ORGANIZATION AS THE OBJECT OF MANAGEMENT

ORGANIZATION AS THE OBJECT OF MANAGEMENT.

STRUCTURE OF AN ORGANIZATION

 

 

 

 

. . . The days of the traditional pyramid shaped corporate hierarchy as a viable business model are coming to an end.

—Michael Hugos

 

. . . in a changing world, organizations must change as surely as individuals must change. Recent years have seen an increase in organizational “flattening,” the tendency to shrink the organizational structure through the removal of layers of hierarchy.

—Charles R. McConnell

 

Consumers can guess the price of a Honda Accord within $1,000 of the cost, but they’re off by $12,000 for a four-day hospital stay.

—(Great-West Health Care, 2006)

 

 

LEARNING OBJECTIVES

The students shall:

•                     describe how the structure of an organization facilitates or impedes communication, flexibility, and job satisfaction

•                     identify characteristics of a bureaucracy as defined by Max Weber

•                     identify line and staff relationships, span of control, unity of command, and scalar chains on the organization chart

•                     describe components of the informal organization structure including employee interpersonal relationships, the formation of primary and secondary groups, and group leaders without formal authority

•                     differentiate between first, middle, and top levels of management

•                     compare and contrast centralized and decentralized decision making

•                     analyze how position on the organization chart is related to centrality

•                     describe at least one model of shared governance and differentiate it from participatory decision making

•                     contrast individual authority, responsibility, and accountability in given scenarios

•                     identify appropriate strategies the leader/manager may take to create a constructive organizational culture

•                     describe characteristics of effective committees and committee members

•                     define “group think” and discuss the impact of group think on organizational decision making and risk taking

•                     identify symptoms of poorly designed organizations

•                     describe characteristics of magnet designated healthcare organizations that exemplify the 14 forces of magnetism

•                     provide examples of an organization’s potential stakeholders

•                     describe the role of the nurse and other stakeholders in the health care system.

•                     discuss health care disparities that affect how people are advantaged or disadvantaged in accessing the health care system and the outcomes they experience as a result.

 

Organizing follows planning as the second phase of the management process and is explored in this unit. In the organizing phase, relationships are defined, procedures are outlined, equipment is readied, and tasks are assigned. Organizing also involves establishing a formal structure that provides the best possible coordination or use of resources to accomplish unit objectives. This topic looks at how the structure of an organization facilitates or impedes communication, flexibility, and job satisfaction, examines the role of authority and power in organizations and how power may be used to meet individual, unit, and organizational goals. It looks at how human resources can be organized to accomplish patient care.

 

 

 

FORMAL AND INFORMAL ORGANIZATIONAL STRUCTURE

 

Fayol (1949) suggested that an organization is formed when the number of workers is large enough to require a supervisor. Organizations are necessary because they accomplish more work than can be done by individual effort. Because people spend most of their lives in social, personal, and professional organizations, they need to understand how organizations are structured—their formation, methods of communication, channels of authority, and decisionmaking processes.

Each organization has a formal and an informal organizational structure. The formal structure is generally highly planned and visible, whereas the informal structure is unplanned and often hidden. Formal structure, through departmentalization and work division, provides a framework for defining managerial authority, responsibility, and accountability. In a well- defined formal structure, roles and functions are defined and systematically arranged, different people have differing roles, and rank and hierarchy are evident.

 

Organizational structure refers to the way in which a group is formed, its lines of communication, and its means for channeling authority and making decisions.

Informal structure is generally social, with blurred or shifting lines of authority and accountability. People need to be aware that informal authority and lines of communication exist in every group, even when they are never formally acknowledged. The primary emphasis of this topic, however, is the identification of components of organizational structure, the leadership roles and management functions associated with formal organizational structure, and the proper utilization of committees to accomplish organizational objectives (Display 12.1).

 

 

ORGANIZATIONAL THEORY

 

Max Weber, a German social scientist, is known as the father of organizational theory. Generally acknowledged to have developed the most comprehensive classic formulation on the characteristics of bureaucracy, Weber wrote from the vantage point of a manager instead of that of a scholar. During the 1920s, Weber saw the growth of the large-scale organization and correctly predicted that this growth required a more formalized set of procedures for administrators. His statement on bureaucracy, published after his death, is still the most influential statement on the subject.

Weber postulated three “ideal types” of authority or reasons why people throughout history have obeyed their rulers. One of these, legal-rational authority, was based on a belief in the legitimacy of the pattern of normative rules and the rights of those elevated to authority under such rules to issue commands. Obedience, then, was owed to the legally established impersonal set of rules rather than to a personal ruler. It is this type of authority that is the basis for Weber’s concept of bureaucracy.

 

Weber argued that the great virtue of bureaucracy—indeed, perhaps its defining characteristic—was that it was an institutional method for applying general rules to specific cases, thereby making the actions of management fair and predictable. Other characteristics of bureaucracies as identified by Weber include the following:

•                     There must be a clear division of labor (i.e., all work must be divided into units that can be undertaken by individuals or groups of individuals competent to perform those tasks).

•                     A well-defined hierarchy of authority must exist in which superiors are separated from subordinates; on the basis of this hierarchy, remuneration for work is dispensed, authority is recognized, privileges are allotted, and promotions are awarded.

•                     There must be impersonal rules and impersonality of interpersonal relationships. In other words, bureaucrats are not free to act in any way they please. Bureaucratic rules provide superiors systematic control over subordinates, thus limiting the opportunities for arbitrary behavior and personal favoritism.

•                     A system of procedures for dealing with work situations (i.e., regular activities to get a job done) must exist.

•                     A system of rules covering the rights and duties of each position must be in place.

•                     Selection for employment and promotion is based on technical competence.

Bureaucracy was the ideal tool to harness and routinize the energy and prolific production of the Industrial Revolution. Weber’s work did not, however, consider the complexity of managing organizations in the 21st century. Weber wrote during an era when worker motivation was taken for granted, and his simplification of management and employee roles did not examine the bilateral relationships between employee and management prevalent in most organizations today.

 

Current research suggests that changing an organization’s structure in a manner that increases autonomy and work empowerment for nurses will lead to more effective patient care.

 

Since Weber’s research, management theorists have learned much about human behavior, and most organizations have modified their structures and created alternative organizational designs that reduce rigidity and impersonality. Yet, almost 100 years after Weber’s findings, components of bureaucratic structure continue to be found in the design of most large organizations.

 

 

COMPONENTS OF ORGANIZATIONAL STRUCTURE

Weber also is credited with the development of the organization chart to depict an organization’s structure. Because the organization chart (Fig. 12.1) is a picture of an organization, the knowledgeable manager can derive much information from reading the chart. For example, an organization chart can help identify roles and their expectations.

 

Indeed, Cowen et al. (2008, p. 417) suggest that contemporary healthcare organizations face many challenges in determining how “to deploy and manage patient-focused interdisciplinary care teams, how to provide them with relevant and timely information, and how to connect them to the resources and priorities of the parent organization.” This necessitates knowing not only how these tasks must be accomplished but also who will complete them. Cowen et al. suggest that the organization chart can provide at least some of these answers since “structure provides the trestles over which disparate organizational entities cross the chasm” (p. 417).

