Leadership and Followership

Today’s climate demands individuals who are flexible, creative, and able to empower others to be flexible and creative. With the nursing shortage, managed care, higher patient acuity, fewer resources, highly diverse demographics, and outside influences, nurses need to be more effective leaders than ever as they manage patients in various settings.

But what is an effective leader without effective followers? This is also a time when nurses need to be effective followers, knowing who to follow, when to follow, how to follow, and how to use the follower role most powerfully. Because most of us are followers more often than we are leaders, the art of followership is a concept that needs to be explored in any contemporary discussion of leadership and management. Burns (2003) viewed leadership as “a master discipline that illuminates some of the toughest problems of human needs and social change” (p. 3). Others suggest that leadership is about having a vision and getting people to follow, using the art of persuasion. Then there are some who equate leadership with management and use the words interchangeably. Bennis and Nanus (1985) described the phenomenon of leadership as well studied, with each interpretation providing a sliver of insight but none providing a holistic and adequate explanation.

Sashkin and Sashkin (2003) took a rather simplistic, but helpful, perspective on leadership, stating that leadership that matters is the critical factor that makes a difference in people’s lives and organizations’ success. Many experts have described leadership as encompassing the leader’s personality, the leader’s behavior, the talents of the followers, and the situational context in which leadership takes place. These experts also tend to agree that leadership can be learned. Knowing that leaders are not necessarily born but made, therefore, is an important concept when one considers that all nurses must be looked to as leaders in and for the profession. Nursing’s focus today is on delivering quality and cost-effective patient care rather than on accomplishing a list of nursing tasks. This focus requires that nurses fulfill both leadership and follower roles effectively. This chapter will explore the concepts of leadership and followership and discuss how nurses can improve their abilities to lead and follow.

Leadership Theories— Past and Contemporary

In order to understand the phenomenon of leader-ship and how contemporary perspectives shape leadership behaviors, it is helpful to know how views about leaders and leadership have changed over time. A brief outline of several of the more significant leadership theories provides such a context.


Just by reading the name of this theory, Great Man, one can imagine that it is not widely accepted today. Yet this was precisely how the world thought of leaders for many years. This theory assumed that all leaders were men and all were great (i.e., of the noble class). Thus, those who assumed leadership roles were determined by their genetic and social inheritance. It was not conceivable that those from the “working class” could be leaders, that leadership could be learned, or that women could be leaders.


During the early part of the 20th century, several researchers studied the behaviors and traits of individuals thought to be effective leaders. Studies revealed that these leaders possessed multiple characteristics. Although there were commonalities among them (e.g., they tended to be taller, be more articulate, or exude self-confidence), there was no standard list that fit everyone or that could be used to predict or identify who was or could be an effective leader.


These theories embodied the idea that the right thing to do depended on the situation the leader was facing. The most well-known and used situational theory involves assessing the nature of the task and the follower’s motivation or readiness to learn and using that to determine the particular style the leader should use. Despite widespread discussion and use of this theory, however, little research exists to support its validity.


A new way of thinking about leadership emerged in the mid-1970s when James McGregor Burns asserted that the true nature of leadership is not the ability to motivate people to work hard for their pay but the ability to transform followers to become more self-directed in all they do. Transformational leaders, therefore, “look for potential motives in followers, seek to satisfy higher needs, and engage the full person of the follower. The result is a relationship of mutual stimulation and elevation that converts followers into leaders and may convert leaders into moral agents” (Burns, 1978, p. 4).

Barker (1990) asserted that transformational leaders need to have a heightened self-awareness and a plan for self-development. This positive selfregard satisfies the leader’s self-esteem needs and

Practice to Strive For 1-1

tends to result in “self-confidence, worth, strength, capability, adequacy, and being useful and necessary” (Barker, 1990, p. 159).


Wheatley (1999) took this paradigm a step further when she described leadership as a method of thinking in a different way, a way that is not standard, orderly, or goal-oriented, Instead, she suggests we think about leadership in a way that reflects naturally occurring events: free-flowing, dynamic, and accepting of an anything-can-happen philosophy. She recommended we think of leadership through a new perspective. Leadership comprises naturally occurring events in which leaders have knowledge and serve as leaders when needed. Thus, there is no need for others to direct and control what we do.

Leadership Practices and Tasks

Kouzes and Posner (1995) asserted that leaders should follow five practices of leadership to assist in transforming followers to realize their own visions and become more self-directed: challenging the status quo, inspiring a shared vision, enabling others to act rather than to react, being a role model, and encouraging the heart. These practices were identified from an analysis of the memoirs of hundreds of managers, who were asked to reflect on what they perceived as their own best leadership experience.

The findings from this research were similar to Bennis and Nanus’ (1985) notions of what constituted leadership strategies: the management of risk; the management of attention; the management of communication; the management of trust, or credibility; and the management of respect. In addition, the work of Kouzes and Posner and Bennis and Nanus is consistent with that of Sashkin and Sashkin (2003) who, after 20 years of research, designed a four-dimensional model of transformational leadership that addresses communication leadership, credible leadership, caring leadership, and risk leadership (a concept they later renamed: creating opportunities). Gardner (1990) also researched the concept of leadership and identified several tasks that leaders perform. Those tasks are as follows:

■ Envisioning goals—pointing the group in a new direction or asserting a vision.

■ Affirming values—reminding the group members of the norms and expectations they share.

■ Motivating—promoting positive attitudes.

■ Managing—keeping the system functioning and the group moving toward realizing the vision.

■ Achieving a workable unity—managing the conflict that inevitably accompanies change and growth.

■ Explaining—teaching followers and helping them understand why they are being asked to do certain things.

■ Serving as a symbol—acting in ways that convey the values of the group and its goals.

■ Representing the group—speaking on behalf of the group.

■ Renewing—bringing members of the group to new levels.

These tasks provide specific guidelines for people interested in increasing their leadership ability, and they highlight the importance of leaders working

closely with followers.

Perspectives on Followership

Although Gardner (1990) and others have acknowledged the importance of leaders and followers working together in order to realize a vision, the literature typically pays little attention to the concept of followership, and there are no “theories” of followership.

Perhaps one of the earliest discussions of followership was presented by Kelley (1992, 1998), who outlined four types of followers: sheep, “yes” people, alienated followers, and effective or exemplary followers. Sheep are passive individuals who comply with whatever the leader or manager directs but are not actively engaged in the work of the group.

“Yes” people, in comparison, are actively involved in the group’s work and eagerly support the leader; they do not, however, initiate ideas or think for themselves. Alienated followers do think for themselves and often are critical of what the leader is doing; they do not, however,  share those ideas openly, they seem disengaged, and they “rarely invest time or energy to suggest alternative solutions or other approaches” (Grossman & Valiga, 2005, p. 47). The individuals who are engaged, suggest new ideas, share criticisms with the leader, and invest time and energy in the work of the group are referred to as effective or exemplary followers. Pittman, Rosenbach, and Potter (1998) also described four types of followers: subordinates, contributors, politicians, and partners. Subordinates are similar to Kelley’s “sheep,” doing what they are told but not actively involved. Contributors are like Kelley’s “yes people,” supportive, involved, and doing a good job, but not willing to challenge the ideas of the leader. Politicians are willing to give honest feedback and support the leader, but they may neglect the job and have poor performance levels. Like Kelley’s effective or exempry followers, the partners described by Pittman, et al. (1998) are highly involved, perform at a high level, promote positive relationships within the group, and are seen as “leaders-in-waiting” (p. 118). Because leaders cannot be leaders unless they have followers, the role of the follower is extremely important in any discussion of leadership. In addition, the characteristics that describe effective/ exemplary followers or partners are quite similar to those outlined for effective leaders themselves.

Although the term “follower” “conjures up images of docility, conformity, weakness, and failure to excel” (Chaleff, 1995, p. 3), those who are effective in the role are independent, critical thinkers, innovative, actively engaged, able and willing to think for themselves, willing to assume ownership, self starters, and able and willing to give honest feed back and constructive criticism (adapted from Grossman & Valiga, 2005, pp. 49–50).

Effective followers are not employees who simply “follow the rules” and accept whatever management decides. In fact, the concept of effective followers may not even be compatible with perspectives on management that assume a complacent, nonquestioning employee. But it is clearly aligned with the concept of leadership, because effective followers are seen as partners with the leader, working collaboratively to realize the vision they share. Thus, it is helpful to outline the differences between leadership and management.

Differences Between Leadership and Management

Leadership and management are related phenomena but they are not the same. It is important torealize that (a) not all individuals in management positions are necessarily leaders, and (b) leadership is not necessarily tied to a position of authority. While only those in management positions are expected to be managers, leadership can and needs to be exercised by each of us wherever we may be. In other words, even though an individual does not hold a management position, she can still be a leader on a clinical unit, in an institution, in her community, or in the profession as a whole. In a classic article written in 1977, Zaleznik asserted that “leaders and managers are very different kinds of people: they differ in their motivations, in their personal history, and in how they think and act; they differ in their orientation toward goals, work, human relations, and themselves; and they differ in their worldviews” (Zaleznik, as quoted in Grossman & Valiga, 2005, p. 5). For example, leaders are creative, innovative, and risk-takers; managers often are more concerned with maintaining the status quo and taking few risks. In addition, managers often have a short-range perspective and are concerned about the “bottom line,” whereas leaders have a long-range, visionary perspective and are concerned about moving toward realization of that vision.

It is important to remember that these distinctions point out the extremes of perspectives to illustrate the points that not all managers are leaders and not all leaders are managers. Despite the differences outlined by Zaleznik and others, however, many individuals are able to function as both leaders and managers simultaneously and effectively. Indeed, our practice world is greatly enhanced when leaders are able to manage and managers are able to lead. Bennis and Nanus (1985, p. 21) have been quoted often as saying “leaders do the right thing, and managers do things right.” In nursing practice, we must both do the right thing and do that thing right. For example, we apply standards of care to our practice that must be followed and acuity quotients that, in most cases, must be assessed in order to make decisions about staffing, admissions, and supports needed. Thus, we must do the thing right. But perhaps we also need to ensure that we are doing the right thing by evaluating if the standards fit our patient population and if the acuity and staffing ratios are relevant to our needs. If they are not, leaders need to step forward to create standards that do fit and that are relevant. All nurses need to lead and manage effectively in patient care settings in order to accomplish tasks

and achieve maximum care quality. All need to share their visions of how patient care can be improved, and all need to learn from the leaders who have gone before them.

