DECISION-MAKING AND CRITICAL THINKING IN MANAGEMENT
. . . the successful nurse executive has the ability to make good decisions consistently.
—Thomas R. Clancy
. . . 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
LEARNING OBJECTIVES
The students shall:
• differentiate between problem solving, decision making, and critical thinking
• explore strengths and limitations of using intuition and heuristics as adjuncts to problem solving and decision making
• identify characteristics of successful decision makers
• select appropriate models for decision making in specific situations
• describe the importance of the individual in the decision-making process
• identify critical elements of decision making
• explore his or her personal propensity for risk taking
• discuss the effect of organizational power on 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 which might suggest using one decision style over another
Decision making is often thought to be synonymous with management and is one of the criteria on which management expertise is judged. Much of any manager’s time is spent critically examining issues, solving problems, and making decisions. The quality of the decisions that leader-managers make is the factor that often weighs most heavily in their success or failure.
Decision making, then, is both an innermost leadership activity and the core of management. This 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.
The IDEALS Model
A more contemporary model for effective thinking and problem solving was developed by Facione (2006). The IDEALS model, as it came to be known, includes six steps for effective thinking and problem solving. While similar to the models already presented, the mnemonic IDEALS makes this model easy to remember and use:
Identify the problem. “What’s the real question we’re facing here?”
Define the context. “What are the facts and circumstances that frame this problem?” Enumerate choices. “What are our most plausible three or four options?”
Analyze options. “What is our best course of action, all things considered?”
List reasons explicitly. “Let’s be clear: Why are we making this particular choice?”
Self-correct. “Okay, let’s look at it again. What did we miss?” (p. 22).
Many other excellent problem analysis and decision models exist. The model selected should be one with which the decision maker is familiar and one appropriate for the problem to be solved. Using models or processes consistently will increase the likelihood that critical analysis will occur. Moreover, the quality of management/leadership problem solving and decision making will improve tremendously via a scientific approach.
Intuitive Decision-Making Model
There are theorists who suggest that intuition should always be used as an adjunct to empirical or rational decision-making models. Ward (2009) suggests that learning to harness one’s instincts and intuition helps individuals make better decisions in all areas of their lives, and indeed, Aloi (2006) suggests that many expert nurses use intuition in solving problems. Experienced nurses often report that gut-level feelings encourage them to take appropriate strategic action that impacts patient outcomes. Aloi warns, however, that the dark side of intuition is misjudgment and that intuition should serve only as an adjunct to decision making founded ourse’s scientific knowledge base.
Contemporary leaders in the field of intuitive decision-making research include Dr. Gary Klein. Klein and his colleagues developed the Recognition-Primed Decision (RPD) model for intuitive decision making in the mid-1980s to explain how people can make effective decisions under time pressure and uncertainty. Considered a part of naturalistic decision making, the RPD model attempts to understand how humans make relatively quick decisions in complex, real-world settings such as firefighting or critical care nursing without having to compare options (Klein, 2008).
Klein’s 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. Recent research conducted by Patterson, Pierce, Fournier, Winterbottom, and Tripp (2009) expanded upon Klein’s work and concludes that a model incorporating conjunction benefits and costs with RPD could potentially be used in the development of decision support tools and training aids.
LEARNING EXERCISE
Applying Scientific Models to Decision Making
You are a registered nurse (RN) who graduated 3 years ago. During the last 3 years, your responsibilities in your first position have increased. Although you enjoy your family (spouse and one preschool-aged child), you realize that you love your job and that your 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 wanted to reduce your work time and spend more time at home with the children. Last week, your supervisor told you that the charge nurse is leaving. You were thrilled and excited when she said that she wants to appoint you to the position. Yesterday, you found out 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. You want the decision that you and your spouse reach to be well thought out, as it has far- reaching consequences and concerns many people.
ASSIGNMENT: 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 problem-solving process used, or was the chosen solution based more on intuition? How many alternatives were generated? Did some of the group members identify alternatives that you had not considered? Was a goal(s) or objective identified? How did your personal values influence your decision?
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 following elements (Display 1.2), considered crucial in problem solving, must occur if a high-quality decision is to be made.