In addition, by observing elements, such as which departments report directly to the chief executive officer (CEO), the novice manager can make some inferences about the organization. For instance, having the top-level nursing manager reporting to an assistant executive officer rather than the CEO might indicate the value (or lack thereof) the organization places oursing. Managers who understand an organization’s structure and relationships will be able to expedite decisions and have a greater understanding of the organizational environment.

 

 

Relationships and Chain of Command

The organization chart defines formal relationships within the institution. Formal relationships, lines of communication, and authority are depicted on a chart by unbroken (solid) lines. These line positions can be shown by solid horizontal or vertical lines. Solid horizontal lines represent communication between people with similar spheres of responsibility and power but different functions. Solid vertical lines between positions denote the official chain of command, the formal paths of communication and authority. Those having the greatest decisionmaking authority are located at the top; those with the least are at the bottom. The level of position on the chart also signifies status and power.

Dotted or broken lines on the organization chart represent staff positions. Because these positions are advisory, a staff member provides information and assistance to the manager but has limited organizational authority. Used to increase his or her sphere of influence, staff positions enable a manager to handle more activities and interactions than would otherwise be possible. These positions also provide for specialization that would be impossible for any one manager to achieve alone. Although staff positions can make line personnel more effective, organizations can function without them.

Advisory (staff) positions do not have inherent legitimate authority. Clinical specialists and in-service directors in staff positions often lack the authority that accompanies a line relationship. Accomplishing the role expectations in a staff position is therefore more difficult because typically little authority accompanies it. Because only line positions have authority for decision making, staff positions may result in an ineffective use of support services unless job descriptions and responsibilities for these positions are clearly spelled out.

Unity of command is indicated by the vertical solid line between positions on the organizational chart. This concept is best described as one person/one boss in which employees have one manager to whom they report and to whom they are responsible. This greatly simplifies the manager-employee relationship because the employee needs to maintain only a minimum number of relationships and accept the influence of only one person as his or her immediate supervisor.

 

Unity of command is difficult to maintain in some large healthcare organizations because the nature of healthcare requires a multidisciplinary approach.

 

Nurses frequently feel as though they have many bosses because healthcare typically involves a multidisciplinary approach. Additional possible bosses may include the immediate supervisor, the patient, the patient’s family, central administration, and the physician. All have some input in directing a nurse’s work. Weber was correct when he determined that a lack of unity of command results in some conflict and lost productivity. This is demonstrated frequently when healthcare workers become confused about unity of command.

 

LEARNING EXERCISE: Who’s the Boss?

In groups or individually, analyze the following and give an oral or written report.

1.          Have you ever worked in an organization in which the lines of authority were unclear? Have you been a member of a social organization in which this happened? How did this interfere with the organization’s functioning?

2.          Do you believe that the “one boss/one person” rule is a good idea? Don’t hospital clerical workers frequently have many bosses? If you have worked in a situation in which you had more than one boss, what was the result?

 

 

Span of Control

Span of control also can be determined from the organization chart. The number of people directly reporting to any one manager represents that manager’s span of control and determines the number of interactions expected of him or her.

Theorists are divided regarding the optimal span of control for any one manager. Quantitative formulas for determining the optimal span of control have been attempted; suggested ranges are from 3 to 50 employees. When determining an optimal span of control in an organization, the manager’s abilities, the employees’ maturity, task complexity, geographic location, and level in the organization at which the work occurs must all be considered. The number of people directly reporting to any one supervisor must be the number that maximizes productivity and worker satisfaction.

 

Too many people reporting to a single manager delays decision making, whereas too few results in an inefficient, top-heavy organization.

 

Until the last decade, the principle of narrow spans of control at top levels of management, with slightly wider spans at other levels, was widely accepted. Now, with increased financial pressures on healthcare organizations to remain fiscally solvent and electronic communication technology advances, many have increased their spans of control and reduced the number of administrative levels in the organization. This is often termed flattening the organization.

Kinnear (2009, para 2) suggests that it is the middle management which is at greatest risk for job elimination in flattened organizations. He argues that “traditionally, middle managers were required to receive and summarize information from the people in the organization below him/her and to pass it up to the executive teams above for decision and/ or action.” With the advent of information technology, managers are no longer needed to gather and summarize data, and instead, technology fulfills that role. Kinnear goes on to question whether organizational flattening has actually gone too far; however, he acknowledges that organizations that can minimize their costs without impacting service to their customers will not only be successful, but also in many ways better off than they were. He concludes that the trend to flatter, leaner, more technology-driven companies is likely to continue.

 

 

Managerial Levels

 

In large organizations, several levels of managers often exist. Top-level managers look at the organization as a whole, coordinating internal and external influences, and generally make decisions with few guidelines or structures. Examples of top-level managers include the organization’s chief operating officer (COO) or CEO and the highest-level nursing administrator. Current nomenclature for top-level nurse-managers varies; they might be called vice president of nursing or patient care services, nurse administrator, director of nursing, chief nurse, assistant administrator of patient care services, or chief nurse officer (CNO).

Some top-level nurse-managers may be responsible for nonnursing departments. For example, a top-level nurse-manager might oversee the respiratory, physical, and occupational therapy departments in addition to all nursing departments. Likewise, the CEO might have various titles, such as president or director. It is necessary to remember only that the CEO is the organization’s highest-ranking person, and the top-level nurse-manager is its highest- ranking nurse. Responsibilities common to top-level managers include determining the organizational philosophy, setting policy, and creating goals and priorities for resource allocation. Top-level managers have a greater need for leadership skills and are not as involved in routine daily operations as are lower-level managers.

Middle-level managers coordinate the efforts of lower levels of the hierarchy and are the conduit between lower and top-level managers. Middle-level managers carry out day-to-day operations but are still involved in some long-term planning and in establishing unit policies. Examples of middle- level managers include nursing supervisors, nurse-managers, head nurses, and unit managers.

Currently, there are many health facility mergers and acquisitions, and reduced levels of administration are frequently apparent within these consolidated organizations. Consequently, many healthcare facilities have expanded the scope of responsibility for middle-level managers and given them the title of “director” as a way to indicate new roles. The old term director of nursing, still used in many small facilities to denote the CNO, is now used in many healthcare organizations to denote a middle-level manager. The proliferation of titles among healthcare administrators has made it imperative that individuals understand what roles and responsibilities go with each position.

First-level managers are concerned with their specific unit’s work flow. They deal with immediate problems in the unit’s daily operations, with organizational needs, and with personal needs of employees. The effectiveness of first-level managers tremendously affects the organization. First-level managers need good management skills. Because they work so closely with patients and healthcare teams, first-level managers also have an excellent opportunity to practice leadership roles that will greatly influence productivity and subordinates’ satisfaction. Examples of first-level managers include primary care nurses, team leaders, case managers, and charge nurses. In many organizations, every RN is considered a first-level manager. All nurses in every situation must manage themselves and those under their care. A composite look at top-, middle-, and first-level managers is shown in Table 12.1.