Nursing Leaders

The nursing profession claims many true leaders. They have expressed bold visions, invested enormous amounts of energy to realize those visions, effectively engaged followers in the quest, been passionate about the futures they hoped to create, and absorbed criticism, setbacks, and opposition on the road to success.

Florence Nightingale, for example, demonstrated how a healthful environment could promote healing and recovery, fought for the proper care of soldiers, and provided careful documentation of interventions and outcomes that laid a foundation for future research activities. Lillian Wald, who literally walked the rooftops of New York tenement buildings to provide care to the poor and helpless, created the concept of public health and demonstrated how nursing care could make a significant difference in the lives and well-being of individualsand communities. In nursing education, Isabel Stewart was a leader in establishing standards of quality for educational programs and instrumental in creating a program of study to prepare individuals for the teaching or faculty role.

In more recent years, nursing leaders have helped us establish ourselves as researchers, expert clinicians, influencers of public policy, theorists, and entrepreneurs. The development of nursing theories occurred through the passionate work of individuals such as Hildegard Peplau, Ida Jean Orlando, Dorothea Orem, Betty Neumann, Jean Watson, Imogene King, and Martha Rogers.

Madeleine Leininger has enhanced cultural awareness and competence of all nurses. The creation of associate degree nursing programs was the result of research conducted by Mildred Montag, and its widespread implementation was realized through her efforts and those of individuals like Verle Waters and Elaine Tagliareni. The ability of nurses to influence public policy evolved from the leadership provided by Shirley Chater, Jessie Scott, Doris Block, Mary Wakefield, and Ada Sue Hinshaw.

Our profession has developed the science of nursing practice through the efforts of such individuals as Mary Naylor, Donna Diers, Nancy Fugate Woods, and Dorothy Brooten. The science of nursing education has been advanced through the sustained work of Nancy Diekelmann, Pamela Ironside, Marilyn Oermann, and Chris Tanner. In nursing administration, the following individuals have provided significant leadership in changing the work environment for nurses: Leah Curtin, Barbara Donoho, and Joyce Clifford. Our nursing organizations have been successful in charting preferred futures for our profession through the leadership of their officers, including Lucille Joel, Nancy Langston, Sr. Rosemary Donnelly, and Angela Barron McBride.

We know the names and accomplishments of these talented nurses because each of them articulated a vision of a better future, was passionate about working to realize that preferred future, was successful in enlisting nurses in the effort, was willing to take risks, accepted criticism and suggestions, spoke eloquently, exhibited enormous amounts of energy, and was unwilling to accept the status quo or settle for “second best.” In other words, each of these individuals was a leader. None of them started out as leaders, but their vision and passion helped

Practice Proof

them become leaders. This same opportunity awaits each of us.

It we have a vision, if we are passionate about realizing it, and if we invest a great deal of energy to create our preferred future, then each one of us might be included in a list of “nursing’s leaders” at some point in the future. We do not need to be in positions of authority right now. We do not need to hold a doctorate. We do not need to be published researchers with major grants. We do not need to be over the age of 50 or teach in a university. What we do need, however, is to exhibit the  qualities of a leader.

Leadership Qualities

Gardner (1990) identified several attributes of leaders, including physical vitality and stamina, intelligence, good judgment, willingness to accept responsibilities, task competence (i.e., knowing what needs to be done), understanding of followers’ needs, ability to work effectively with others, a need to achieve, ability to motivate others, and courage.


In a presentation at the April 2004 American Society of Association Executives Foundation Forum, one of the most influential individuals in the area of leadership, Warren Bennis, offered his ideas about exemplary leaders. He asserted that leaders have the following six competencies:

1. Leaders must foster a clear vision with an endowed purpose that is owned by the people involved with the leader. To illustrate this competency, Bennis gave the following example of how Howard Schultz, founder of the Starbucks Coffee conglomeration, views his company’s vision: “We aren’t in the coffee business serving people; we’re in the people business serving coffee.”

2. Getting people to support a vision or mission takes work. Leaders must “keep reminding people of what is important [because] people really can forget what they are there for.” Followers also need regular recognition in order to maintain their engagement with and commitment to the vision.

3. Leaders must be optimistic and see possibilities. Leaders must be adaptive to the constant change in our society, which “takes a hardiness attitude that allows [them] to face challenges and adapt all of it in a way that results in alignment.”

4. Leaders must create a culture of candor. Bennis asserted that such a culture requires integrity, which evolves from a balance of ambition, competence, and having “a moral compass.” When ambition surpasses competence or overrides one’s moral compass, for example, integrity is lost, a culture of candor cannot be created, and one cannot be an effective leader.

5. Leaders must mentor others and acknowledge their ideas and accomplishments. Bennis said, “Drawing out the leadership qualities [of others] is the way of the true leader.”

6. Good leaders must be in tune to getting results. Bennis shared a conversation he had with Jack Welch, previous CEO of General Electric. This highly successful corporate manager and leader noted that “gettingresults depends on customer satisfaction, employee satisfaction, and cash flow. If I have those three measurements, I can win.” Thus, vision, good intentions, and strong desires are not enough; leaders are leaders because they make things happen.


Today there are more women than ever before who are effective leaders, and it is expected that the number of women leaders, particularly those from minority groups, will continue to increase (Bennis, Spreitzer, & Cummings, 2003). There are more women governors, senators, and representatives.

There are more women leaders in sports, science, business, education, and many other fields than ever before. In nursing, women have always led the profession toward change and development. It is reported that women have different styles than men in many things, and because of these differences, it is assumed that women are better at some things (e.g., child-rearing, nursing) and men are better at others (e.g., sales, construction work). But when it comes to leadership, the styles of men and women allow both to be successful, particularly if stereotypical maleness is combined with stereotypical femaleness. A more androgynous perspective on leadership—one that combines the best of “femaleness” and the best of “maleness” and draws on the strengths of each style—therefore, is most helpful.

The androgynous leader “blends dominance, assertiveness and competitiveness [often thought to be “male” characteristics]….with concern for relationships, cooperativeness, and humanitarian values [often associated with a “female” style]” (Grossman & Valiga, 2005, p. 112). Such a combination is critical in a world characterized by declining resources and increasing chaos and uncertainty.


McClelland and Burnham (1976) determined that power is a definitive aspect of leadership because it motivates individuals and contributes to their charisma. The concept of power is discussed more fully in Chapter 13 so it will not be examined in depth here. But it is important to look at power as a component of leadership.

The two primary sources of power are one’s position in an organization and one’s personal qualities. McClelland and Burnham (1976) asserted that hierarchical power, or the amount of authority one has in an organization, and the ability to provide rewards or “punishments” to others are used to attain organizational goals. They also noted that personal power, deriving from one’s knowledge, competence, and trustworthiness, or from followers’ respect for and desire to be associated with the leader, is used to influence others.

It is only when one’s personal power is well established that one can exert transformational leadership. Transformational leaders with highly developed power are comfortable with themselves, have high self-efficacy, and empower followers to attain their own goals and, ultimately, the goals of the group or organization. We are well aware of the many disadvantages of people abusing their power, but when power is used in the service of others, positive results are realized. Greenleaf (1977) and Block (1993) used the term stewardship to describe the phenomenon of directing one’s power toward the service of others, and they asserted that such a quality is essential in leaders. Stewardship is “the willingness to be accountable for the wellbeing of the larger organization by operating in service, rather than in control, of those around us” (Block, 1993).

Similar notions of building relationships through nurturing and empowerment, gaining power through community networking, and leading groups based on values of cooperation were offered by Chinn (2004). Chinn advocated for building one’s personal power base so that it can be used to enhance the group’s ability to achieve its goals and realize its vision, thereby using it to fulfill the leader role.


Nurses need to view themselves as leaders, develop their leadership abilities, and embrace the challenges that face them in health care today (Grossman & Valiga, 2005). In order to become leaders, however,  nurses must learn about leadership in their academic programs (Fagin, 2000), through on-the-job experiences, through mentors, or through other avenues. In order to develop their leadership skills, it is imperative for nurses to observe expert leaders, work hand-in-hand with such individuals, and receive constructive feedback on their performance. Having a “shadowing,” or preceptor, experience with a leader, for example, allows nursing students to understand the context of an organization, develop their negotiation skills, think more broadly, communicate more effectively, collaborate more effectively, and be empowered (Grossman, 2005). Personal involvement, immersion in a situation, learning by doing, and practicing in the clinical setting with an experienced nurse have been cited as important to learning generally.

They are also strategies to be used to help individuals learn how to be leaders. Bennis and Thomas (2002) reinforced the notion that in order to become an effective leader an individual must be able to define her uniqueness or what makes her special. She must then continually grow and increase her expertise in that unique area so that she can be a leader who influences policy development, evidence-based practice, and dissemination of new understandings.

Many health-care organizations have leadership programs for their managers and those aspiring to become managers. Leadership skills can also be learned as part of the professional development of all nurses. Many professional organizations have leadership institutes and seminars at their annual conferences. When the nursing profession realizes that nurses need leadership skills as much as patient care and management skills and that every nurse, from the entry-level staff nurse to the chief executive nurse, needs to become an effective leader, we can expect that patient care outcomes will be enhanced and that nursing will most effectively influence health care.

All Good Things…….

The mantle of leadership does not fall to only a few.Indeed, all nurses must think of themselves as a leader, act as a leader, and take on the challenges of a leadership role. All leaders are not managers or organizational office holders; many of them are staff nurses, faculty, and individuals on the “front lines” of patient care. By the same token, all managers are not leaders. Nurses also need to be effective followers, knowing who to follow, when to follow, and how to follow. It is only through the exercise of leadership and effective followership that nurses will be able to influence health care and reate a preferred future for the profession.

Those of us who are leaders in the field must guide, support, and encourage those who aspire to this role. Those who aspire to genuine leadership must learn about this role, take the risks associated with expressing and moving forward to achieve a vision, and allow passions to drive actions. The patients, families, and communities we serve deserve nothing less.


Management Theory

Nurses manage care for individual clients, families, and communities in hospitals, outpatient settings, clinics, health departments, home health agencies, long-term care facilities, and rehabilitation centers as well as in other specialized healthcare organizations. The strategies they use to organize care are drawn from leadership and management theories. The approaches to leadership and management reflect the dynamic state of health-care delivery as nurse managers and leaders strive to empower nurses to provide care that produces optimal outcomes. Management and leadership have evolved and continue to evolve from a hierarchical structure based in early management theory to a more flattened and inclusive approach that incorporates concepts from the physical and social sciences. In the early 1900s, these theories drew from newtonian science that viewed the world from a mechanistic, functional point of view.