Display 1.2. Critical Elements in Decision Making
1. Define objectives clearly.
2. Gather data carefully.
3. Generate many alternatives.
4. Think logically.
5. 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 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 their most important objective is career advancement, having more time with family, or meeting the needs of their spouse. None of these goals is more “right” than the others, but not having clarity about which objective(s) 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. 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 1.3.
Display 1.3. Questions to Examine in Data Gathering
1. What is the setting?
2. What is the problem?
3. Where is it a problem?
4. When is it a problem?
5. Who is affected by the problem?
6. What is happening?
7. Why is it happening? What are the causes of the problem? Can the causes be prioritized?
8. What are the basic underlying issues? What are the areas of 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.
LEARNING EXERCISE
Gathering Necessary Information
Identify a poor decision that you recently made because of faulty data gathering. Have you ever made a poor decision because necessary information was intentionally or unintentionally withheld from you?
Use an Evidence-Based Approach
To gain knowledge and insight into managerial and leadership decision making, individuals must reach outside their current sphere of knowledge in solving the problems presented in this text. Some data-gathering sources include textbooks, periodicals, experts in the field, colleagues, and current research. Indeed, most experts agree that the best practices iursing care and decision making are also evidence-based practices (Prevost & Salyer, 2010).
Nurses, then, must use an evidence-based approach in gathering data to make decisions regarding their nursing practice. Sigma Theta Tau International, the honor society for nurses, defines evidence-based nursing practice as “the process of shared decision-making between practitioner, patient, and others significant to them based on research evidence, the patient’s experiences and preferences, clinical expertise or know-how, and other available robust sources of information” (2008, p. 57).
Yet Prevost and Salyer (2010) 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 1.4.
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 & Salyer, 2010). 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 & Salyer, 2010). This approach to care is even being recognized as a standard expectation of accrediting bodies, such as the Joint Commission on Accreditation of Healthcare Organizations as well as an expectation for magnet hospital designation.
Display 1.4. Strategies for the New Nurse to Promote Evidence-Based Best Practice
1. Keep abreast of the evidence—subscribe to professional journals and read widely.
2. Use and encourage use of multiple sources of evidence.
3. Use evidence not only to support clinical interventions but also to support teaching strategies.
4. Find established sources of evidence in your specialty—do not reinvent the wheel.
5. Implement and evaluate nationally sanctioned clinical practice guidelines.
6. Question and challenge nursing traditions, and promote a spirit of risk taking.
7. Dispel myths and traditions not supported by evidence.
8. Collaborate with other nurses locally and globally.
9. Interact with other disciplines to bring nursing evidence to the table.
Source: Reprinted from Prevost, S., & Salyer, S. (2010). Defining evidence-based best practices. in C. Huston (Ed.), Professional issues iursing. 2nd Edition. Philadelphia, PA: Lippincott Williams & Wilkins.
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
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 child care.
• Take the position, and hire child care.
• Have your spouse reduce the law practice and continue helping with child care.
• Ask the supervisor 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.
ASSIGNMENT: 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 topic. 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 cast in stone. Often, judgments found to be ineffective or inappropriate can be changed. By later evaluating decisions, managers can learn more about their abilities and where the problem solving was faulty. However, decisions must continue to be made, although some are of poor quality, because through continued decision making, people develop improved decision-making skills.
INDIVIDUAL VARIATIONS IN DECISION MAKING
If each person receives the same information and uses the same scientific approach to solve problems, an assumption could be made that identical decisions would result. However, in practice, this is not true. Because decision making involves perceiving and evaluating, and people perceive by sensation and intuition and evaluate their perception by thinking and feeling, it is inevitable that individuality plays a part in decision making. Because everyone has different values and life experiences, and each person perceives and thinks differently, different decisions may be made given the same set of circumstances. No discussion of decision making would, therefore, be complete without a careful examination of the role of the individual in decision making.