One of the leadership responsibilities of organizing is to periodically examine the number of people in the chain of command. Organizations frequently add levels until there are too many managers. Therefore, the nursing manager should carefully weigh the advantages and disadvantages of adding a management level. For example, does having a charge nurse on each shift aid or hinder decision making? Does having this position solve or create problems?

 

Centrality

Centrality, or where a position falls on the organizational chart, is determined by organizational distance. Employees with relatively small organizational distance can receive more information than those who are more peripherally located. This is why the middle manager often has a broader view of the organization than other levels of management. A middle manager has a large degree of centrality because this manager receives information upward, downward, and horizontally.

 

 

Centrality refers to the location of a position on an organization chart where frequent and various types of communication occur.

 

Because all communication involves a sender and a receiver, messages may not be received clearly because of the sender’s hierarchical position. Similarly, status and power often influence the receiver’s ability to hear information accurately. An example of the effect of status on communication is found in the “principal syndrome.” Most people can recall panic, when they were school-age, at being summoned to the principal’s office. Thoughts of “what did I do?” travel through one’s mind. Even adults find discomfort in communicating with certain people who hold high status. This may be fear or awe, but both interfere with clear communication. The difficulties with upward and downward communication are discussed in more detail in Topic 19.

 

LEARNING EXERCISE

Change Is Coming

This learning exercise refers to the organization chart in Figure 12.1. Because Memorial Hospital is expanding, the Board of Directors has made several changes that require modification of the organization chart. The directors have just announced the following changes:

•                     The name of the hospital has been changed to Memorial General Hospital and Medical Center.

•                     State approval has been granted for open-heart surgery.

•                     One of the existing medical-surgical units will be remodeled and will become two critical care units (one six-bed coronary and open-heart unit and one six-bed trauma and surgical unit).

•                     A part-time medical director will be responsible for medical care on each critical care unit.

•                     The hospital administrator’s title has been changed to executive director.

•                     An associate hospital administrator has been hired.

•                     A new hospital-wide educational department has been created.

•                     The old pediatric unit will be remodeled into a seven-bed pediatric wing and a seven-bed rehabilitation unit.

•                     The director of nursing’s new title is vice president of patient care services.

ASSIGNMENT: If the hospital is viewed as a large, open system, it is possible to visualize areas where problems might occur. In particular, it is necessary to identify changes anticipated in the nursing department and how these changes will affect the organization as a whole. Depict all of these changes on the old organization chart, delineating both staff and line positions. Give the rationale for your decisions. Why did you place the education department where you did? What was the reasoning in your division of authority? Where do you believe there might be potential conflict in the new organization chart? Why?

 

 

It is important, then, to be aware of how the formal structure affects overall relationships and communication. This is especially true because organizations change their structure frequently, resulting iew communication lines and reporting relationships. Unless one understands how to interpret a formal organization chart, confusion and anxiety will result when organizations are restructured.

 

LEARNING EXERCISE

Cultures and Hierarchies

Having been with the county health department for 6 months, you are very impressed with the physician who is the county heath administrator She seems to have a genuine concern for patient welfare. She has a tea for new employees each month to discuss the department’s philosophy and her own management style. She says that she has an open-door policy, so employees are always welcome to visit her.

Since you have been assigned to the evening immunization clinic as charge nurse, you have become concerned wth a persistent problem. The housekeeping staff often spends part of the evening sleeping on duty or socializing for long periods. You have reported your concerns to your health department supervisor twice. Last evening, you found the housekeeping staff having another get together This mainly upsets you because the clinic is chronically ieed of cleaning. Sometimes, the public bathrooms get so untidy that they embarrass you and your staff. You frequently remind the housekeepers to empty overflowing waste paper baskets. You believe that this environment is demeaning to patients. This also upsets you because you and your staff work hard all evening and rarely have a chance to st down. You believe it is unfair to everyone that the housekeeping staff is not doing its share.

On your way to the parking lot this evening, the health administrator stops to chat and asks you how things are going. Should you tell her about the problem with the housekeeping staff? Is this following an appropriate chain of command? Do you believe that there is a conflict between the housekeeping unit’s culture and the nursing unit’s culture? What should you do? List choices and alternatives. Decide what you should do, and explain your rationale.

Note: Attempt to solve this problem before referring to a possible solution posted in the Appendix.

Is it ever appropriate to go outside the chain of command? Of course, there are isolated circumstances when the chain of command must be breached. However, those rare conditions usually involve a question of ethics. In most instances, those being bypassed in a chain of command should be forewarned. Remember that unity of command provides the organization with a workable system for procedural directives and orders so that productivity is increased and conflict is minimized.

 

 

TYPES OF ORGANIZATIONAL STRUCTURES

 

Traditionally, nursing departments have used one of the following structural patterns: bureaucratic, ad hoc, matrix, flat, or various combinations of these. The type of structure used in any healthcare facility affects communication patterns, relationships, and authority.

 

Line Structures

 

Bureaucratic organizational designs are commonly called line structures or line organizations. Those with staff authority may be referred to as staff organizations. Both of these types of organizational structures are found frequently in large healthcare facilities and usually resemble Weber’s original design for effective organizations. Because of most people’s familiarity with these structures, there is little stress associated with orienting people to these organizations. In these structures, authority and responsibility are clearly defined, which leads to efficiency and simplicity of relationships. The organization chart in Figure 12.1 is a line-and-staff structure.

These formal designs have some disadvantages. They often produce monotony, alienate workers, and make adjusting rapidly to altered circumstances difficult. Another problem with line and line-and-staff structures is their adherence to chain of command communication, which restricts upward communication. Good leaders encourage upward communication to compensate for this disadvantage. However, when line positions are clearly defined, going outside the chain of command for upward communication is usually inappropriate.

 

Ad Hoc Design

 

The ad hoc design is a modification of the bureaucratic structure and is sometimes used on a temporary basis to facilitate completion of a project within a formal line organization. The ad hoc structure is a means of overcoming the inflexibility of line structure and serves as a way for professionals to handle the increasingly large amounts of available information. Ad hoc structures use a project team or task approach and are usually disbanded after a project is completed. This structure’s disadvantages are decreased strength in the formal chain of command and decreased employee loyalty to the parent organization.

 

Matrix Structure

 

A matrix organization structure is designed to focus on both product and function. Function is described as all the tasks required to produce the product, and the product is the end result of the function. For example, good patient outcomes are the product, and staff education and adequate staffing may be the functions necessary to produce the outcome.

The matrix organization structure has a formal vertical and horizontal chain of command. Figure 12.2 depicts a matrix organizational structure and shows that the director of maternal child care could report both to a vice president for maternal and women’s services (product manager) and a vice president for nursing services (functional manager). Although there are less formal rules and fewer levels of the hierarchy, a matrix structure is not without disadvantages. For example, in this structure, decision making can be slow because of the necessity of information sharing, and it can produce confusion and frustration for workers because of its dual-authority hierarchical design. The primary advantage of centralizing expertise is frequently outweighed by the complexity of the communication required in the design.

 

Matrix organizational structure

 

 

 

Service Line Organization

 

Similar to the matrix design is service line organization, which can be used in some large institutions to address the shortcomings that are endemic to traditional large bureaucratic organizations. Service lines, sometimes called care-centered organizations, are smaller in scale than a large bureaucratic system. For example, in this organizational design, the overall goals would be determined by the larger organization, but the service line would decide on the processes to be used to achieve the goals.