From the late 1980s until the present, the scientific view has shifted to include chaos theory and complexity science. Complexity science is based upon discoveries in physics and biology that emphasize emergent relationships and recognize the self-organization inherent in complex, adaptive systems. Management theorists have been incorporating these concepts into new approaches to the complex world of business and health care. This chapter provides a chronology of this evolution and presents a foundation for nurse leaders in the 21st century.

Managers have traditionally been responsible for the control of resources required to accomplish organizational goals. These responsibilities include budgeting, staffing, and maintaining the functions of the organization while simultaneously balancing fiduciary responsibility for the resources of the organization. Rowland and Rowland (1997) define management as a five-step process:

1. Planning

2. Organizing

3. Directing

4. Coordinating

5. Controlling

The manager is employed by an organization and given the responsibility to accomplish specified goals for the organization. Managers are expected to teach workers the best way to perform the job; match the employee to the job; provide motivational incentives to workers; see that time, energy, and materials are used efficiently, and ensure that the organization fulfills its objectives. At the same time, managers seek to enhance efficiency, develop resources required to reach the goals of the organization’s strategic plan, and manage across boundaries in the organization (Huber, 2000). Nursing management roles in the hospital vary, and the work to be accomplished depends on the span of authority inherent in a particular position. Nurses occupy such positions as chief nursing officer, vice president for patient care, and director of nursing, and are sought to serve on the executive councils of hospitals, public health organizations, and other places that deliver or impact patient care. In many cases they are responsible not only for the nursing units in the organization but also for those areas that support patient care, such as pharmacy, respiratory care, physical therapy, cardiac rehabilitation, and other such departments. The span of control for nurses in these roles is broad, encompassing supervision of other nurse managers who focus on delivery of care within patient units as well as of managers in other disciplines who direct the delivery of care in ancillary departments important to overall patient care. Collaboration with other professionals on the patient care delivery team is an important part of these management roles.

Newly graduated staff nurses assume responsibility for leading a team of direct care providers and, therefore, need to know how to manage a patient care team effectively. This team often includes nursing assistants, patient care technicians, licensed vocational/practical nurses, and other registered nurses. In this role of team leader, the nurse is responsible for identifying outcomes that must be reached by the end of the shift and assigning work that is appropriate to the preparation, scope of practice, and expertise of those on the patient care team. Within a few months of graduation, new nurses are likely to find themselves in the role of charge nurse, in which they must employ management skills to ensure delivery of care to an entire patient unit. All nurses, with few exceptions, will find themselves in positions in which accomplishment of their functions requires coordinated effort of a team that they must lead.

Nursing students often conceptualize management roles as those of clinical manager, head nurse, director of nurses, or chief nursing officerand do not envision themselves in such positions of leadership. Although it is true that students do not immediately occupy these roles, the roles newly graduating nurses will assume do require knowledge and application of management and leadership strategies. Therefore, students should examine management principles very carefully, learn how to use them effectively, and implement them upon graduation and entry into practice. This chapter presents the evolution of management theories, their application to nursing practice, and the roles that nurse managers assume in managing time, money, and people to accomplish the mission and goals of the organization.

Management and Leadership Revisited

During the late 1980s and early 1990s, a debate began regarding whether management or leadership was the better approach to accomplishing the goals of an organization. In reality, management and leadership are two sides of the same coin. There is no doubt that management is an important function of any leadership position; both are required for the organization to function effectively. There is a lack of consensus about whether management is a subset of leadership or whether leadership is a subset of management. Often, leadership is conceptualized as the broader of the two concepts, with managing including such tasks as controlling resources, budgeting, and staffing. It is apparent that nurses in leadership positions are responsible for such activities, but their most important role involves the development of mission and goals for their areas of responsibility that support those of the organization. Development of mission and goals is necessarily a collaborative effort, and the leader must engender support for their development. Once developed, the leader must cast the vision in such a way that it garners support from the staff. Effective leadership calls to mind the notion of a manager with vision, who uses power in positive ways, challenges others to join with the team to accomplish the vision or mission, and creates a synergistic environment.

In his book  On Becoming a Leader, Warren Bennis contrasts the concepts of management and leadership in this way:

■ The manager administers; the leader innovates.

■ The manager maintains; the leader develops.

■ The manager focuses on systems and structure; the leader focuses on people.

■ The manager relies on control; the leader inspires trust.

■ The manager has a short-range view; the leader has a long-range perspective.

■ The manager asks how and when; the leader asks what and why.

■ The manager has his eye on the bottom line; the leader has his eye on the horizon.

■ The manager imitates; the leader originates.

■ The manager accepts the status quo; the leader challenges it.

■ The manager is the classic good soldier; the leader is his own person.

■ The manager does things right; the leader does the right thing (Bennis, 1994, p. 45).

Whereas Bennis sees leadership and management as two distinct concepts, with leadership being the more desirable, it is our belief that both management and leadership are essential to organizational life and growth and frequently reside within the same individual. The juxtaposition of the manager as being “bottom line–oriented” with the leader as “vision oriented” can and must occur simultaneously to keep the organization healthy. For example, one cannot ignore the budget and the available resources in favor of developing new strategies for meeting organizational needs. Both are necessary. The principles required to achieve the goals of organizations are continuing to evolve as our society and our knowledge of the principles of our universe expand. Table 2-1 examines Bennis’ juxtaposed ideas to see how they could be combined in light of knowledge in the 21st century. The current state of health-care delivery in the United States clearly calls for innovation and the development of original solutions that challenge the status quo. Complexity theory, which will be discussed later in the chapter, recognizes that small changes “nudge” organizations in the right direction. As this transformation of the healthcare delivery system takes place, it remains vitally important that nurse leaders manage resources to foster the adaptation that must occur to sustain the current systems that support patient care.

Management and Leadership: 21st-Century View

To get a better sense of the essence of leadership and management and their interaction with one another, knowledge of management theory is essential. Understanding current management thought requires an appreciation for the development of management theory across the time span of the late 18th, 19th, 20th, and early 21st centuries. The next section will paint a broad picture of the evolution of management theory. Drucker (2001) makes the following comment about leadership in the 21st century: “One does not ‘manage’ people. The task is to lead people. The goal is to make productive the specific strengths and knowledge of each individual” (p. 81). He believes that this perspective is necessary to creating a climate that supports the productivity of the “knowledge worker.” Rather than being subordinates, knowledge workers are associates; for the organization to work effectively, the knowledge workers must actually know more about their own jobs than their boss knows. The desired relationship is more like that between an orchestra conductor and the musicians than the traditional concept of the “superior-subordinate” dyad. In his book  The Essential Drucker (Drucker, 2001), Drucker contrasts this current opinion of management with that in his 1954 book The Practice of Management. The assumption he held at that time was, “There is one right way to manage people—or at least there should be” (p. 77), which he now believes is at odds with reality and productivity. How is it possible that one of the most respected management theorists changed his view so drastically? This question is best answered by examining from a historical perspective the changes that have occurred in management theory.


Prior to the mid-19th century, in preindustrial times, skilled artisans or craftsmen oversaw their trades. They accepted apprentices to work with them and taught them the skills of the trade. The master craftsmen made decisions about how and when to initiate and complete work. The master was in charge of the work, which typically was conducted in what became known as “cottage industries,” in which only a few people worked together to create goods. Once the industrial age arrived in the mid-1800s, this worldview of work began to change (Nixon, 2003). Three genres of traditional management theory have evolved: scientific management, general administrative management, and bureaucratic management.

The Scientific Management Movement

Frederick Winslow Taylor (1856–1915) is known as the father of scientific management. He detailed his principles on increasing the productivity of workers in the Midvale Steel Works plant in Pennsylvania (Taylor, 1911). His principles included the ideas that:

1. a worker’s job could be measured with scientific accuracy;

2. workers’ characteristics could be selected scientifically and could be developed to investigate the causes of and solutions to work problems;

3. productivity would be improved through scientific selection of and progressive development of the worker; and

4. there should be continuing cooperation of management and workers (Inman, 2000). The Industrial Revolution gave rise to large factories and created the need to organize the efforts of the supervisors and workers in the factories.

Management theory developed to organize and teach work process in a scientific manner, fulfilling the all-important desire for profit (Taylor, 1911).

Taylor’s scientific management principles were based on managing time, materials, and work specialization. For example, he developed the concept of the time and motion study, with the idea that wasted time and effort could and should be eliminated. He analyzed workflow and created an inventory of stored materials. By controlling these variables, he was able to decrease production costs and increase productivity. These strategies are highly effective for managing task-oriented work. In the early 1980s, hospital facilities sought to use time and motion studies to determine patient:nurse ratios and staffing needs. Nurses and other healthcare workers were shadowed by analysts who tried to determine the amount of time required to provide patient care. However,  the application to a profession such as nursing failed to capture the critical thinking, decision making, and judgment required for patient care.

Taylor believed that organizational function was optimal when the roles of individuals were designed to be highly specialized, thereby taking advantage of a particular skill set that existed within a worker. To achieve this level of specialization, he implemented the concept of functional foremanship, in which each worker would fall under a foreman responsible for each area of specialization. This emphasis on specialization was an early impetus for the development of specialty certification in nursing and was really an extension of the master apprentice paradigm.

General Administrative Theory

Henri Fayol (1841–1925) was a Frenchman who is remembered for the development of general administrative theory. He developed his management strategies in the mining industry and was writing at about the same time as Taylor. Management, according to Fayol’s work, includes five overriding concepts: (1) prevoyance, or the anticipation of the future and the development of a plan of action to deal with it; (2) organization of people and materials; (3) command of the activity among personnel; (4) coordination of the parts of the organization into a unified whole; and (5) control through application of rules and procedures. In order for an organization to be productive, leaders must participate actively in all five of these areas.

Fayol is remembered for his 14 principles of management, which he felt supported the accomplishment of the overriding concepts. Although he did not specify which of the principles he believed to be directly related to each of the concepts, we have developed a table to illustrate how these principles help accomplish each of the required concepts. See Table 2-2 (Inman, 2000).

The Relationship Between Fayol’s Concepts and Principles of Management

These principles introduced some ideas that continue to be used. For example, in the 21st century,hospital personnel departments continue to have a pay scale that strives to provide fair remuneration based on educational preparation and years of experience. Every organization strives to retain its staff because of the cost of recruiting, training, and orienting new employees. The development of “esprit de corps,” or team spirit, continues to be important in today’s workplace. Teamwork remains essential to providing optimal patient care, and high morale is conducive to the levels of collaboration and teamwork that are required in the complex health-care environment. Patient care is delivered by a collaborative team of knowledge workers including nurses, physicians, and therapists from a variety of disciplines, all of whom are necessary to the outcome of optimal patient care.