Gender
New research suggests that gender may play a role in how individuals make decisions. For example, research conducted by Sanz de Acedo Lizarraga, Sanz de Acedo Baquedano, and Cardelle-Elawar (2007, p. 387) suggests that women are more concerned with uncertainty, doubts, and the dynamism involved in decision making and that “they place more value on time and money”; thus, they are “more concerned about the consequences that may derive from the decision, no matter whether these affect them or other people.” In addition, Sanz de Acedo Lizarraga et al. suggest that “women are more aware of the constraints that the setting and close persons put on them, and their emotions are more important to them in the decision process” than with males. Conversely, “men assign more importance to the analysis of the information required to carry out the decision and to the definition of the goals or purposes of the decision. Men are more motivated during the process and also feel more intensely the pressure from all the work-related aspects” (Sanz de Acedo Lizarraga et al., 2007, p. 387).
Individual decisions are based on each person’s value system. No matter how objective the criteria, value judgments will always play a part in a person’s decision making, either consciously or subconsciously. The alternatives generated and the final choices are limited by each person’s value system. For some, certain choices are not possible because of a person’s beliefs. Because values also influence perceptions, they invariably influence information gathering, information processing, and final outcome. Values also determine which problems in one’s personal or professional life will be addressed or ignored.
No matter how objective the criteria, value judgments will always play a part in a person’s decision making, either consciously or subconsciously.
Life Experience
Each person brings to the decision-making task past experiences that include education and decision-making experience. The more mature the person and the broader his or her background, the more alternatives he or she can identify. Each time a new behavior or decision is observed, that possibility is added to the person’s repertoire of choices.
In addition, people vary in their desire for autonomy, so some nurses may want more autonomy than others. It is likely that people seeking autonomy may have much more experience at making decisions than those who fear autonomy. Likewise, having made good or poor decisions in the past will influence a person’s decision making.
Individual Preference
With all the alternatives a person considers in decision making, one alternative may be preferred over another. The decision maker, for example, may see certain choices as involving greater personal risk than others and therefore may choose the safer alternative. Physical, economic, and emotional risks and time and energy expenditures are types of personal risk and costs involved in decision making. For example, people with limited finances or a reduced energy level may decide to select an alternative solution to a problem that would not have been their first choice had they been able to overcome limited resources.
Brain Hemisphere Dominance and Thinking Styles
Our way of evaluating information and alternatives on which we base our final decision constitutes a thinking skill. Individuals think differently. Some think systematically—and are often called analytical thinkers—whereas others think intuitively. It is believed that most people have either right- or left-brain hemisphere dominance. Analytical, linear, left-brain thinkers process information differently from creative, intuitive, right-brain thinkers. Left- brain thinkers are typically better at processing language, logic, numbers, and sequential ordering while right-brain thinkers excel at nonverbal ideation and holistic synthesizing (Rigby, Gruver, & Allen, 2009). The end result is that individuals with left-brain dominance do well in mathematics, reading, planning, and organizing while right-brain dominant individuals are better at handling images, music, colors, and patterns (Rigby et al.). Although the authors encourage whole-brain thinking, and studies have shown that people can strengthen the use of the less dominant side of the brain, most people continue to have a dominant side.
Some researchers, including Nobel Prize winner Roger Sperry, suggest that there are actually four different thinking styles based on brain dominance. Ned Herrmann, a researcher in critical thinking and whole brain methods, also suggested that there are four brain hemispheres and that decision making varies with brain dominance (12 Manage: The Executive Fast Track, 2009). For example, Herrmann suggested that individuals with upper-left-brain dominance truly are analytical thinkers who like working with factual data and numbers. These individuals deal with problems in a logical and rational way. Individuals with lower-left-brain dominance are highly organized and detail oriented. They prefer a stable work environment and value safety and security over risk taking. Individuals with upper-right-brain dominance are big picture thinkers who look for hidden possibilities and are futuristic in their thinking. They also frequently rely on intuition to solve problems and are willing to take risks to seek new solutions to problems. Individuals with lower-right-brain dominance experience facts and problem solve in a more emotional way than the other three types. They are sympathetic, kinesthetic, and empathetic and focus more on interpersonal aspects of decision making (12 Manage: The Executive Fast Track).
In the past, some organizations more openly valued their logical, analytical thinkers but more recently have recognized that intuitive thinking is also a valuable managerial resource. Indeed, organizations need all types of thinkers and in fact, smart leaders will see that teams are composed of individuals with different types of brain dominance. Rigby et al. (2009, p. 79) agree, suggesting that when resources are constrained, “the key to growth is pairing an analytic left-brained thinker with an imaginative right-brain partner.” The right-brained thinker will be creative in producing innovation, and the left-brained thinker will give the idea structure so that it can become a reality.