 

Flat Designs

 

Flat organizational designs are an effort to remove hierarchical layers by flattening the chain of command and decentralizing the organization. In good times, when organizations are financially well off, it is easy to add layers to the organization in order to get the work done, but when the organization begins to feel a financial pinch, they often look at their hierarchy to see where they can cut positions.

In flattened organizations, there continues to be line authority, but because the organizational structure is flattened, more authority and decision making can occur where the work is being carried out. Figure 12.3 shows a flattened organizational structure. Many managers have difficulty letting go of control, and even very flattened types of structure organizations often retain many characteristics of a bureaucracy.

Flattened organizational structure

 

 

 

DECISION MAKING WITHIN THE ORGANIZATIONAL HIERARCHY

 

The decision-making hierarchy, or pyramid, is often referred to as a scalar chain. By reviewing the organization chart in Figure 12.1, it is possible to determine where decisions are made within the management hierarchy. Although every manager has some decision-making authority, its type and level are determined by the manager’s position on the chart.

In organizations with centralized decision making, a few managers at the top of the hierarchy make the decisions. Decentralized decision making diffuses decision making throughout the organization and allows problems to be solved by the lowest practical managerial level. Often, this means that problems can be solved at the level at which they occur. As a rule, larger organizations benefit from decentralized decision making.

 

In general, the larger the organization, the greater the need to decentralize decision making.

 

Decision making needs to be decentralized in large organizations because the complex questions that must be answered can best be addressed by a variety of people with distinct areas of expertise. Leaving such decisions in a large organization to a few managers burdens those managers tremendously and could result in devastating delays in decision making.

In fact, Hugos (2009, para 2) argues that contemporary organizations must “swear off that fatal tendency to organize themselves as hierarchical pyramids where most people are powerless drones who just follow orders while the important decisions are made by a small group of powerful executives at the top of the pyramid. Given the pace of change, no small group of executives regardless of their smarts, hard work or fancy computer systems can make all those decisions in a timely or competent manner.” In addition, individuals at the top of the hierarchy “are too far away from the scene of action to really understand what’s happening; and by the time decisions are made, they usually too little and too late” (Hugos, para 3).

STAKEHOLDERS

 

 

Stakeholders are those entities in an organization’s environment that play a role in the organization’s health and performance or that are affected by the organization. Stakeholders may be both internal and external, they may include individuals and large groups, and they may have shared goals or diverse goals. Internal stakeholders, for example, may include the nurse in a hospital or the dietitian in a nursing home. Examples of external stakeholders for an acute care hospital might be the local school of nursing, home health agencies, and managed care providers who contract with consumers in the area. Even the Chamber of Commerce in a city could be considered a stakeholder for a healthcare organization.

 

Every organization should be viewed as being part of a greater community of stakeholders.

 

Stakeholders have interests in what the organization does but may or may not have the power to influence the organization to protect their interests. Stakeholders’ interests are varied, however, and their interests may coincide on some issues and not others. Organizations do not choose their own stakeholders; rather, the stakeholders choose to have a stake in the organizations’ decisions. Stakeholders may have a supportive or threatening influence on organizational decision making. For many decisions an organization makes, it may face a diverse set of stakeholders with varied and conflicting interest and goals.

As a part of planned change, discussed in Topic 8, and decision making, discussed in Topic 1, a stakeholder analysis is an important aspect of the management process. Such an analysis should be performed when there is a need to clarify the consequences of decisions and changes. In addition to identifying stakeholders who will be impacted by a change, it is necessary to prioritize them and determine their influence. Astute leaders and managers must always be cognizant of who their stakeholders are and the impact they may have on an organization. A depiction of some possible stakeholders for a local community hospital appears in Display 12.2.

 

LIMITATIONS OF ORGANIZATION CHARTS

 

Because organization charts show only formal relationships, what they can reveal about an institution is limited. The chart does not show the informal structure of the organization. Every institution has in place a dynamic informal structure that can be powerful and motivating. Knowledgeable leaders never underestimate its importance because the informal structure includes employees’ interpersonal relationships, the formation of primary and secondary groups, and the identification of group leaders without formal authority. The informal structure, known as the grapevine, also has groups, leaders, and channels.

 

The informal structure also has its own leaders. In addition, it also has its own communication channels, often referred to as the grapevine.

 

These groups are important in organizations because they provide workers with a feeling of belonging. They also have a great deal of power in an organization; they can either facilitate or sabotage planned change. Their ability to determine a unit’s norms and acceptable behavior has a great deal to do with the socialization of new employees. Informal leaders are frequently found among long-term employees or people in select gatekeeping positions, such as the CNO’s secretary. Frequently, the informal organization evolves from social activities or from relationships that develop outside the work environment.

Organization charts are also limited in their ability to depict each line position’s degree of authority. Authority is defined as the official power to act. It is power given by the organization to direct the work of others. A manager may have the authority to hire, fire, or discipline others.

Equating status with authority, however, frequently causes confusion. The distance from the top of the organizational hierarchy usually determines the degree of status: the closer to the top, the higher the status. Status also is influenced by skill, education, specialization, level of responsibility, autonomy, and salary accorded a position. People frequently have status with little accompanying authority.

Because organizations are dynamic environments, an organization chart becomes obsolete very quickly. It also is possible that the organization chart may depict how things are supposed to be, when in reality, the organization is still functioning under an old structure because employees have not yet accepted new lines of authority.

Another limitation of the organization chart is that although it defines authority, it does not define responsibility and accountability. A responsibility is a duty or an assignment. It is the implementation of a job. For example, a responsibility common to many charge nurses is establishing the unit’s daily patient care assignment. Managers should always be assigned responsibilities with concomitant authority. If authority is not commensurate to the responsibility, role confusion occurs for everyone involved. For example, supervisors may have the responsibility of maintaining high professional care standards among their staff. If the manager is not given the authority to discipline employees as needed, however, this responsibility is virtually impossible to implement.

Accountability is similar to responsibility, but it is internalized. Thus, to be accountable means that individuals agree to be morally responsible for the consequences of their actions. Therefore, one individual cannot be accountable for another. Society holds us accountable for our assigned responsibilities, and people are expected to accept the consequences of their actions. A nurse who reports a medication error is being accountable for the responsibilities inherent in the position. Display 12.3 discusses the advantages and limitations of an organization chart.

The manager should understand the interrelationships and differences among these three terms. Because the use of authority, power building, and political awareness are so important to functioning effectively in any structure, Topic 13 discusses these organizational components in depth.

 

Advantages and Limitations of the Organization Chart

 

 

 

 

Organizational culture is the total of an organization’s values, language, traditions, customs, and sacred cows—those few things present in an institution that are not open to discussion or change. For example, the hospital logo that had been designed by the original board of trustees is an item that may not be considered for updating or change.

Similarly, BusinessDictionary.com (2009) defines organizational culture as “a pervasive, deep, largely subconscious, and tacit code that gives the ‘feel’ of an organization and determines what is considered right or wrong, important or unimportant, workable or unworkable in it, and how it responds to the unexpected crises, jolts, and sudden change” (para 1). Both of these definitions impart a sense of the complexity and importance of organizational culture.