Bureaucratic Management

Max Weber (1846–1920) was a German sociologist who developed what was known as the “ideal bureaucracy.” The ideal bureaucracy includes the concepts of division of labor, authority hierarchy, formal selection, formal rules and regulations, impersonality, and career orientation. He recognized that it would be impossible for people to be completely impersonal in their relationships at work, but he believed that impersonality would be optimal and would remove favoritism. Weber believed that the more impersonal, rational, and regulated the work environment, the more likely the employees were to be treated fairly, and the more likely the organization was to reach its objectives. Weber focused on what it was that made people respond to authority. He perceived that only through concentrating power in the hands of a few people in a hierarchical structure could an organization be managed effectively and efficiently. While he did not necessarily agree that bureaucracy was the best strategy, because it removed autonomy from the individual, he believed it was the only way to assure the overall success of an organization (Inman, 2000).

During the early 20th century when Taylor, Fayol, and Weber developed these approaches to management, the worldview was still based upon 17th-century science science. Classical physics had been established as Newton synthesized the work of Copernicus, Galileo, and Kepler. Newton’s laws of motion and universal gravitation, along with the development of calculus to compute planetary orbits, set the stage for a framework of cause and effect and a reliance on prediction through formulae (Whittemore, 1999). It was from this perspective that the early management theorists developed their management strategies for the Industrial Age. The emphasis of management was to master the world of work through controls designed using the principles of classical physics and science as they were understood at that time. Within health-care organizations today, one sees the continuing influence of traditional management theory in, for example, job descriptions that outline the responsibilities of each person, thereby dividing the labor, and in organization charts that depict the hierarchical structure and the areas of authority for particular positions. Job descriptions emphasize the functions to be associated with each job, and one of the functions of the manager is to avoid overlap between positions and to delineate clearly the functions expected. These methods are helpful in that job descriptions let workers know the expectations and responsibilities associated with the positions they occupy. However, it is also true that work would not get done if the only functions carried out each day were limited to those outlined on the job description. The work to be accomplished is too complex to be listed in a document of any reasonable length. In addition, the complexity of the health-care environment is such that people need to be treated as knowledge workers and allowed to have both the responsibility and the authority to make decisions about operational issues. In general, traditional management styles have their advantages and disadvantages. The prime advantage is that they enhance the organization and efficiency of industry. The disadvantages of traditional management include rigid rules, top-down decision making, and authoritarianism. In other words, traditional management theory created an environment that was less optimal from a humanistic perspective. Thus, at the end of the 1920s, the stage was set for the era of behavioral management. The pendulum would swing from an emphasis on the structure and organization of management to a focus on the people who work in the organization.


The recognized beginning of the behavioral movement was a much cited study that lent its name to the Hawthorne Effect. Elton Mayo (1887–1957), a clinical psychologist working at the Harvard Business School, conducted studies at the Hawthorne plant of the Western Electric Company from 1927 to 1932. Mayo designed a study in which light levels in the workplace were first increased, during which time worker productivity increased. Subsequently, he lowered the light levels, and yet worker productivity continued to improve. His conclusion was that the environmental changes were not responsible for the increasing level of productivity but rather the fact that the workers received attention from the experimenters, which increased levels of self-esteem and group pride, which led to increased production. It was from this study that Mayo concluded that management must be concerned with preserving the dignity of the workers, demonstrating appreciation for their accomplishments and, in general, recognizing workers as social beings with social needs (Mayo, 1953). This has great implications for research because it is always possible that results may be altered by the very acts of observation and increased attention. This threat to validity has become known as the Hawthorne.

Effect, after the name of the company where Mayo conducted his research. Another well-known behavioral theorist, Douglas McGregor (1960), developed Theory X and Theory Y. Theory X represented the traditional viewpoints of management, which hold managers responsible for organizing money, materials, equipment, and people as well as for directing workers’ efforts and motivating workers, controlling their actions, and modifying their behavior to fit the needs of the organization. Theory X suggests that, without active intervention by management, workers would be passive and nonproductive in their roles in the organization. Theory Y assumes that the desire to work is just as natural as the desire to play or rest, that external control and threat or punishment are not required to achieve organizational objectives because workers are self-motivated, and that the capacity to work creatively to solve problems is widely distributed in the workforce. McGregor believed that these were the two major managerial attitudes about employees and that these approaches directly affect how the employee responds to managerial leadership (Marquis & Huston, 2006).


In 1981 William G. Ouchi wrote a book on Japanese management style, entitled Theory Z. In this book he discussed the management methodologies used by Japanese corporations. This approach to management relied on principles that were diametrically opposed to those used in businesses in the West, including America, England, and Europe. Employment in the Japanese corporation is described as being lifelong, dependent upon the development of consensus, collaborative work, incentives for group work, and pride in the product or service being developed or provided. See Table 2-3 for a comparison of the principles of the Japanese management style with Western management style. Henry Mintzberg (1999) chairs an international Masters of Practicing Management program in which Japanese professors teach a module entitled Managing People: The Collaborative Mind-Set. The module emphasizes gaining contributions from all the people in the organization and on reaching consensus. Ouchi (1981) says that there are three components

Comparison of Japanese and Western Management Styles

to a valid consensus: (1) I believe that you have heard and understand me, (2) I have heard and understand your point of view, and (3) I can support the decision we have made together. In Japan, the word kaizen refers to the principle of encouraging all people in the organization to contribute improvement ideas on a biweekly basis (Bodeck, 2002). This results in 24 improvement ideas per employee each year, compared with one idea per employee per year in the United States and one idea per 6 years, on average, in the United Kingdom. Organizational growth has been shown to be directly related to innovation. The more leadership encourages participation and ownership among the employees, the more productive the organization becomes. Ouchi (1981) discusses the importance of encouraging group contributions. In Japan, individuals rarely desire personal recognition because they believe that nothing is possible without everyone’s contributions. Although in the United States the predominant values focus on individual accomplishments, it is increasingly recognized that shared governance, which recognizes the importance of contributions from every employee, is the desired model. The American

Nurses Credentialing Center (ANCC) has emphasized the importance of shared governance through its Magnet Hospital program. This type of management is becoming more acceptable for the knowledge worker in the nursing profession in the United States.


Management theory in the first decade of the 21st century is influenced by a new worldview, which has, once again, had its roots in the physical sciences. Managers are beginning to recognize that the direct cause and effect relationships, to which they held in the past, frequently do not exist in reality. Additionally, management theories are being promulgated in more complex systems and in professional systems, in contrast to the earlier management theories that began to emerge during the manufacturing environment of the 17th century. During that time, the worldview incorporated the strict “cause and effect” ideas that originated from newtonian science. Chaos theory and complexity theory, which have emerged from quantum physics, now underscore our understanding and interpretation of the work people do in organizations. Hock (2000) has even coined a new term for management based in complexity science: chaordic (kay-ordic). The word borrows the first syllable of the word chaos and the word order. He defines the term chaord as “any self-organizing, self-governing, adaptive, nonlinear, complex organism, organization, community or system, whether physical, biological or social, the behavior of which blends characteristics of both chaos and order” (p. 22). Organizations have elements of both chaos andorder, with innovation and progress occurring “at the edge of chaos.”

Complexity science “is not a single theory. It is the study of complex adaptive systems—the patterns of relationships within them, how they are sustained, how they self-organize, and how outcomes emerge. Within the science there are many theories and concepts….Complexity science is highly interdisciplinary including biologists, anthropologists, economists, sociologists, management theorists and many others in a quest to answer some fundamental questions about living, adaptable, changeable systems” (Zimmerman, Lindberg, and Plsek, 2001, p. 5.) The idea that systems in nature are self-organizing lends support for the knowledge worker supported by Drucker in that individuals within an organization can build a better system, bringing order out of chaos, when allowed to self-organize. Small changes occur that move the system into ever-evolving patterns. Ideas from complexity theory, such as chunking, attractors, self-organization, distributed control, and leveraging incremental changes, can be used in health-care organizations. See Table 2-4 for terms used in complexity science. Application of complexity science represents a significant divergence from the traditional management notion that employees are “machines” to be controlled by management through specific job descriptions and charts. Organizations become “living entities” encompassing all of the traits and foibles of the individuals of which they are composed. Employees, managers, and organizations are rapidly changing and becoming more flexible in their interactions with each other. As stated earlier, it has been long understood that if an employee adhered rigidly to a job description, over half of the work to be accomplished would be left undone.

Unstated in a job description is the expectation that the employee engage in the critical thinking, innovation, and interpersonal relationships required to accomplish the goals and objectives of the position. This shift is evidenced through the changes in Peter Drucker’s perception of management referenced in the beginning of the chapter. He originally thought that there was one and only one way to manage people. He revised his thinking to recognize that in the 21st century employees are actually “knowledge workers” who necessarily know more about their area of responsibility than do their managers. The knowledge worker must be able to make

The Language of Complexity Science

decisions and implement strategies that work; these changes can be made more effectively and efficiently at the point of contact of the worker with the environment than by management removed by several layers.

If employees are self-organizing, what does this leave the manager to do? Hock (2000) says managers first must manage themselves to ensure their own integrity, character, ethics, knowledge, wisdom, words, and acts. He thinks this should take about 50% of managers’ time. Second, Hock says that 25% of managers’ time should be spent managing the people who have authority over them to ensure that they will have higher-up support. The support and consent of those managers above are vital for achieving goals and desired results. Third, 25% of managers’ time must be spent managing peers, competitors, and customers. This is done through developing collaborative relationships that result in outcomes that are good for all and tailored to meet the needs of peers and customers. This leaves no time for the people over whom the manager has authority. Hock’s idea is that managers should hire ethical people who are in tune with the goals of the organization and then unleash them to do what they were hired to do. This idea matches well with the concept of a knowledge worker who is the specialist in the designated area of work.

Complexity theory does not disregard previous management theories; instead, it borrows concepts from many theories, modifying them as part of the evolutionary process. Management using complexity

theory is neither totally mechanistic nor behaviorist. Instead, it is a new, ever-changing process. The manager has much in common with the artistic director of a ballet production who choreographs the dance moves, selects the music, and plans lighting and scenery. During the production, however, the dancers make the magic of the movements come to life. The entire performance is much more than the sum of the individual movements and roles. Another analogy is found in the coach of a team who works day after day to make a game plan that, at the time of the game, must be acted out and adjusted by the players on the field in response to the opposing team (Hock, 2000).