There is no evidence that any one thinking style or that having either right- or left-brain dominance is better.
LEARNING EXERCISE
Thinking Styles
In small groups, examine how each individual in the group thinks. Did you have a majority of individuals with right- or left-brain dominance? Did group members self-identify with one or more of the four thinking styles noted by Herrmann (12 Manage: The Executive Fast Track, 2009)? Did gender seem to influence thinking style or brain hemisphere dominance? What types of thinkers were represented in group members’ families? Did most group members view variances in a positive way?
OVERCOMING INDIVIDUAL VULNERABILITY IN DECISION MAKING
Values
How do people overcome subjectivity in making decisions? This caever be completely overcome, nor should it. After all, life would be boring if everyone thought alike. However, managers and leaders must become aware of their own vulnerability and recognize how it influences and limits the quality of their decision making. Using the following suggestions will help to decrease individual subjectivity and increase objectivity in decision making.
Being confused and unclear about one’s values may affect decision-making ability. Overcoming a lack of self-awareness through values clarification decreases confusion. People who understand their personal beliefs and feelings will have a conscious awareness of the values on which their decisions are based. This awareness is an essential component of decision making and critical thinking. Therefore, to be successful problem solvers, managers must periodically examine their values.
Life Experience
It is difficult to overcome inexperience when making decisions. However, a person can do some things to decrease this area of vulnerability. First, use available resources, including current research and literature, to gain a fuller understanding of the issues involved. Second, involve other people, such as experienced colleagues, trusted friends, or superiors, to act as sounding boards and advisors. Third, analyze decisions later to assess their success. By evaluating decisions, people learn from mistakes and are able to overcome inexperience.
In addition, novice nurse leaders of the future may increasingly choose to improve the quality of their decision making by the use of commercially purchased expert networks— communities of top thinkers, managers, and scientists—to help them make decisions (Saint- Amand, 2008). Such network panels are typically made up of researchers, healthcare professionals, attorneys, and industry executives.
Individual Preference
Overcoming this area of vulnerability involves self-awareness, honesty, and risk taking. The need for self-awareness was discussed previously, but it is not enough to be self-aware; people also must be honest with themselves about their choices and their preferences for those choices. In addition, the successful decision maker must take some risks. Nearly every decision has some element of risk, and most decisions involve consequences and accountability.
Those who can do the right but unpopular thing and who dare to stand alone will emerge as leaders.
Individual Ways of Thinking
People making decisions alone are frequently handicapped because they are not able to understand problems fully or make decisions from both an analytical and intuitive perspective. However, most organizations include both types of thinkers. Using group process, talking management problems over with others, and developing whole-brain thinking also are methods for ensuring that both intuitive and analytical approaches will be used in solving problems and making decisions. Use of heterogeneous rather than homogeneous groups will usually result in better-quality decision making. Indeed, learning to think “outside the box” is often accomplished by including a diverse group of thinkers when solving problems and making decisions.
Although not all experts agree, many consider the following to be qualities of a successful decision maker:
• Courage. Courage is particularly important and involves the willingness to take risks.
• Sensitivity. Good decision makers seem to have some sort of antenna that makes them particularly sensitive to situations and others.
• Energy. People must have the energy and desire to make things happen.
• Creativity. Successful decision makers tend to be creative thinkers. They develop new ways to solve problems.
DECISION MAKING IN ORGANIZATIONS
In the beginning of this topic, the need for managers and leaders to make quality decisions was emphasized. The effect of the individual’s values and preferences on decision making was discussed, but it is important for leaders and managers to also understand how the organization influences the decision-making process. Because organizations are made up of people with differing values and preferences, there is often conflict in organizational decision dynamics.
Effect of Organizational Power
Powerful people in organizations are more likely to have decisions made (by themselves or their subordinates) that are congruent with their own preferences and values. On the other hand, people wielding little power in organizations must always consider the preference of the powerful when they make management decisions. In organizations, choice is constructed and constrained by many factors, and therefore choice is not equally available to all people.
