
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 humanities
MSN Essential IV: Translating and integrating scholarship into practice
AONE Nurse Executive Competency I: Communication and relationship building
AONE Nurse Executive Competency III: Leadership
ANA Standard of Professional Performance 13: Evidence-based practice and research
ANA Standard of Professional Performance 16: Resource utilization
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 situations
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 making
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
Introduction
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 a new 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.
BusinessDictionary.com (2016, para. 1) defines decision making as “the thought process of selecting a
logical choice from the available options.” 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 solve. 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. Dictionary.com (2016) defines critical thinking
as “the mental process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and
evaluating information to reach an answer or conclusion” (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.
DISPLAY
1.1
Open to New Ideas
Intuitive
Energetic
Analytical
Persistent
Assertive
Communicative
Characteristics of a Critical Thinker
Flexible
Empathetic
Caring
Observant
Risk taker
Resourceful
“Outside-the-box” thinker
Creative
Insightful
Willing to take action
Outcome directed
Willing to change
Knowledgeable
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 is a collaborative and
reflective process that involves content-specific knowledge, engagement of the patient and family in
understanding the clinical problem, and incorporation of critical contextual factors (Furze, Gale, Black,
Cochran, & Jensen, 2015). All of these factors lead to deliberative decision making and sound clinical
judgment. Thus, clinical reasoning uses both knowledge and experience to make decisions at the point of
care.
Vicarious Learning to Increase Problem-Solving and DecisionMaking 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 perspectives.
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 Learning
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.
In addition, simulation models are increasingly being used by schools of nursing to allow students the
opportunity to gain skill mastery before working directly with acutely ill and vulnerable clients. For
example, research by Shelestak, Meyers, Jarzembak, and Bradley (2015) found that the majority of
students who successfully recognized cues in human patient simulation were able to make correct
judgments and decisions in clinical practice (see Examining the Evidence 1.1). In addition, simulation
allows students to apply and improve the critically important “nontechnical” skills of communication,
teamwork, leadership, and decision making.
EXAMINING THE EVIDENCE 1.1
Source: Shelestak, D. S., Meyers, T. W., Jarzembak, J. M., & Bradley, E. (2015). A process to
assess clinical decision-making during human patient simulation: A pilot study. Nursing
Education Perspectives, 36(3), 185–187. doi:10.5480/13-1107.1
The purpose of this pilot study of senior nursing students was to describe
a process to measure clinical decision making and to examine clinical
judgment of nursing students using human patient simulation (HPS). A
total of 51 students participated in the study. Data were collected over six
simulation sessions, with 10 students in each group. Students alternated
between active participant and observer roles during the simulation; at
any given time, five students had active roles and five students were
observers.
A descriptive design was used to assess students’ understanding at
various critical decision points during an HPS. The HPS consisted of two
separate situations where changes in the patient’s condition warranted
action by the nurse. The scenario was developed using American Cardiac
Life Support (ACLS) guidelines for bradycardia and pulseless ventricular
algorithms. At Time 1, 49% correctly identified the situation; at Time 2,
71% correctly recognized the cues. The descriptive results of this pilot
study suggest that correctly identifying cues is foundational to clinical
decision making. The majority of students who correctly recognized cues
also provided correct judgments and decisions.
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 Model
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 approach.
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 management.
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. Finally, 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 examined.
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 problemsolving situations, and assessment of personal attitudes and values. Some exercises include opinions,
speculation, 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
Most people make decisions too quickly and fail to systematically examine a problem or its alternatives
for solution. Instead, most individuals rely on discrete, often unconscious processes known as heuristics,
which allows them to solve problems more quickly and to build on experiences they have gained in their
lives. Thus, heuristics use trial-and-error methods or a rule-of-thumb approach to problem solving rather
than set rules.
Although heuristics are often considered “second-best solutions” as a result of relying heavily on
intuition and nonscientific strategies, Bodemer, Hanoch, and Katsikopoulos (2015) suggest that heuristics
can actually be more accurate, faster, and easier to apply in comparison to more complex strategies. “This
holds particularly true for uncertain situations such as emergency medicine where knowledge, time, and
resources are limited. However, arguing for heuristics does not assume an argument against more
complex, statistical tools. The quality of any strategy depends on the environment” (p. 203).
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.)
DISPLAY
1.
2.
3.
4.
1.2
Traditional Problem-Solving Process
Identify the problem.
Gather data to analyze the causes and consequences of the problem.
Explore alternative solutions.
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-confidence.com (2006–2015) includes the six steps shown in Display 1.3.