It is clear that management has moved beyond the mechanistic views of organizations and people that characterized management theories in the Industrial Age. The application of complexity theory, with its reliance on self-organization, offers solutions for nursing and today’s health-care organizations. Strategies for applying this new science will continue to evolve. The next section of the chapter applies some of management concepts to the identified roles of managers.

Management for Nurses

The nurse manager has many varied formal and informal roles, which involve team building, decision making, communication, negotiation, delegation, and mentorship. Whether managing a group of patients or functioning in the role of charge nurse, clinical manager, director of nursing, vice president of patient care, or president of the local chapter of the American Nurses Association, nurses fulfill these tasks in order to lead and manage successfully.


In order to lead and manage effectively, a nurse must be able to build a strong team. The delivery of health care is a team activity, involving professionals and unlicensed personnel from a variety of disciplines. Based on traditional management models, the emphasis was on individuals in the workplace and was more likely to value individual performance. New management strategies emphasize the importance of self-organizing teams and the value of group activity. In the complex world of health-care delivery, each individual’s participation as a team member is a requirement; failure to work as a team creates fragmentation of patient care.

Managers must first recognize that the workers they “supervise” are knowledge workers who can and will make the right contributions to patient care. Managers must communicate to all team members

Practice to Strive

their belief in the ability of the team to work well together. Because health-care systems have traditionally been very hierarchical, employees may not be accustomed to being allowed to organize their own work or solve their own problems. When members of a team indicate their unwillingness to participate or their lack of faith in other team members, the leader must listen carefully and avoid saying too much. The objective is to help the concerned individuals assess their own contributions to the team and their expectations of other team members.

Then, the manager must communicate a strong belief in the team’s contributions to the goals of theorganization. This conversation serves the purpose of empowering each team member to contribute fully to the work that is to be accomplished. Chaos theory supports the notion that small inputs can create a ripple effect with far-reaching consequences. Each input affects the system, and the system is altered in response to each input. The team leader, rather than being the purveyor of change, has the responsibility of ensuring that the changes are aligned with the organization’s mission, goals, and objectives.

The mission and goals of the organization unify the team and should reflect the goals of the members of the organization. A mission of “providing excellent care to the patients on the ABC unit” is a good starting point. For example, through the use of attractors, the leader can help the team focus and move forward in the use of the knowledge and expertise of its members.


The leader is well served to recall Drucker’s (2001) comments about the knowledge worker of the 21st century. The individual who does the work of the organization is the one who knows the most about it. Participative and transformational leaders enter into relationships with the professionals in their organizations. They share information, discuss values, and collaborate on decisions. The self-esteem of team members correlates with involvement with decision making. Sometimes decisions need to be made quickly, but even in those circumstances the leader is illadvised to make the decision without gaining input from those who will be affected by the decision. If the decision will involve the need for change, thegreater the number of people whose views have been considered, the greater will be the support for the change. A paradox that exists within organizations is that frequently there is an artificial time constraint placed on decision making, supposedly to move the organization along more rapidly.

A decision made quickly without adequate consideration and input can often result in an excessive amount of time being required to respond to the problems associated with rapid, uninformed change. A wise leader negotiates for the time to make a well-informed decision and thus avoids the frustration and time associated with negative outcomes of hasty decision making.


Information is power. Current literature recognizes the importance of keeping the members of an organization informed about issues with which they are involved. Many health-care organizations function around the clock, which can make the role of communicator more complex. Personal face-to-face communication is optimal, so managers must make every effort to stagger their hours in the organization to allow this communication on a regular basis. Both formal and informal communication is important. Managers who make time for informal communication will have a more accurate understanding of the issues with which the knowledge workers are dealing; will develop more open, trusting relationships within the organization; as well as a greater understanding of factors affecting morale.

In the past, communication books were used as a way to enhance “asynchronous” communication among various shifts of workers. Today’s computer technology supports communication through listserves, e-mail, and discussion boards. If an organization is not taking advantage of the technology that is available, the manager should investigate the availability and understanding of that technology. An important aspect of communication is that it must be mutual. In bureaucratic organizations information often flows only downward, and there is a propensity for the information to fail to reach the unit level. Moreover, information rarely moves from the unit level up the hierarchy, leaving the higher-ups out of touch. This type of communication is a sure recipe for disaster. Under these circumstances, the knowledge workers on the unit are lacking important information about their environment, and their contributions cannot be fully informed. Likewise, individuals responsible for guiding the overall vision of the organization are uninformed about day-to-day happenings, which makes it difficult to create realistic strategies.


The nurse manager must exhibit excellent negotiation skills. These skills are important in helping a team arrive at decisions, gaining organizational support for a new plan, gaining the cooperation of another department or organization, and in many other facets of the manager’s role.

The first rule of negotiation is to understand the positions of the stakeholders, including nurses, patients, interdisciplinary professionals, community members, families of patients, unlicensed assistive personnel, and administration. Communication is an important part of negotiation, and one of the vital attributes of a negotiator is to encourage discussion and trust among group members. Many times, negotiation surrounds a decision in which it is perceived that there will be “winners” and “losers.” Negotiation focuses on understanding who the perceived winners and losers are; the best negotiations result in win-win solutions. Ask the question, “Under what circumstances do you think this goal can be accomplished?” This question frequently moves participants from a defensive position to one of creativity and innovation, and it uses the concept of establishing an attractor, which causes people to come together to discuss possibilities.


Delegation is no longer a “top-down” activity. Instead, the leader will recognize the wisdom of members of the health-care team, support the interconnectedness of team members in the health-care delivery system, and embrace a more fluid, innovative system. The manager will foster an environment that supports the notion of associates (1) being partners in the delivery of health care, (2) being accountable for evaluating the outcomes of their interventions, (3) having the equity in the organization to make “point of service delivery” decisions, and (4) feeling a sense of ownership in the organization (Wilson & Porter-O’Grady, 1999).


Roles and Competencies of Nurse Managers


It is often said that effective managers are always in the business of replacing themselves so their professional development and advancement can continue. Mentorship is the process to accomplish this. The identification of potential protégés can occur through a variety of methods. Team members who express an interest in leadership, individuals who have recently taken on new leadership roles, and professionals who show promise in the area of leadership through their interactions with others are all likely candidates. Mentoring relationships can be formal (assigned through an organization) or informal (simply a handshake agreement between a seasoned leader and an aspiring one). Sigma Theta Tau International, the nursing honor society, is an example of an organization that seeks to foster formal mentoring relationships, as does the American Association of Colleges of Nursing.

Whether a mentoring relationship is formal or informal, there are a few guidelines for success. Mutual respect, goal setting, accountability to each other, and open dialogue are hallmarks of an effective mentoring relationship. The mentoring relationship must be mutually rewarding; it must involve the opportunity for real work and stimulating challenges; there must be agreement on ownership of any projects created through the partnership; and the relationship must remain on professional grounds at all times. The mentor has the responsibility to create opportunities for professional growth and involvement, whereas the protégé is responsible for responding to these opportunities. The mentor has the responsibility to provide opportunities for the protégé to gain recognition for the work accomplished; the protégé is accountable for being responsible and reliable with the work accepted. The mentor empowers, encourages, and challenges the protégé. All nurses have a professional responsibility to mentor new members of the profession. See Table 2-5.

All Good Things…

Management has evolved from its emphasis on control and measurement as conceptualized by Taylor, Fayol, and Weber. These strategies were helpful during the industrial revolution, but in the 21st century they are less useful for organizations that rely on the daily contributions of knowledge workers.

The evolving management theories recognize the complexity of the work involved in professions such as nursing. “The uncertainty of healthcare flows from the quantum and chaotic nature of the world over time. Therefore, we should stop trying to plan every step and predict each happening. Indeed, we must realize that we can never come close to knowing all there is to know about a topic or planning every step…Hence we have to accept that no matter how much we know about the world, there are far more questions than there are answers, and uncertainty is a natural part of our lives” (Grossman & Valiga, 2005, p. 125).


Motivating Yourself and Others for a Satisfying Career

Is motivation as simple as Benson implies? Perhaps not, but the heart of motivation is for employees to believe that their work is meaningful and that it offers them a reasonable standard of living. Mosley, Megginson, and Pietri (2005) said it well when they defined motivation “as the willingness of individuals and groups, as influenced by various needs and perceptions, to strive toward a goal” (p. 191).

Why is it important to understand motivation? When health-care workers are motivated and subsequently satisfied with their jobs, motivation leads to patient satisfaction and, ultimately, organizational effectiveness. Employee motivation holds a critical key to organizational success. If leaders and managers understand and take action to motivate their employees, the organization will increase its bottom line. This chapter will discuss theories of motivation and explore the links between motivation, job satisfaction, and patient outcomes.

Theories of Employee Motivation

Many theoretical perspectives have been used to explain worker motivation.


One theory, well known to nurses and other professionals, is Maslow’s Hierarchy of Needs. Maslow (1970) stated that lower order needs, such as physiological and safety needs, must be met before higher order needs, such as love and belonging, esteem, and self-actualization, can be fulfilled. The physiological needs include such things as the need for food and sleep. Safety needs involve the need to be free from fear and to feel secure. Love, self-esteem, and selfactualization are the higher order psychological needs. Maslow’s theory views individuals as holistic beings. This theory has been quite popular in managerial literature, despite the fact it was developed from observations of psychotherapists and not for the workplace environment. It does provide a framework to help managers understand the complexities of human behavior. A manager might use this theory, for instance, to help understand why an employee with financial difficulties may not have the motivation to undertake a complex work project that might bring some personal acclaim. While the theory can help explain human behavior, research findings have not clearly supported the theoretical model’s utility in the job environment (Porter, Bigley, & Steers, 2003).


Alderfer (1972) revised Maslow’s theory and applied it specifically to the organizational context (Porter, et al., 2003). His ERG theory (existence, relatedness, growth) classifies worker needs into three categories: existence needs, which are similar to Maslow’s physiological needs; relatedness needs, which are similar to Maslow’s belonging needs; and growth needs, which encompass Maslow’s esteem and self-actualization needs. There are two important differences, however, between the theories of Alderfer and Maslow. An employee does not have to move through the need levels sequentially in Alderfer’s theory. Unlike Maslow, Alderfer states that an employee can be motivated by more than one need category at the same time and not necessarily in a sequential fashion. For example, a nurse can have multiple motivations for working, including salary and self-esteem. If fulfillment of selfesteem needs is thwarted because staffing negatively affects the quality of care given, the nurse may focus on a lower order need, such as belongingness, and ignore the need to deliver highquality care. For the manager, this change in motivation may help to retain the nurse for the time being, but quality care will continue to suffer until the staffing issues are addressed.