In addition, not only do the preferences of the powerful influence decisions of the less powerful, but the powerful also can inhibit the preferences of the less powerful. This occurs because individuals who remain and advance in organizations are those who feel and express values and beliefs congruent with the organization. Therefore, a balance must be found between the limitations of choice posed by the power structure within the organization and totally independent decision making that could lead to organizational chaos.
The ability of the powerful to influence individual decision making in an organization often requires adopting a private personality and an organizational personality.
For example, some might believe they would have made a different decision had they been acting on their own, but they went along with the organizational decision. This “going along” in itself constitutes a decision. People choose to accept an organizational decision that differs from their own preferences and values.
Rational and Administrative Decision Making
For many years, it was widely believed that most managerial decisions were based on a careful, scientific, and objective thought process and that managers made decisions in a rational manner. In the late 1940s, Herbert A. Simon’s work revealed that most managers made many decisions that did not fit the objective rationality theory. Simon (1965) delineated two types of management decision makers: the economic man and the administrative man.
Managers who are successful decision makers often attempt to make rational decisions, much like the economic man described in Table 1.2. Because they realize that restricted knowledge and limited alternatives directly affect a decision’s quality, these managers gather as much information as possible and generate many alternatives. Simon believed that the economic model of man, however, was an unrealistic description of organizational decision making. The complexity of information acquisition makes it impossible for the human brain to store and retain the amount of information that is available for each decision. Because of time constraints and the difficulty of assimilating large amounts of information, most management decisions are made using the administrative man model of decision making.
Most management decisions are made by using the administrative man model of decision making.
The administrative maever has complete knowledge and generates fewer alternatives. Simon argued that the administrative man carries out decisions that are only satisficing, a term used to describe decisions that may not be ideal but result in solutions that have adequate outcomes. These managers want decisions to be “good enough” so that they “work,” but they are less concerned that the alternative selected is the optimal choice. The “best” choice for many decisions is often found to be too costly in terms of time or resources, so another less costly but workable solution is found.
DECISION-MAKING TOOLS
There is always some uncertainty in making decisions. However, management analysts have developed tools that provide some order and direction in obtaining and using information or that are helpful in selecting who should be involved in making the decision. Because there are so many decision aids, this topic presents selected technology that would be most helpful to beginning- or middle-level managers, including decision grids, pay-off tables, decision trees, consequence tables, logic models, and program evaluation and review technique (PERT).
It is important to remember, though, that any decision-making tool always results in the need for the person to make a final decision and that all such tools are subject to human error. Beinhocker, Davis, and Mendonca (2009, p. 58) agree, suggesting that while “data, computing power, and mathematical models have transformed many realms of management from art to science,” that the economic downturn experienced worldwide late in the first decade of the 21st century, pointed out the folly of the reliance by banks, insurance companies, and other “on financial models that assumed economic rationality, linearity, equilibrium, and bell-shaped distributions.” Beinhocker et al. point out that while it would be wrong to eliminate the use of such tools, they caution managers to “look inside the black boxes that advanced quantitative tools often represent” so that they can better understand their functioning, assumptions, and limitations (p. 58).
The decision aids known as payoff tables have a cost-profit-volume relationship and are very helpful when some quantitative information is available, such as an item’s cost or predicted use. To use payoff tables, one must determine probabilities and use historical data, such as a hospital census or a report on the number of operating procedures performed. To illustrate, a payoff table might be appropriately used in determining how many participants it would take to make an in-service program break even in terms of costs.
If the instructor for the class costs $400, the in-service director would need to charge each of the 20 participants $20 for the class, but for 40 participants, the class would cost only $10 each. The in-service director would use attendance data from past classes and the number of nurses potentially available to attend to determine probable class size and thus how much to charge for the class. Payoff tables do not guarantee that a correct decision will be made, but they assist in visualizing data.
A decision grid allows one to visually examine the alternatives and compare each against the same criteria. Although any criteria may be selected, the same criteria are used to analyze each alternative. An example of a decision grid is depicted in Figure 1.3. When many alternatives have been generated or a group or committee is collaborating on the decision, these grids are particularly helpful to the process. This tool, for instance, would be useful when changing the method of managing care on a unit or when selecting a candidate to hire from a large interview pool. The unit manager or the committee would evaluate all of the alternatives available using a decision grid. In this manner, every alternative is evaluated using the same criteria. It is possible to weight some of the criteria more heavily than others if some are more important. To do this, it is usually necessary to assign a number value to each criterion. The result would be a numeric value for each alternative considered.