 

Organizational culture is a system of symbols and interactions unique to each organization. It is the ways of thinking, behaving, and believing that members of a unit have in common.

 

Organizational culture should not, however, be confused with organizational climate— how employees perceive an organization. For example, an employee might perceive an organization as fair, friendly, and informal or as formal and very structured. The perception may be accurate or inaccurate, and people in the same organization may have different perceptions about the same organization. Therefore, since the organizational climate is the view of the organization by individuals, the organization’s climate and its culture may differ.

Although assessing unit culture is a management function, building a constructive culture, particularly if a negative culture is in place, requires the interpersonal and communication skills of a leader. The leader must take an active role in creating the kind of organizational culture that will ensure success. The more entrenched the culture and pattern of actions, the more challenging the change process is for the leader. Given such entrenchment of culture, success in building a new culture often requires new leadership and/or assistance by the use of outside analysis.

Organizations, if large enough, also have many different and competing value systems that create subcultures. These subcultures shape perceptions, attitudes, and beliefs and influence how their members approach and execute their particular roles and responsibilities. A critical challenge then for the nurse leader-manager is to recognize these subcultures and to do whatever is necessary to create shared norms and priorities. Managers must be able to assess their unit’s culture and choose management strategies that encourage a shared culture. Such transformation requires both management assessment and leadership direction.

Such was the case in research completed by Beehr, Glazer, Fischer, Linton, and Hansen (2009) exploring how best to foster alignment of organizational subunits’ processes and goals. Beehr et al. found that organizations must make a concerted effort to communicate, reinforce, and support their goals and objectives to their various subunits and to ensure that everyone shares a common perspective. They also suggested that an organization’s leaders must assume responsibility in supporting the organization’s goals and ensuring that the subunits of the organization are operating in a manner that is congruent with those goals (see Examining the Evidence 12.1).

In addition, much of an organization’s culture is not available to staff in a retrievable source and must be related by others. For example, feelings about collective bargaining, nursing education levels, nursing autonomy, and nurse-physician relationships differ from one organization to another. These beliefs and values, however, are rarely written down or appear in a philosophy. Therefore, in addition to creating a constructive culture, a major leadership role is to assist subordinates in understanding the organization’s culture. Display 12.4 identifies questions that leaders and followers should ask when assessing organizational culture.

 

 

Assessing the Organizational Culture

 

 

 

Findings suggested that managerial effectiveness, communication about goals and objectives, and employee enhancement positively related with alignment at a group or subunit level. Alignment, in turn, positively related with company satisfaction at an individual level. The researchers concluded that in order to achieve goals, organizations must make a concerted effort to communicate, reinforce, and support their goals and objectives to their various subunits and ensure that everyone shares a common perspective. They also suggested that an organization’s leaders must assume responsibility in supporting the organization’s goals and ensuring that the subunits of the organization are operating in a manner that is congruent with those goals. In addition, the organization must afford all its employees opportunities for growth through feedback, training, encouraging decision making, risk taking, and teamwork.

 

 

SHARED GOVERNANCE: ORGANIZATIONAL DESIGN FOR THE 2IST CENTURY?

 

Shared governance, one of the most innovative and idealistic of organization structures, was developed in the mid-1980s as an alternative to the traditional bureaucratic organizational structure. A flat type of organizational structure is often used to describe shared governance but differs somewhat, as shown in Figure 12.4. In shared governance, the organization’s governance is shared among board members, nurses, physicians, and management. Thus, decision-making and communication channels are altered. Group structures, in the form of joint practice committees, are developed to assume the power and accountability for decision making, and professional communication takes on an egalitarian structure.

 

 

 

Shared governance model

 

In healthcare organizations, shared governance empowers decision makers, and this empowerment is directed at increasing nurses’ authority and control over nursing practice. Shared governance thus gives nurses more control over their nursing practice by being an accountability-based governance system for professional workers.

The stated aim of shared governance is the empowerment of employees within the decision-making system.

Although participatory management lays the foundation for shared governance, they are not the same. Participatory management implies that others are allowed to participate in decision making over which someone has control. Thus, the act of “allowing” participation identifies the real and final authority for the participant.

There is no single model of shared governance, although all models emphasize the empowerment of staff nurses. Generally, issues related to nursing practice are the responsibility of nurses, not managers, and nursing councils are used to organize governance. These nursing councils, elected at the organization and unit levels, use a congressional format organized like a representative form of government, with a president and cabinet.

A sample operational framework of an organization using shared governance is shown in Figure 12.5. In this model, from Wake Forest University Baptist Medical Center (n.d.), there are four governance councils and a coordinating council. The governance councils are the Practice Council, Professional Development Council, Quality Council, and Leadership Council. The councils participate in decision making and coordination of the department of nursing and provide input through the shared governance process in all other areas where nursing care is delivered.

 

 

Sample nursing councils in a shared governance model

 

 

The number of healthcare organizations using shared governance models continues to increase. However, a major impediment to the implementation of shared governance has been the reluctance of managers to change their roles. The nurse-manager’s role becomes one of consulting, teaching, collaborating, and creating an environment with the structures and resources needed for the practice of nursing and shared decision making betweeurses and the organization. This new role is foreign to many managers and difficult to accept. In addition, consensus decision making takes more time than autocratic decision making, and not all nurses want to share decisions and accountability. Although many positive outcomes have been attributed to implementation of shared governance, the expense of introducing and maintaining this model also must be considered because it calls for a conscientious commitment both on the part of the workers and the organization.

 

Shared governance requires a substantial and long-term commitment on the part of the workers and the organization.

MAGNET DESIGNATION AND PATHWAY TO EXCELLENCE

 

During the early 1980s, the American Academy of Nursing (AAN) began conducting research to identify the characteristics of hospitals that were able to successfully recruit and retain nurses. What they found were high-performing hospitals with well-qualified nurse executives in a decentralized environment, with organizational structures that emphasized open, participatory management.

A desire to formally recognize these high-performing hospitals was accomplished when the AAN established the American Nurses Credentialing Center (ANCC) in 1990. Later the same year, the American Nurses Association (ANA) Board of Directors approved the establishment of the Magnet Hospital Recognition Program for Excellence in Nursing Services and the ANCC was developing the criteria for, reviewing applications, and awarding the coveted “magnet” status to high-performing organizations. The term “magnet” was used to denote organizations that were able to attract and retain professional nurses (The Magnet Recognition Program, 2008).

Earning a magnet designation is not easy. To achieve designation as an organization, first, the organization must create and promote a comprehensive professional practice culture. Then, it must apply to ANCC, submit comprehensive documentation that demonstrates its compliance with standards in the ANA Scope and Standards for Nurse Administrators, and undergo a multiday onsite evaluation to verify the information in the documentation submitted and to assess the presence of the 14 “forces of magnetism” (Display 12.5) within the organization (Pinkerton, 2008). “Approximately 80% of those who submit an application follow through to submit written documentation for the first phase of the facility appraisal. Of those who submit written documentation about 80% progress to a site visit” (ANCC, 2009b). Magnet status is awarded for a 4-year period, after which the organization must reapply.