Another well-known theory is Frederick Herzberg’s Two-Factor, or Motivation-Hygiene, Theory (1966). Although his theory has been criticized for not taking into consideration an employee’s individual needs, Herzberg’s work has fostered much research on work motivation and is used widely by managers to foster a motivating work environment (Porter et al., 2003). Herzberg’s theory is built on the proposition that workers have two sets of needs: intrinsic and extrinsic. The intrinsic needs (or motivators) are growth, advancement, responsibility, the work itself, recognition, and achievement. The extrinsic needs (or hygiene factors) are security, status, relationship with subordinates, personal life, relationship with peers, salary, work conditions, and

relationship with supervisor, supervision, company policy, and administration. It is possible for an employee to be satisfied intrinsically but dissatisfied extrinsically. For example, a nurse may find herself enjoying her responsibilities and a recent promotion while at the same time bemoaning her coworker’s unwillingness to be part of a team. What this means is that the nurse is satisfied with the work itself but is dissatisfied with her interpersonal relationships within the workplace environment. In order to be motivated, employees should be satisfied both extrinsically and intrinsically. Herzberg (2003) points out that many human resource consultants focus on facts that satisfy extrinsic needs, such as compensation and human relations. Job enrichment, on the other hand, should not be overlooked.

It promotes motivation and thus job satisfaction. For example, a nurse manager could send a staff nurse for training in a new procedure, thereby enhancing the staff nurse’s knowledge and enabling her to grow in her position.


Maslow, Alderfer, and Herzberg assume that motivational factors—whatever they may be—are global in scope or the same for all employees. Vroom (1964), on the other hand, recognized that motivation is more individualized and tailored to what individual employees expect from the job itself. According to Vroom, workers weigh their options and engage in behaviors that will bring aboutdesired rewards or outcomes termed positive valences. If the worker sees that a certain behavior might bring about a negative outcome, Vroom called this negative valence. Behaviors, negative or positive, are reinforced if the expected outcome is achieved. In essence, if an expected outcome occurs, then the workplace behavior will continue. For example, Nurse Jones is late for work at least 2 days each week. The nurse manager counsels Nurse Jones and states the next time she is late a formal disciplinary notice will be placed in her personnel file. Nurse Jones is not late again because she knows what the negative outcome will be.


David McClelland (1971) also recognized that individual employees have different motivational needs and that managers could use information about individual employees to create a motivating work environment. McClelland stated that the three need categories are achievement, power, and affiliation. Those who have high achievement needs are motivated by task accomplishment. For many, the tasks need to be challenging, not routine (Porter, et al., 2003). Those that have a need for power might be more fulfilled in supervisory roles, and those that have a high need for affiliation have a strong need to be liked and to work in an environment that is friendly towards them and that involves team work. See Box 3-1 to learn about additional motivational theories.


Generational differences can also account for variability in worker motivation (Atkinson, 2003;Billings & Kowalski, 2004; Cordeniz, 2002; Hill, 2004; Izzo & Klein, 1998). Baby Boomers are interested, for the most part, in job security. If an employee from this generation knows that performance will lead to long-term employment, the employee will work to maintain that employment.

Unfortunately, recent layoffs at major corporations, including health-care corporations, have challenged the notion that good performance leads to job security. Baby Boomers, born largely between the post–World War II era and 1964, grew up in era in which they learned to challenge those in power and authority (Cordeniz, 2002). Thus, Baby Boomers often question what others tell them to do and want to know the reasons why decisions have been made. Rules are not motivators for behavior for Baby Boomers.

Generation X’ers, born between 1965 and about 1977, grew up in an era when technology became paramount. This group works primarily for personal satisfaction and growth (Cordeniz, 2002). Balancing work and personal life is an important goal for this group. Whereas their parents valued organizational loyalty, members of this group change jobs when the work environment no longer challenges or satisfies them (Cordeniz, 2002; Hill, 2004). Money is more of a motivator for this group than for earlier generations.

The Net Generation is just now coming into the workforce. These workers were born in the 1980s. In McClelland’s terms, these workers are motivated by affiliation. They prefer to work in groups and teams and are hands-on learners (Billings & Kowalski, 2004). Unlike earlier generations, they grew up in a very diverse society (Hill, 2004). The Net Generation is more motivated and satisfied when working within diverse group settings. This group is also most comfortable with technology; cell phones and e-mail have always existed for them. Exposed to a wide array of technology, the Net Generation is motivated by settings where the technology is advanced and current.

Motivation can be complex, and it differs by the individual. In order to maximize organizational effectiveness, the task for leaders and managers is to discover what motivates individual workers and to create a work environment that capitalizes on these motivations.

Motivation Yields Job Satisfaction Yields More Successful Organizations

Job satisfaction occurs when a nurse’s motivational needs are met. Nurses and other employees work in

order to have certain needs met, such as finan-cial and growth needs. When those needs are met, employees express satisfaction with their jobs. This crucial link between motivation and job satisfaction has far-reaching consequences for an organization.

In short, if nurses and other health-care employees are satisfied, personnel turnover decreases, the quality of patient care increases, and the organization’s financial outlook improves.


What leads to job satisfaction for nurses and other health-care workers? Herzberg (2003) and Timmreck (2001) suggest that money is not the primary motivation for job satisfaction for nurses.

Of course, nurses and others need to make a decent living, but other factors masy play a more important role in job satisfaction. McNeese-Smith (1999) found that while nurses did derive some satisfaction from salary, benefits, and the ability to balance work and family life, the most satisfying part of the job was patient care itself. Factors that inhibited job satisfaction were those that hindered the ability to accomplish patient care, including lack of supplies, feeling overloaded, and difficulties in communicating with physicians. Relationships with coworkers could cause satisfaction or dissatisfaction as well.

Control over work environment and autonomy in decision making also contribute to job satisfaction (Freeman & O’Brien-Pallas, 1998). Allowing nurses to decide how patient care is to be delivered and the opportunity to use their skills promotes a satisfying work climate.

Hackman and Oldham’s (1980) Job Characteristics Model of Work hypothesizes that the combination of core job dimensions, such as skill variety, task identity, task significance, autonomy, feedback on job performance, perceived meaningfulness of work, and knowledge of and responsibility for outcomes, leads to job satisfaction. Edgar (1999) used this model to confirm that autonomy, meaningful work, and opportunity to use a variety of skills promote job satisfaction for nurses who work in hospitals.

Autonomy and work enrichment are also important for nurses who work in community-based settings. Laamanen, Broms, Happola, and Brommels (1999) found that work motivation and job satisfaction did increase when home health nurses had autonomy and variability in tasks. They became dissatisfied when the workload became unmanageable.

Likewise, school nurses have ranked autonomy as the most important job satisfier (Foley, et al., 2004). School nurses ranked the other following factors as important to job satisfaction: interaction with coworkers, professional status, pay, organizational policies, and task requirements. A study of hospice nurses also revealed that autonomy was positively linked to job satisfaction, as was positive supervisory support (DeLoach, 2003).


Knowing what promotes job satisfaction for nurses is significant because the level of job satisfaction has been connected to patient outcomes (Scott, Sochalski, & Aiken, 1999). In a series of studies of magnet hospitals, Aiken and her colleagues discovered a clear link between organizational characteristics, including nurse job satisfaction, and patient outcomes. According to Scott et al., magnet hospitals are characterized by lower nurse turnover, more nursing autonomy and control over practice, and better nursing relationships with physicians.

Scott et al. noted that magnet hospitals also have lower patient mortality and higher patient satisfaction. More recently, Aiken, et al., (2002) reported that organizational characteristics such as high patient to nurse ratios contributed to nurse burnout, job dissatisfaction, and higher patient morbidity and mortality rates. Aiken and colleagues’ work demonstrates that attending to job satisfaction is a necessity in order to achieve positive patient outcomes.

On an international scale, Tzeng and Ketefian (2002) demonstrated in an exploratory study conducted in Taiwan that nurse job satisfaction was related in part to some measure of patient satisfaction, such as satisfaction with pain management and arrangement for follow-up care post-discharge.

This study confirms that nurse satisfaction does influence customer satisfaction, which is critical because if customers are not satisfied with care they receive, they will go elsewhere, and that health-care organization will suffer financially.

Nurse satisfaction also affects the bottom line of health-care organizations. If nurses become dissatisfied and subsequently leave their jobs, the organizations suffer. According to Atencio, Cohen, and Gorenberg (2003), the cost of turnover is up to two times the nurse’s salary. For example, if the average nurse’s salary in an organization is $46,000 and 10 nurses leave in a year’s time, the cost to the organization is close to a million dollars.

As Herzberg’s theory suggests, nurses will leave organizations if the dissatisfiers outweigh the motivators (Herzberg, 1966). Davidson, Folcarelli, Crawford, Duprat, and Clifford (1997) report that intent to leave was predicted by poor communication within the organization and heavy workload (Hinshaw & Atwood, 1983; Pearlin & Schooler, 1978; Price & Mueller, 1981). Additionally, Cline, Reilly, and Moore (2003) confirm that nurses will leave when management is nonsupportive, the pay is unsatisfactory, and staffing ratios are poor.

They point out that nurses will tolerate understaffed and perceptually unsafe settings for only a limited amount of time. If nurses cannot get their concerns addressed, they will leave the organization.

Leadership Makes a Difference

One of the critical determinants of job satisfaction for nurses is relationships with supervisors. Being able to communicate effectively with supervisors can, in and of itself, serve as a motivating factor for nurses. Early on, McGregor (1960) described the relationship between leadership style and worker motivation. According to McGregor, a Theory X management style presupposes that humans inherently dislike work, do not want to be accountable and responsible for their actions, and need to be prodded to do work. Managers who espouse Theory X use such strategies as rewards, threats, and punishment to get workers to do their jobs. A Theory Y leadership style, on the other hand, assumes that workers can achieve their personal goals by integrating their goals with those of the organization. The Theory Y manager’s job, then, is to foster this integration by using a variety of human relations approaches. For example, a nurse who wants to work for a master’s degree in nursing may choose an organization that promotes educational mobility. The nurse’s supervisor might work with the nurse to develop a schedule that will facilitate this goal. A manager who espouses the Theory Y approach is more likely to attract employees than a Theory X manager who rules with an iron fist.

One particular human relations approach was tested in research conducted by Mayfield, Mayfield, and Kopf (1998). They demonstrated that if a leader used motivating language in giving direction and sharing feelings, nurses expressed a higher level of job satisfaction and job performance. One such example of motivating communication could be telling a nurse in front of peers that he did a good job with a particular patient. They caution, however, that communication is not enough to sustainjob satisfaction. Rather, communication plus organizational behavior, such as providing meaningful rewards, help to improve employee performance and job satisfaction.