Decision Trees
Because decisions are often tied to the outcome of other events, management analysts have developed decision trees.
The decision tree in Figure 1.4 compares the cost of hiring regular staff with the cost of hiring temporary employees. Here, the decision is whether to hire extra nurses at regular salary to perform outpatient procedures on an oncology unit or to have nurses available to the unit on an on-call basis and pay them on-call and overtime wages. The possible consequences of a decreased volume of procedures and an increased volume must be considered. Initially, costs would increase in hiring a regular staff, but over a longer time, this move would mean greater savings if the volume of procedures does not dramatically decrease.
Consequence Tables
Consequence tables demonstrate how various alternatives create different consequences. A consequence table lists the objectives for solving a problem down one side of a table and rates how each alternative would meet the desired objective.
For example, consider this problem: “The number of patient falls has exceeded the benchmark rate for two consecutive quarters.” After a period of analysis, the following alternatives were selected as solutions:
1. Provide a new educational program to instruct staff on how to prevent falls.
2. Implement a night check to ensure that patients have side rails up and beds in low position.
3. Implement a policy requiring soft restraints orders on all confused patients.
The decision maker then lists each alternative opposite the objectives for solving the problem, which for this problem might be (a) reduces the number of falls, (b) meets regulatory standards, (c) is cost-effective, and (d) fits present policy guidelines. The decision maker(s) then ranks each desired objective and examines each of the alternatives through a standardized key, which allows a fair comparison between alternatives and assists in eliminating undesirable choices. It is important to examine long-term effects of each alternative as well as how the decision will affect others. See Table 1.3 for an example of a consequence table.
Logic Models
Logic models are schematics or pictures of how programs are intended to operate. The schematic typically includes resources, processes, and desired outcomes and depicts exactly what the relationships are between the three components. Scheirer (2009) says that logic models can be used to better understand and specify project elements in project planning; for monitoring and improving project implementation in project management; for communicating and building consensus; for demonstrating assumptions in line of reasoning; for suggesting measures needed for project evaluation; and for improving communications.
Program Evaluation and Review Technique
PERT is a popular tool to determine the timing of decisions. Developed by the Booz-Allen- Hamilton organization and the U.S. Navy in connection with the Polaris missile program, PERT is essentially a flowchart that predicts when events and activities must take place if a final event is to occur. Figure 1.5 shows a PERT chart for developing a new outpatient treatment room for oncology procedures. The number of weeks to complete tasks is listed in optimistic time, most likely time, and pessimistic time. The critical path shows something that must occur in the sequence before one may proceed. PERT is especially helpful when a group of people is working on a project. The flowchart keeps everyone up-to-date, and problems are easily identified when they first occur. Flowcharts are popular, and many people use them in their personal lives.
LEARNING EXERCISE
Using a Flowchart for Project Management
Think of a project that you are working on; it could be a dance, a picnic, remodeling your bathroom, or a semester schedule of activities in a class.
ASSIGNMENT: Draw a flowchart, inserting at the bottom the date that activities for the event are to be completed. Working backward, insert critical tasks and their completion dates. Refer to your flowchart throughout the project to see if you are staying on target.
PITFALLS IN USING DECISION-MAKING TOOLS
A common flaw in making decisions is to base decisions on first impressions. This then typically leads to confirmation biases. A confirmation bias has a tendency to affirm one’s initial impression and preferences as other alternatives are evaluated. So, even the use of consequence tables, decision trees, and other quantitative decision tools will not guarantee a successful decision.
It is also humaature to focus on an event that leaves a strong impression, so individuals may have preconceived notions or biases that influence decisions. Too often, managers allow the past to unduly influence current decisions.
Many of the pitfalls associated with management decision-making tools can be reduced by choosing the correct decision-making style and involving others when appropriate.
Although there are times when others should be involved, it is not always necessary to involve others in decision making, and frequently a manager does not have time to involve a large group. However, it is important to separate out those decisions that need input from others and those that a manager can make alone.