Currently, magnet recognition is awarded both to individual organizations (not just hospitals) as well as to systems (Pinkerton, 2008). To achieve designation as a system, the system must not only retain the 14 forces of magnetism required for individual organizations, they must also demonstrate empirical modeling of five key components: transformational leadership; structural empowerment; exemplary professional practice; new knowledge innovation and improvements; and empirical quality results (Pinkerton). In addition, all parts of the system are judged as one when seeking system designation, so if one entity within the system fails, the entire system application will be denied (Pinkerton).

 

The 14 Forces of Magnetism for Magnet Hospital Status

 

 

 

Growth in the number of magnet designated organizations has been geometric and more than 90 magnet designations were awarded in 2009 alone (ANCC, 2009b). Currently, approximately 6.2% of all healthcare organizations in the United States have achieved ANCC Magnet Recognition® status (ANCC, 2009b).

A driving force to achieve magnet status is the clear link between this designation and improved outcomes. Fifteen out of the top 21 medical centers featured in the 2009 U.S. News & World Report showcase of “America’s Best Hospitals,” were magnet-recognized organizations (ANCC, 2009a). In the Children’s Hospital Honor Roll, 9 of the top 10 (90%) hospitals were ANCC magnet recognized (ANCC, 2009a).

In addition, ANCC established the Pathway to Excellence program in 2003, based on findings from the Texas Nurse-Friendly™ Program for Small/Rural Hospitals. The Pathway to Excellence designation, ideally suited to small- and medium-sized healthcare organizations, is earned by organizations that are committed to nurses, to what nurses identify as important to their practice, and to valuing nurses’ contributions in the workplace. To earn the Pathway to Excellence designation, organizations must undergo a thorough review process that “documents foundational quality initiatives in creating a positive work environment—as defined by nurses and supported by research. These initiatives must be present in the facility’s practices, policies, and culture. Nurses in the organization verify the presence of the criteria in the organization through participation in a completely confidential online survey” (ANCC, 2009c, para 7).

 

 

LEARNING EXERCISE

Why Work for Them?

A list of current magnet recognized organizations and their contact information can be found at the ANCC Web site: http://www.nursecredentialing.arg/MagnetOrg/getall.cfm.

ASSIGNMENT: Select one of the current organizations, and prepare a one-page written report about how that particular organization demonstrates the excellence exemplified by magnet status. Speak to at least five of the “forces of magnetism.” Would you want to work for this particular organization?

 

 

COMMITTEE STRUCTURE IN AN ORGANIZATION

 

Managers also are responsible for designing and implementing appropriate committee structures. Poorly structured committees can be nonproductive for the organization and frustrating for committee members. However, there are many benefits to and justifications for well-structured committees. To compensate for some of the difficulty in organizational communication created by line and line-and-staff structures, committees are used widely to facilitate upward communication. The nature of formal organizations dictates a need for committees in assisting with management functions. In addition, as organizations seek new ways to revamp old bureaucratic structures, committees may pave the road to increased staff participation in organization governance. Committees may be advisory or may have a coordinating or informal function. They generate ideas and creative thinking to solve operational problems or improve services and often improve the quality and quantity of work accomplished. Committees also can pool specific skills and expertise and help to reduce resistance to change.

 

Because committees communicate upward and downward and encourage the participation of interested or affected employees, they assist the organization in receiving valuable feedback and important information.

 

However, all of these positive benefits can be achieved only if committees are appropriately organized and led. If not properly used, the committee becomes a liability to the organizing process because it wastes energy, time, and money and can defer decisions and action. One of the leadership roles inherent in organizing work is to ensure that committees are not used to avoid or delay decisions but to facilitate organizational goals. Display 12.6 lists factors to consider when organizing committees.

 

 

RESPONSIBILITIES AND OPPORTUNITIES OF COMMITTEE WORK

 

Committees present the leader-manager with many opportunities and responsibilities. Managers need to be well grounded in group dynamics because meetings represent a major time commitment. Managers serve as members of committees and as leaders or chairpersons

 

 

Factors to Consider When Organizing Committees and Making Appointments

 

 

 

The committee should be composed of people who want to contribute in terms of commitment, energy, and time.

The members should have a variety of work experience and educational backgrounds. Composition should, however, ensure expertise sufficient to complete the task. Committees should have enough members to accomplish assigned tasks but not so many that discussion cannot occur. Six to eight members is usually ideal.

The tasks and responsibilities, including reporting mechanisms, should be clearly outlined. Assignments should be given ahead of time, with clear expectations that assigned work will be discussed at the next meeting.

All committees should have written agendas and effective committee chairpersons. of committees. Because committees make major decisions, managers should use the opportunities available at meetings to become more visible in the larger organization. The manager has a responsibility to select appropriate power strategies, such as coming to meetings well prepared, and to use skill in the group process to generate influence and gain power at meetings.

Another responsibility is to create an environment at unit committee meetings that leads to shared decision making. Encouraging an interaction free of status and power is important. Likewise, an appropriate seating arrangement, such as a circle, will increase motivation for committee members to speak up. The responsible manager is also aware that staff from different cultures may have different needs in groups, which is why multicultural committees should be the norm. In addition, because gender differences are increasingly being recognized as playing a role in problem solving, communication, and power, efforts should be made to include both men and women on committees.

 

When assigning members to committees, cultural and gender diversity should always be a goal.

 

The manager must not rely too heavily on committees or use them as a method to delay decision making. Numerous committee assignments exhaust staff, and committees then become poor tools for accomplishing work. An alternative that will decrease the time commitment for committee work is to make individual assignments and gather the entire committee only to report progress.

In the leadership role, an opportunity exists for important influence on committee and group effectiveness. A dynamic leader inspires people to put spirit into working for a shared goal. Leaders demonstrate their commitment to participatory management by how they work with committees. Leaders keep the committee on course. Committees may be chaired by an elected member of the group, appointed by the manager, or led by the department or unit manager. Informal leaders also may emerge from the group process.

It is important for the manager to be aware of the possibility for groupthink to occur in any group or committee structure. Groupthink occurs when group members fail to take adequate risks by disagreeing, being challenged, or assessing discussion carefully. If the manager is actively involved in the work group or on the committee, groupthink is less likely to occur. The leadership role includes teaching members to avoid groupthink by demonstrating critical thinking and being a role model who allows his or her own ideas to be challenged.

 

 

ORGANIZATIONAL EFFECTIVENESS

 

There is no one “best” way to structure an organization. Variables such as the size of the organization, the capability of its human resources, and the commitment level of its workers should always be considered. Regardless of what type of organizational structure is used, certain minimal requirements can be identified:

•           The structure should be clearly defined so that employees know where they belong and where to go for assistance.

•           The goal should be to build the fewest possible management levels and have the shortest possible chain of command. This eliminates friction, stress, and inertia.

•           The unit staff need to be able to see where their tasks fit into common tasks of the organization.

•           The organizational structure should enhance, not impede communication.

•           The organizational structure should facilitate decision making that results in the greatest work performance.

•                     Staff should be organized in a manner that encourages informal groups to develop a sense of community and belonging.