Leadership style can also be characterized by whether leaders are transformational or transactional. Transformational leaders direct by role modeling, promoting employee development, providing a stimulating work environment, and inspiring optimism. Transactional leaders lead by being taskfocused, focusing on the daily work of the organization, setting employee goals for them, and focusing on the reward system (Marriner-Tomey, 2004). Morrison, Jones, and Fuller (1997) found that

Practice to Strive

job satisfaction was higher when leaders were perceived as both transformational and transactional but that the relationship between nurses and transformational-style managers was stronger. Only transformational leadership was positively related to empowerment (intrinsic task motivation). An interesting finding was that the relationship between job satisfaction and transformational leadership style was more powerful for unlicensed personnel. These findings may suggest that different categories of employees are motivated by different leadership styles.

Leaders who maintain a positive work environment also have more success in keeping employees satisfied. Spence-Laschinger, Finegan, and Shamian (2001) suggest that work environments that empower nurses to use their expert decision making promote trust within the organization and lead to job satisfaction. Nurse leaders/managers are crucial in promoting trusting work environments.

Aside from staff nurse perceptions of the importance of leadership, nurse leaders, by their own admission, know that being accessible and fostering a professional practice environment that promotes teamwork are crucial to nurse job satisfaction (Upenieks, 2003). Like Frank, Eckrick, and Rohr (1997), Upenieks also noted that leaders play a critical role in obtaining resources for the delivery of optimal patient care, which in turn promotes job satisfaction. If leaders fail to promote teamwork and acquire the needed resources for quality patient care, job satisfaction and quality of patient care decrease.

All Good Things…

In this chapter, we have explored ways that nurse leaders/managers can motivate employees to deliver high-quality care. Motivating employees, while not a simple task, has significant payoffs both for the employees and the organization as a whole. A variety of theories can be used by leaders/managers to guide them in promoting a climate that fosters job satisfaction and subsequent quality patient care. Leaders/managers need to be cognizant of the fact that what motivates one employee may not motivate another. Therefore, they may need to use a variety of motivational strategies in order to achieve positive patient and organizational outcomes.


Understanding Organizational Structures

Organizational mergers and health-care changes are rampant in the 21st century. In health care today, organizational structures are affected by the economic, political, social, and technological pressures in society (Marriner Tomey, 2000, p. 231). The structure identifies the authority, the responsibility, and the decision-making processes. Today’s structures are no longer simple and hierarchical; they are complex systems with cross-functional teams and communications and interactions occurring at many levels. The structure of the organization is representative of its mission, vision, and values and how it functions. Nursing is an integral and major component of the health-care organization, with nursing being the largest group of employees within the health-care setting. As a result, it is essential that nurses know their organization, the structures within which they function, and be able to relate this to their individual clinical unit. As health-care delivery expands, organizations will continuously take on a new look and approach to structure. By studying and learning the organizational structure, nurses will better understand their role within it. The nurse is the key person at the bedside, coordinating the care for the patient. Registered nurses work within a matrix of systems within the health-care organization, being a gatekeeper of information that can improve outcomes for the organization. In this chapter, the reader will learn about organizational theory and its role; review the characteristics and the different types of health-care organizations; and understand how the corporate vision, mission, values, and philosophy guide the organization. The chapter also presents information on governance models, the different types of health-care delivery settings, and the importance of continuity of care for the health of the organization. The chapter concludes with predictive future trends related to organizations.

Organizational Theory

Organizations consist of groups of people coming together for a common purpose. An organization can be defined as “a group of persons with specific responsibilities who are acting together for the achievement of a specific purpose determined by the organization” (Huber, 2000, p. 454). It is “the structure that supports the organizational processes,” according to Yoder-Wise (2003). Organizations comprise people who are given specific tasks to complete within their defined job role. Organizational “theory,” technically, dates back to biblical times, when thought was given to how groups were organized. Pharaoh utilized theories to build the pyramids of Egypt. Workers were organized into specific groups with specific tasks to be completed for the success of the structure. Modern organizational theory began during the Industrial Revolution. Many theories have been reviewed to demonstrate the how and the what of organizational structure. Today’s view of the structure emphasizes the relationships of the groups within the organization, the people, and how work is accomplished in a self-organized system (Crowell, 1998). It is important to understand the different theories of how organizations have come to be because the theory serves as the foundational component and the driving force for how groups are formed and function in today’s health-care arena. As we discuss the theories, it will reveal the transitions and variations that shape organizational functions today. By studying organizational theories, the reader will understand the functionality of organizational structures.


The Classical Theory, dating to the 1890s, is one of the oldest theories regarding organizational structure. The focus of this theory was on the struc ture of the formal organization: it examined the efficiency of the organization as a by-product of the design of the system. The concept was that the people of an organization will be productive if they are given a well-defined task to complete. By dividing work into tasks and requesting employees to complete the same task every day, the theory proposed that productivity would increase because of the repetition of the task. This worked from an industrial perspective.

Results of this theory have come to be known as the classical principles of organizational design. These principles examine how members are divided into work teams, who reports to whom, the number of people for whom the managers are responsible, and the shape of the structure. From classical principles, Max Weber, called the Father ofOrganizational Theory, created the bureaucratic model of organizational structure. Weber’s model consists of the following components:

■ Organizational structure

■ Division and specialization of labor

■ Chain of command

■ Span of control

The organizational structure concerns the arrangement of the work groups within the organization and is intended to support the organization’s survival and success. The structure determines accountability and responsibility. It dictates who makes the decisions and who has authority and oversight of workers. The structure shows who reports to whom and gives a pictorial view of the organization. In the Classical Theory, workers were placed into departments in relation to the work they were assigned to complete.

Specialization of labor dictates that the work of the organization be divided into tasks and employees be assigned a specific task to complete. Limiting the number of tasks assigned to each individual increases the efficiency and improves the organization’s product. Just as in an assembly line, the worker who puts steering wheels on a car every day will become very proficient at the task. The risk of error is reduced, and efficiency is increased.

Chain of command refers to the formal line of authority and responsibility within the organization. Authority is the power to guide and direct workers within their specific area. This authority is usually depicted by vertical lines on an organization chart. This linkage is from the key position on top to the positions directly below. Responsibility refers to the obligation to produce or to complete the task. Each worker is responsible to finish the task assigned by a superior. Span of control refers to the number of employ ees who report to a manager or a supervisor. A wide span of control indicates that many employees report to a supervisor; a narrow span means that few employees report to one. The number of people reporting determines the organizational structure (Altaffer, 1998). A narrow span of control is indicative of a tall structure because each manager has only a few people in the reporting structure. There are many managers responsible for a limited number of people, which results in many layers to get to the top of the organizational structure. There are often many layers for the change of command, and the span of control is narrow. A wide span of control is indicative of fewer managers and more reporting workers, resulting in a flat organizational structure.

Many organizations still base their structure on the Classical Theory principles, utilizing some of the components to make up their structure. As organizations begin to function leaner with limited resources, other approaches and options to organize the employees are being implemented. The Classical

Theory is based on the concept that the employee does one job and will learn it well. In health-care organizations today, multiple tasks are being managed and completed by fewer employees.


The Neoclassical Theory became popular in the 1930s. It placed emphasis on cooperation and participation in the workplace (Sullivan & Decker, 2001). The key factor in this theory is motivation. A motivated employee will produce better output in the job setting (see Chapter 3 on motivation in this book). If employees are given satisfactory working conditions and have opportunities to socialize with other employees, job satisfaction will improve, and the employee will be more motivated.

The Neoclassical Theory links with a democratic style of leadership because the employees are encouraged and allowed to participate in the functions of the organization and the decision-making process. For example, employees may participate on committees related to patient education and care outcomes. Nurses and other members of the healthcare team have a voice in the decision-making process. The Neoclassical Theory relates to a flat organizational structure. Processes are decentralized, and member involvement is encouraged.


Systems Theory is based on the work of Von Bertalanffy (1968). This theory asserts that systems are a whole and that organizations should be viewed as a whole, considering the relationships within the structure of the organization. A system is a complex mix of intertwined elements, including inputs, throughputs, and outputs. Inputs are the

items being put into the organization to create the product. The throughputs are the processes put intoplace to assist with the creation of the outputs. These elements work together to accomplish specific goals within the organization. Changes in one part of the system affect the other parts of the system, creating a ripple effect. The resources are inputs, such as the employees, patients, materials, money, and equipment imported from the environment. The work is considered the throughput. This is the work within the organization, transforming energy and resources to yield a product. The product (the output) is then exported to the environment. The organization is a constant recurring cycle of inputs, throughputs, and outputs.


The Chaos Theory stresses the importance of change within organizations. Change is the stimulation of the organization, and it is constant in health care today. Change can create stress or relief for organizations, depending on how it is perceived and interpreted (see Chapter 11 on leading change). Leaders must constantly assess the organizational environment and determine whether there is consistency within the structure. Organizational leaders working under the Chaos Theory will excel with change and creativity (McGuire, 1999). Management is flexible and will  reward those organizational members who thrive on adaptive behaviors and innovation. The overall goal of the organization is to be successful in an environment of constant change. This theory works well with healthcare organizations today. Change is inevitable, and employees must learn to adapt and excel to remain employable in health care.


The concept within the  Contingency Theory is that the organization’s structure must match the working of the environment. The most common aspect of the Contingency Theory recognizes the style of the leader and how this influences the situation. How the leader leads will determine how the organizational structure is established. There is variation in leadership style to gain expected outcomes. There is no one leadership style that fits every situation; a good leader will learn how to adapt to each situation to support the desired outcomes. The organizational structure based on this theory is flexible and varies based on the needs of the organization and the leader.


In a learning organization, the people and the systems respond and expand their capabilities to obtain the results that are desired. The basic concept is that in situations of change, the organization that is adaptive to the change will thrive. Learning organizations are becoming more popular in businesses today. Members of organizations have the ability to create and manage the changes (Senge, 1999). Particular people are employed becauseof their commitment to the organization, and this commitment serves as a resource for the success of the organization. Peter Senge (1990) identifies five disciplines for a learning organization to be successful: systems thinking, personal mastery, mental models, building a shared vision, and team learning.