SUMMARY
This topic has discussed effective decision making, problem solving, and critical thinking as requisites for being a successful leader and manager. The effective leader-manager is aware of the need for sensitivity in decision making. The successful decision maker possesses courage, energy, and creativity. It is a leadership skill to recognize the appropriate people to include in decision making and to use a suitable theoretical model for the decision situation.
Managers who make quality decisions are effective administrators. The manager should develop a systematic, scientific approach to problem solving that begins with a fixed goal and ends with an evaluation step. Decision tools exist to help make more effective decisions; however, leader-managers must remember that they are not foolproof and that they often do not adequately allow for the human element in management. In addition, managers should strive to make decisions that reflect research-based best practices and nursing’s scientific knowledge base. Yet the role of intuition as an adjunct to quality decision making should not be overlooked.
The integrated leader-manager understands the significance that gender, personal values, life experience, preferences, willingness to take risks, brain hemisphere dominance, and thinking styles have on selected alternatives in making the decision. The critical thinker pondering a decision is aware of the areas of vulnerability that hinder successful decision making and will expend his or her efforts to avoid the pitfalls of faulty logic and data gathering.
Both managers and leaders understand the impact that the organization has on decision making and that some of the decisions that will be made in the organization will be only satisficing. However, leaders will strive to problem solve adequately in order to reach optimal decisions as often as possible.
KEY CONCEPTS
• Successful decision makers are self-aware, courageous, sensitive, energetic, and creative.
• The rational approach to problem solving begins with a fixed goal and ends with an evaluation process.
• Naturalistic decision making blends intuition and analysis, but pattern recognition and experience guide decision makers when time is limited or systematic rational decision making is not possible.
• Evidence-based nursing practice integrates the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities who are served.
• The successful decision maker understands the significance that gender, personal, individual values, life experience, preferences, willingness to take risks, brain hemisphere dominance, and predominant thinking style have on alternative identification and selection.
• The critical thinker is aware of areas of vulnerability that hinder successful decision making and makes efforts to avoid the pitfalls of faulty logic in his or her data gathering.
• The act of making and evaluating decisions increases the expertise of the decision maker.
• There are many models for improving decision making. Using a systematic decisionmaking or problem-solving model reduces heuristic trial and error or rule of thumb methods and increases the probability that appropriate decisions will be made.
• Left- and right-brain dominance as well as thinking styles influences, at least to some degree, how individuals think.
• Two major considerations in organizational decision making are how power affects decision making and whether management decision making needs to be only satisficing.
• Management science has produced many tools to help decision makers make better and more objective decisions, but all are subject to human error, and many do not adequately consider the human element.
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 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.
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
LEARNING EXERCISE
Evaluating Decision Making
Describe the two best decisions that you have made in your life and the two worst. What factors assisted you in making the wise decisions? What elements of critical thinking went awry in your poor decision making? How would you evaluate your decision-making ability?
LEARNING EXERCISE
Economic and Administrative Man
Examine the process that you used in your decision to become a nurse. Would you describe it as fitting a profile of the economic man or the administrative man?
LEARNING EXERCISE
Considering Critical Elements in Decision Making
You are a college senior and president of your nursing organization. You are on the committee to select a slate of officers for the next academic year. Several of the current officers will be graduating, and you want the new slate of officers to be committed to the organization. Some of the brightest members of the junior class involved in the organization are not well liked by some of your friends in the organization.
ASSIGNMENT: Looking at the critical elements in decision making, compile a list of the most important points to consider in making the decision for selecting a slate of officers. What must you guard against, and how should you approach the data gathering to solve this problem?
LEARNING EXERCISE
Examining the Decision-Making Process
You have been a staff nurse for the 3 years since your graduation from nursing school. There is a nursing shortage in your area and many openings at other facilities. In addition, you have been offered a charge nurse position by your present employer. Last, you have always wanted to do community health nursing and know that this is also a possibility. You are self-aware enough to know that it is time for a change, but which change, and how should you make the decision?