•                     Nursing services should be organized to facilitate the development of future leaders.

 

Despite the known difficulties of bureaucracies, it has been difficult for some organizations to move away from the bureaucratic model. However, perhaps as a result of magnet hospital research demonstrating both improved patient outcomes and improved recruitment and retention of staff, there has been an increasing effort to redesign and restructure organizations to make them more flexible and decentralized. Still, progress toward these goals continues to be slow.

 

 

INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS ASSOCIATED WITH ORGANIZATIONAL STRUCTURE

 

Integrated leader-managers need to look at organizational structure as the road map that tells them how organizations operate. Without organizational structure, people would work in a chaotic environment. Structure becomes an important tool, then, to facilitate order and enhance productivity.

Astute leader-managers understand both the structure of the organization in which they work as well as external stakeholders. The integrated leader-manager, however, goes beyond personal understanding of the larger organizational design. The leader-manager takes responsibility for ensuring that subordinates also understand the overall organizational structure and the structure at the unit level. This can be done by being a resource and a role model to subordinates. The role modeling includes demonstrating accountability and the appropriate use of authority.

The effective manager recognizes the difficulties inherent in advisory positions and uses leadership skills to support staff in these positions. This is accomplished by granting sufficient authority to enable advisory staff to carry out the functions of their role.

Leadership requires that problems are pursued through appropriate channels, that upward communication is encouraged, and that unit structure is periodically evaluated to determine if it can be redesigned to enable increased lower-level decision making. The integrated leader- manager also facilitates constructive informal group structure. It is important for the manager to be knowledgeable about the organization’s culture and subcultures. It is just as important for the leader to promote the development of a shared constructive culture with subordinates.

It is a management role to evaluate types of organizational structure and governance and to implement those that will have the most positive impact in the department. It is a leadership skill to role model the shared authority necessary to make newer models of organizational structure and governance possible.

When serving on committees, the opportunity should be used to gain influence to present the needs of patients and staff appropriately. The integrated leader-manager comes to meetings well prepared and contributes thoughtful comments and ideas. The leader’s critical thinking and role-modeling behavior discourages groupthink among work groups or in committees.

Integrated leader-managers also refrain from judging and encourage all members of a committee to participate and contribute. An important management function is to see that appropriate work is accomplished in committees, that they remain productive, and that they are not used to delay decision making. A leadership role is the involvement of staff in organizational decision making, either informally or through more formal models of organizational design, such as shared governance. The integrated leader-manager understands the organization and recognizes what can be molded or shaped and what is constant. Thus, the interaction between the manager and the organization is dynamic.

 

 

 

 

 

KEY CONCEPTS

 

·        Many modern healthcare organizations continue to be organized around a line or line-and- staff design and have many attributes of a bureaucracy; however, there is a movement toward less bureaucratic designs, such as ad hoc, matrix, or care-centered systems.

·        A bureaucracy, as proposed by Max Weber, is characterized by a clear chain of command, rules and regulations, specialization of work, division of labor, and impersonality of relationships.

·        An organization chart depicts formal relationships, channels of communication, and authority through line-and-staff positions, scalar chains, and span of control.

·        Unity of command means that each person should have only one boss so that there is less confusion and greater productivity.

·        Centrality refers to the degree of communication of a particular management position.

·        In centralized decision making, decisions are made by a few managers at the top of the hierarchy. In decentralized decision making, decision making is diffused throughout the organization, and problems are solved at the lowest practical managerial level. Organizational structure affects how people perceive their roles and the status given to them by other people in the organization.

·        Organizational structure is effective when the design is clearly communicated, there are as few managers as possible to accomplish goals, communication is facilitated, decisions are made at the lowest possible level, informal groups are encouraged, and future leaders are developed.

·        The entities in an organization’s environment that play a role in the organization’s health and performance, or which are affected by the organization, are called stakeholders. Authority, responsibility, and accountability differ in terms of official sanctions, self- directedness, and moral integration.

·        Organizational culture is the total of an organization’s beliefs, history, taboos, formal and informal relationships, and communication patterns.

·        Subunits of large organizations also have a culture. These subcultures may support or be in conflict with other cultures in the organization.

·        Informal groups are present in every organization. They are often powerful, although they have no formal authority. Informal groups determine norms and assist members in the socialization process.

·        Shared governance refers to an organizational design that empowers staff nurses by making them an integral part of patient care decision making and providing accountability and responsibility iursing practice.

·        Magnet designation is conferred by the ANCC to healthcare organizations exemplifying well-qualified nurse executives in a decentralized environment, with organizational structures that emphasize open, participatory management. Magnet designated organizations demonstrate improved patient outcomes and higher staff nurse satisfaction than organizations which do not have magnet status.

·        The Pathway to Excellence designation, also conferred by the ANCC, recognizes healthcare organizations with foundational quality initiatives in creating a positive work environment, as defined by nurses and supported by research.

·        Too many committees in an organization is a sign of a poorly designed organizational structure.

·        Committees should have an appropriate number of members, prepared agendas, clearly outlined tasks, and effective leadership if they are to be productive.

·        Groupthink occurs when there is too much conformity to group norms.

 

Decision making, then, is both an innermost leadership activity and the core of management. This topic 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 topic 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, AND CRITICAL THINKING

Decision making is a complex, cognitive process often defined as choosing a particular course of action. Encarta World English Dictionary (2009a) defines decision making as “the process of making choices or reaching conclusions” (para 1). Both definitions imply that there was doubt about several courses of action and that a choice was made that eliminated the 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 manner that does not focus on eliminating the underlying problem. For example, if a person decided to handle a conflict crisis 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 sooo 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 (2009) 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 upon the meaning of statements, examining the offered evidence and reasoning, and forming judgments about facts. 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 a cognitive and affective component. 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.

 

 

 

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

 

 

VICARIOUS LEARNING TO INCREASE PROBLEM-SOLVING AND DECISION-MAKING SKILLS

 

Decision making, one step in the problem-solving process, is an important task that relies heavily on critical thinking 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 are seldom presented within the context of real-life situations.

 

 

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 address problems. Indeed, research done by Lunney (2008) concluded that case studies provided a positive experience in learning how to vicariously diagnose and select appropriate health outcomes and nursing interventions. Tanner (2009) agrees, suggesting that case-based teaching, as a “cluster of similar teaching approaches, holds great promise for helping students develop habits of thought as they learn from experience” (p. 300).

Similarly, simulation models are increasingly being used by schools of nursing to allow students the opportunity to apply knowledge and gain skill mastery before working directly with acutely ill and vulnerable clients. In fact, Schiavenato (2009) suggests that the human patient simulator or high-fidelity mannequin has become synonymous with the word “simulation” iursing education, although she cautions that evidence validating its application is limited. She also suggests that greater direction is needed as to simulation’s role and place iursing education.

 

 

Examining the Evidence I. I

Source: Ozturk, C., Muslu, G., & Dicle, A. (2008, July). A comparison of problem-based and traditional education oursing students’ critical thinking dispositions. Nurse Education Today, 28(5), 627-632.