DISPLAY
1.
2.
3.
4.
5.
6.
1.3
Managerial Decision-Making Model
Determine the decision and the desired outcome (set objectives).
Research and identify options.
Compare and contrast these options and their consequences.
Make a decision.
Implement an action plan.
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 their 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 decisionmaking 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).
DISPLAY
1.
2.
3.
4.
5.
1.4
Nursing Process
Assess.
Diagnose.
Plan.
Implement.
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.
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.
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
A more contemporary model for effective thinking and problem solving was developed by Park (2012)
upon review of 20 existing models for ethical decision making (Display 1.5). Although developed
primarily for use in solving ethical problems, the model also works well as a general problem-solving
model. Similar to 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 a means for evaluation. The model does go one step further, however,
in requiring the learner to specifically identify strategies that reduce the likelihood of a problem
recurring.
DISPLAY
1.
2.
3.
4.
5.
6.
1.5
Integrated Ethical Problem-Solving Model
State the problem.
Collect additional information and analyze the problem.
Develop alternatives and analyze and compare them.
Select the best alternative and justify your decision.
Develop strategies to successfully implement a chosen alternative and take action.
Evaluate the outcomes and prevent a similar occurrence.
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.
LEARNING EXERCISE
1.1
Applying Scientific Models to Decision Making
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.
ASSI GNM ENT:
Determine what you should do. 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 problemsolving 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 decision?
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 (Payne, 2015), although
intuition generally serves as an adjunct to decision making founded on a nurse’s scientific knowledge
base.
Pearson (2013) agrees, suggesting that intuition can and should be used in conjunction with evidencebased practice and that it deserves to be acknowledged as a factor in achieving good outcomes within
clinical practice. Pearson goes on to say that intuition is, in reality, often a rapid, automatic process of
recognizing familiar problems instantly and using experience to identify solutions. Thus, intuition may be
perceived as a cognitive skill rather than a perception or knowing without knowing how.
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 recognitionprimed 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 is allowed to 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.
Reiter-Palmon, Kennel, Allen, Jones, and Skinner (2015) explored naturalistic decision making in
health care by studying how after-action reviews (postfall huddles) could be utilized as a learning tool to
reduce errors. Their research found that these self-guided postfall huddles increased over the time of the
project, indicating adoption of the process and that the types of errors identified as contributing to patient
falls changed, with a reduction in task and coordination errors over time.
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.
DISPLAY
1.6
Critical Elements in Decision Making
1.
2.
3.
4.
5.
6.
Define objectives clearly.
Gather data carefully.
Take the time necessary.
Generate many alternatives.
Think logically.
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
her 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.
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 (2015) 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, 2015). 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.
DISPLAY
1.
2.
3.
4.
5.
6.
7.
8.
9.
1.7
Questions to Examine in Data Gathering
What is the setting?
What is the problem?
Where is it a problem?
When is it a problem?
Who is affected by the problem?
What is happening?
Why is it happening? What are the causes of the problem? Can the causes be prioritized?
What are the basic underlying issues? What are the areas of conflict?
What are the consequences of the problem? Which is the most serious?
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?
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 the 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.
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 datagathering 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 evidencebased practices (Prevost & Ford, 2017).
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 researchbased 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
(2017) 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, most 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.
DISPLAY
1.
2.
3.
4.
5.
6.
7.
8.
9.
1.8
Strategies for the New Nurse to Promote Evidence-Based
Best Practice
Keep abreast of the evidence—subscribe to professional journals and read widely.
Use and encourage use of multiple sources of evidence.
Use evidence not only to support clinical interventions but also to support teaching strategies.
Find established sources of evidence in your specialty—do not reinvent the wheel.
Implement and evaluate nationally sanctioned clinical practice guidelines.
Question and challenge nursing traditions and promote a spirit of risk taking.
Dispel myths and traditions not supported by evidence.
Collaborate with other nurses locally and globally.
Interact with other disciplines to bring nursing evidence to the table.
Source: Reprinted fromPrevost, S., & Ford, C. D. (2017). Evidence-based practice. In C. Huston (Ed.), Professional issues in nursing:
Challenges & opportunities (4th ed., pp. 17–27). 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, 2017). Too few nurses understand what best
practices and evidence-based practice are all 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, 2017). 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 designation.
Generate Many 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.
LEARNING EXERCISE
1.2
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.
ASSI GNM ENT:
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 good nurse-manager does not necessarily possess all the
same skills as a good 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 factors?
2. What are the financial implications in each alternative? 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 choices.
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 sensat…
Purchase answer to see full
attachment