ASSIGNMENT: Examine both the individual aspects of decision making and the critical elements in making decisions. Make a plan including a goal, a list of information, and data that you need to gather and areas where you may be vulnerable to poor decision making. Examine the consequences of each alternative available to you. After you have done this, as an individual, form a small group and share your decision-making planning with members of your group. How was your decision making like others in the group, and how was it different?
LEARNING EXERCISE
Using Models in Decision Making
Do you use a problem-solving or decision-making model to solve problems? Have you ever used an intuitive model? Think of a critical decision that you have made in the last year. What model, if any, did you use?
ASSIGNMENT: Write a one-page essay about a problem that you solved or a decision that you made this year. Describe what theoretical model, if any, you used to assist you in the process. Determine if you consciously used the model or if it was purely by accident. Did you enlist the help of other experts in solving the problem?
LEARNING EXERCISE
Decision Making and Risk Taking
You are a new graduate nurse just finishing your 3-month probation period at your first job in acute care nursing. You have been working closely with a preceptor; however, he has been gradually transitioning you to more independent practice. You now have your own patient care assignment and have been giving medications independently for several weeks. Today, your assignment included an elderly confused patient with severe coronary disease. Her medications include antihypertensives, antiarrhythmics, and beta blockers. It was a very busy morning, and you have barely had a moment to reorganize and collect your thoughts.
It is now 2:30 pm, and you are preparing your end-of-shift report. When you review the patient’s 2:00 PM vital signs, you note a significant rise in this patient’s blood pressure and heart rate. The patient, however, reports no distress. You remember that when you passed the morning medications, the patient was in the middle of her bath and asked that you just set the medications on the bedside table and that she would take them in a few minutes. You meant to return to see that she did but were sidetracked by a problem with another patient.
You now go to the patient’s room to see if she indeed did take the pills. The pill cup and pills are not where you left them, and a search of the wastebasket, patient bed, and bedside table yields nothing. The patient is too confused to be an accurate historian regarding whether she took the pills. No one on your patient care team noticed the pills.
At this point, you are not sure what you should do next. You are frustrated that you did not wat to give the medications in person but cannot change this now. You charted the medications as being given this morning when you left them at the bedside. You are reluctant to report this as a medication error since you are still on probation and you are not sure that the patient did not take the pills as she said she would. Your probation period has not gone as smoothly as you would have liked anyway, and you are aware that reporting this incident will likely prolong your probation and that a copy of the error report will be placed in your personnel file. The patient’s physician is also frequently short tempered and will likely be agitated when you report your uncertainty about whether the patient received her prescribed medications. The reality is that if you do nothing, it is likely that no one will ever know about the problem.
You do feel responsible, however, for the patient’s welfare. The physician might want to give additional doses of the medication if indeed the patient did not take the pills. In addition, the rise in heart rate and blood pressure has only just become apparent, and you realize that her heart rate and blood pressure could continue to deteriorate over the next shift. The patient is not due to receive the medications again until 9 pm tonight (b.i.d. every 12 hours).
ASSIGNMENT: Decide how you will proceed. Determine whether you will use a systematic problem-solving model, intuition, or both in making your choices. How did your values, preferences, life experiences, willingness to take risks, and individual ways of thinking influence your decision?
LEARNING EXERCISE
Determining a Need to Know
You are a nursing student. You are also HIV positive as a result of some high-risk behaviors you engaged in a decade ago. (It seems like a lifetime ago.) You are now in a committed, monogamous relationship and your partner is aware of your HIV status. You have experienced relatively few side effects from the antiretroviral drugs you take and you appear to be healthy. You have not shared your sexual preferences, past history, or HIV status with any of your classmates, primarily because you do not feel that it is their business and because you fear being ostracized in the local community, which is fairly conservative.
Today, in the clinical setting, one of the students accidentally stuck herself with a needle right before she injected it into a patient. Laboratory follow-up was ordered to ensure that the patient was not exposed to any blood-borne disease from the student. Tonight, for the first time, you recognize that no matter how careful you are, there is at least a small risk that you could inadvertently expose patients to your bodily fluids and thus to some risk.
ASSIGNMENT: Decide what you will do. Is there a need to share your HIV status with the school? With future employers? With patients? What determines whether there is “a need to tell” and a “need to know”? What objective weighted most heavily in your decision?
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