This descriptive, analytic study compared levels of critical thinking among senior nursing students (N = 147) in two educational programs, one which used a PBL model and one which used a traditional model. The California Critical Thinking Disposition Inventory was used as a data collection tool and comparisons were made between the groups using t-test analysis. Significant differences (p < 0.05) were found between the critical thinking disposition scores of the seniors in the PBL school and those in the school implementing the traditional model. Analysis of subscale scores showed significant differences in truth-seeking and open-mindedness. The authors concluded that this research adds to the evidence that the active and self-directed nature of PBL encourages students’ ability to think critically, be tolerant of the ideas of others, and evaluate conflicting information before reaching a conclusion.

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. Learning is collaborative as the teacher guides the students to be selfdirected in their learning, and many experts suggest that this helps to develop critical thinking skills. This certainly was the case in research done by Ozturk, Muslu, and Dicle (2008) (Examining the Evidence 1.1).

 

 

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, while formal instruction in critical thinking is important, using a formal decisionmaking 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 topic; 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.

 

 

 

 

 

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

 

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

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 upon experiences they have gained in their lives. Thus, heuristics use trial and error methods or a rules of thumb approach, rather than set rules, and in doing so, encourages learners to discover solutions for themselves (Encarta World English Dictionary, 2009b). Facione (2006) recognizes the value of heuristics in decision making but warns that heuristics are only shortcuts, not fail-safe rules, and that relying on heuristics may work most of the time but will not be the best all of the time.

In contrast, 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 critical 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.

 

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

 

To improve decision-making ability, it is important to use an adequate process model as the theoretical base for understanding and applying critical thinking skills. Many acceptable problem-solving models exist, and most include a decision-making step; only four are reviewed here.

 

 

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 follow. (Decision-making occurs at step 5.)

1.           Identify the problem.

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

3.           Explore alternative solutions.

4.            Evaluate the alternatives.

5.            Select the appropriate solution.

6.            Implement the solution.

7.            Evaluate the results.

 

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

 

 

Managerial Decision-Making Models

To address the weaknesses of the traditional problem-solving process, many contemporary models for management decision making have added an objective-setting step. These models are known as managerial decision-making models or rational decision-making models. One such model suggested by Decision-making-confidence.com (n.d.) includes the following steps:

1.           Determine the decision and the desired outcome (set objectives).

2.            Research and identify options.

3.           Compare and contrast these options and their consequences.

4.            Make a decision.

5.            Implement an action plan.

6.            Evaluate results.

 

In the first step, problem solvers must identify the decision to be made, who needs to be involved in the decision process, the timeline for the decision, and the goals or outcomes that should be achieved. Identifying objectives to guide the decision making help 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 decision-making grids or payoff tables (discussed further later in this topic), 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.

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 iot 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.

 

 

LEARNING EXERCISE:

Restructuring—In Depth

You are the supervisor at a home health agency. There are 22 RNs in your span of control. In a meeting today, John Dao, the CNO, tells you that your span of control needs adjustment to be effective. Therefore, the CNO has decided to flatten the organization and decentralize the department. To accomplish this, he plans to designate three of your staff as shift coordinators. These shift coordinators will “schedule patient visits for all the staff on their shift and be accountable for the staff that they supervise.” The CNO believes that this restructuring will give you more time for implementing a continuous quality improvement (CQI) program and promoting staff development.

Although you are glad to have the opportunity to begin these new projects, you are somewhat unclear about the role expectations of the new shift coordinators and how this will change your job description. In fact, you worry that this is just a precursor to the elimination of your position. Will these shift coordinators report to you? If so, will you have direct line authority or staff authority? Who should be responsible for evaluating the performance of the staff nurses now? Who will handle employee disciplinary problems? How involved should the shift coordinators be in strategic planning or determining next year’s budget? What types of management training will be needed by the shift coordinators to prepare for their new role? Are you the most appropriate person to train them?

ASSIGNMENT: There is great potential for conflict here. In small groups, make a list of 10 questions (not including the ones listed in the learning exercise) that you would want to ask the CNO at your next meeting to clarify role expectations. Discuss tools and skills that you have learned in the preceding units that could make this role change less traumatic for all involved.

 

 

 

LEARNING EXERCISE

Problem Solving: Working Toward Shared Governance

 

You are the supervisor of a surgical services department in a nonunion hospital. The staff on your unit have become increasingly frustrated with hospital policies regarding staffing ratios, on-call pay, and verbal medical orders but feel that they have limited opportunities for providing feedback to change the current system. You would like to explore the possibility of moving toward a shared governance model of decision making to resolve this issue and others like it but are not quite sure where to start.

ASSIGNMENT: Assume that you are the supervisor in this case. Answer the following questions.

1.  Who do I need to involve in this discussion and at what point?

2.  How might I determine if the overarching organizational structure supports shared governance? How would I determine if external stakeholders would be impacted? How would I determine if organizational culture and subculture would support a shared governance model?

3.  What types of nursing councils might be created to provide a framework for operation?

4.  Who would be the members on these nursing councils?

5.  What support mechanisms would need to be in place to ensure success of this project?

6.  What would be my role as a supervisor in identifying and resolving employee concerns in a shared governance model?

 

 

LEARNING EXERCISE:

Finding Direction

 

You are a new graduate working in the 3 pm to 11 pm shift in a large, metropolitan hospital on the pediatrics unit. You feel frustrated because you had many preceptors while you were being oriented, and each told you slightly different variations of the unit routine. In addition, the regular charge nurse has just been promoted and moved to another unit, and the charge nurse position on your unit is being filled by two part-time nurses.

You feel inadequately prepared for the job and do not know where to turn or to whom you should direct your questions. Assuming that your organization chart resembles the one in Figure 12.1, outline a plan of action that would be appropriate to take. Share your plan with a larger group.

 

 

LEARNING EXERCISE:

Thinking About Committee Work

 

As a writing exercise, choose one of the following to examine in depth:

1.                  What has contributed to the productivity of the committees on which you have served?

2.                  Have you ever served on a committee that made recommendations on which higher authority never acted? What was the effect on the group?

 

 

LEARNING EXERCISE

Participation and Productivity

You are a 3 pm to 11 pm charge nurse on a surgical unit. You have been selected to chair the unit’s safety committee. Each month, you have a short committee meeting with the other committee members. Your committee’s main responsibility is to report upward any safety issues that have been identified. Lately, you have found an increase ieedle-stick incidents, and the committee has been addressing this problem.

The committee is made up of two nursing assistants, one unit clerk, two staff RNs, and two LPN/ LVNs. All shifts and staff cultures are represented. Lately, you have found that the meetings are not going well because one member of the group, Mary, has begun to monopolize the meeting time. She is especially outspoken about the danger of HIV and seems more interested in pointing blame regarding the needle sticks than in finding a solution to the problem.

You have privately spoken to Mary about her frequent disruption of the committee business; although she apologized, the behavior has continued. You feel that some members of the committee are becoming bored and restless, and you believe that the committee is making little progress.

ASSIGNMENT: Using your knowledge of committee structure and effectiveness, outline steps that you would take to facilitate more group participation and make the committee more productive. Be specific, and explain exactly what you would do at the next meeting to prevent Mary from taking over the meeting.

 

 

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