Systems thinking is the ability to examine an organization as a whole entity, not separate units, and to see the interrelationships between the units. Successful organizations explore systems as a whole and as very dynamic processes. Personal mastery refers to a continuous learning process by each individual. It is based on self-discipline and the idea that individuals never stop learning. Mental models refer to an individual’s ability to see things differently and work with pictures within the mind to influence how a given situation is seen and interpreted. This means taking a situation and being able to view all sides of it to discover the objectivity of it. Building a shared vision is the ability of the organization to create a shared idea of the future goals and dreams. This vision creates energy for the members of the organization to work together as a team and meet the goals of the organization. The final component, team learning, refers to the organizational members’ ability to unite as a whole for the betterment of the organization. This will improve organizational results. When members work together, processes improve, and outcomes are enhanced.

Organizational theory plays an important role in the productivity and success of the organization. The theory helps determine the type of organizational structure and how the organization will function. It is important for managers and leaders to understand the theories, how they relate to their organizations, and how they can influence the members of their organization.

Organizational Components and Planning

Health-care organizations have been transformed by the many changes in social, structural, political, and human resource allocations (Bolman & Deal, 2003). Some specific factors that have contributed to these changes include quality care issues, increasing health-care costs, and the focus on patient satisfaction. These factors affect how the organization is run and contribute to changes within the structure. Organizations with a strong value set, mission, vision, and philosophy will be more prepared to successfully meet these ever-changing events. Goals and objectives, policies and procedures, and strategic planning are also key components of facile organizational operation.


The stated values of an organization give meaning to its existence and help its members act in concert with its motives. The values clarify what is important to the organization in regard to its customers, products, and/or services. Values set the standards for behavior within the organization and supportthe mission and the strategic plan. Organizational leaders determine a set of values that align with the mission and the vision of the organization.

The values for the organization serve as the foundational cornerstone for the events and activities of the facility. Organizational values are related to the success of the organization and determine how it will function when working with its customers. For example, if a hospital as an organization values service, the members will work hard on methods to improve their patient satisfaction surveys. A client who returns for future care at the hospital is usually one who is pleased with the type of service given. Leaders of the organization express these values on a daily basis within their work and responsibilities to the system. Values can be an implicit or explicit part of the mission statement and are incorporated implicitly into the organization’s culture. See Box 4-1 for some examples of organizational values.


The purpose or the mission statement encapsulates the intent and goal of the organization. It explains, in a short statement, the core reasons behind the organization’s existence and a primary focus on a single strategic thrust for the organization. The purpose of each area of the organization is to pursue the stated mission of the organization. The mission statement sets standards for the organization’s philosophy and its goals and objectives; it is the baseline for decisions of the organization. The mission statement drives the organization’s existence and is

a reflection of the culture. See Box 4-2 for an example of a mission statement.


The vision statement incorporates an organization’s mission and values. It serves as the future-oriented plan for the organization, the wish list of future development ideas, and the plan to set this wish list into motion. The vision statement serves as the dream of the organization and provides guidance on where an organization wants to be 10–15 years into the future. See Box 4-3 for an example of a vision statement.


The philosophy of an organization is derived from its mission and incorporates the organizational values that direct the behavior of the organization. The information provided in the philosophy—the values and principles of the organization—provides the framework for the decision-making process of the organization and shapes the social and professional development of the organization. The philosophy serves to allow employees to achieve common goals (Wendenhof & Strahley, 1995). The philosophy underlies the goals and objectives of the organization, so it is imperative that nurses understand and know their organization’s philosophy. See Box 4-4 for a sample philosophy



The specific goals and objectives of the organization provide more concrete information on what and how the organization plans to provide/act, under the guiding hands of its established mission and philosophy. The organizational goals are the broad statements of intent, and the objectives are the specific ways to accomplish the goals. Goals are a part of the planning process, which is one of the functions of management. Generally, the goals and the objectives explain the services offered, the resource allocation, the future plans, and the responsibility to the customer (Box 4-5).


Each organization also has established policies and procedures. A policy is a written plan stating how the organization will function and work together. Policies help the organization to accomplish the established goals and directives and provide cohesive guidance for the members of the organization. The procedures are the methods and direction on how the policy will be implemented. Procedures

offer step-by-step guidance as to how to implement and carry out the policy. Policies and procedures are used during employee orientation, daily routines, and decision making. Both establish interdepartmental consistency within the organization. The policies and procedures familiarize employees with the rules and also serve to provide guidance and organizational direction.


Many organizations do strategic planning 3–5 years (see Chapter 14) out for the purpose of preparing to reach future goals. Strategic planning begins with analysis of where the organization stands currently and where it wants to be in the future. The strategic plan has to have value for the members of the organization, and it needs to fit with the vision and mission of the organization. The strategic plan may include new services for patients, building opportunities, and other growth for the organization. It serves as the blueprint for the future. The strategic plan maps out ideas from the vision while focusing on the mission of the organization.Implementation of the strategic plan requires strong leadership and managerial skills, support from the board of directors, administrative acceptance, and an understanding by all employees. It is critical that members of the organization understand what the strategic plan contains and where it will guide them for the future. Many organizations hold informational sessions to obtain employee input and feedback. Informed employees are happy employees, and there will be greater acceptance when all understand and participate in creating the goals for the organization’s future.

The chart displays the decision-making authority within the organization, illustrating who has the power to make and enforce decisions for the organization. Organizational leadership has the unique ability to implement and follow the values, mission, vision, philosophy, and strategic plan in order to ensure the organization’s future. The leadership of the organization is identified and described in the organization chart.

The formal channels of communication are identified as well as how members fit within the given structure. The chart demonstrates the formal relationships within the organization but does not demonstrate the informal communication and relationships that often develop as a result of working within the organization. The chart shows how the organization is supposed to run and how departments support one another in this process. Charts change frequently and require updating at least annually so that they represent what is really happening within the organization. Organization charts generally reflect the components displayed in Figure 4-1.


Chain of command demonstrates who formally reports to whom within the organization. The vertical lines in the chart represent chain of command. It is a formal line of authority and communication within the organization and the structure. Authority and responsibility are delegated down through the chain of command. This philosophy works well, as organizations are attempting to decrease the number of layers within their structures in order to decrease the number of management positions and save money.

Organizational components.

Line Positions

Line positions are depicted by the solid vertical lines within the organization chart. These lines demonstrate who is responsible to whom within the organization. The positions with the most decisionmaking power are near the top of the organization chart. An example of a line position would be the Nurse Manager of the Pediatric unit, who has power and authority over the staff nurses on the unit. Another example would be the vice president of the organization who reports directly to the president.

Staff Positions

Staff positions are broken horizontal lines or dashes within the organization chart, showing the relationship between two people who work together to support objectives within the organization. These positions are primarily advisory in nature, with no direct authority over the people they are working with. The staff positions support each other within the organization by consultation, education, role modeling, and development. An example would be the vice presidents of the organization with respect to one another. These members advise and consult with each other but report to a person in a higher position, through the vertical line connection.

Organizations would be hard-pressed to function without staff positions. Managers usually work closely with people in staff positions to support a specific cause or opportunity for the unit. For example, the manager works closely with the nursing educator to support the educational needs of the nursing unit. The manager would find it difficult to do this task without the educator’s assistance and expertise. The educator does not necessarily report to the manager, nor do the staff nurses directly report to the educator. This is an example of the advisory nature of the staff position.

Unity of Command

The concept of unity of command is central to the hierarchy of the organization. The overall thought is that each person on the organization chart has one manager or one boss. This is observed on the chart by the vertical solid lines that connect positions on the chart. As health-care organizations continue to grow and increase in complexity, there may be more than one person to whom an employee must report.

Span of Control

Span of control is denoted on the chart as the number of people reporting to each manager. The span of control determines how the organizational structurewill appear on paper (Altaffer, 1998). A wide span of control indicates that many people are reporting to a manager, and a narrow span of control indicates that only a few people are reporting to the manager. In the 1990s, many managers were let go, and their positions were combined to cover many different units in an effort to reduce management costs. Due to the hierarchical nature of the chart, the higher a leader resides within the organizational structure, the fewer the people who report, but the greater the overall responsibility that leader has within the organization. As health-care organizations change and consolidate, upper-level managers are taking on a greater span of control (Altaffer, 1998).


Organization charts also depict how decisions are made within an organization. Centralized decision making occurs when a few people at the top levels of the organizational structure make decisions. Such a chart will appear tall and hierarchical on

paper. Decentralized decision making occurs when decisions are made throughout the organization, at the lowest level possible within the organization. Such an organization chart takes on a flattened appearance. In decentralized decision making, authority, responsibility, and accountability are given to the person closest to the problem to resolve the issue. This method increases employee morale and job satisfaction. Employees given such authority tend to be more motivated and feel valued as members of the organization (Huber, 2000; Marquis & Huston, 2003).

The management and the leadership of the organization have to be comfortable with the type of decision making that will evolve with the organization. The method used to make decisions is influenced by the mission, the vision, the values, and the philosophy. The size of the organization may also influence what method is used.

Type of Organizational Structures

Health-care providers should be familiar with the type of structure used within their organization. The structure affects communication patterns, relationships, and authority within the health-care setting (Marquis & Huston, 2006). The structure provides stability for the mission, the vision, the values, and the goals of the organization. The structure aligns itself with the goals of the organization and provides efficiency for the organization. The structure provides stability for decision making within the organization. The structure determines how the decision will be made. The organization chart depicts the lines of authority and chain of command and identifies communication patterns and relationships for the employees of the organization.


The centralized structure, a tall structure, also known as the bureaucracy, is a hierarchical structure (Fig. 4-2). Decision making and power are held by a few people within the top level. Each person who has some power and authority is responsible for only a few people. There are many layers of


departments, and communication tends to be slow as it travels through this type of a system. This type of structure is noted for its subdivision and specialization of labor. Advantages to this type of structure are that managers have a narrow span of control and can maintain close supervision of their employees. A disadvantage is that there may be a delay in decision making due to the many layers of people that the decision must pass through to get to the top administrative level. It predisposes leaders to an autocratic style of leadership because many decisions must go to the top of the organization or the higher-level supervisor for an answer.


The decentralized structure is flat in nature, and organizational power is spread out throughout the structure (Fig. 4-3). There are few layers in the reporting structure, and managers have a broad span of control. Communication patterns are simplified, and problems tend to be addressed with ease and efficiency at the level at which they occur. Employees have autonomy and increased job satisfaction within this type of structure. A disadvantage is the broad span of control, which may make it hard for management to process information quickly and efficiently for the employees. This is especially true for decisions that need to span the whole structure. Management at all levels takes on a greater sense of responsibility within this structure, so education across teams is important. Managers may be super-

vising areas with which they are not familiar or have limited working experience.


The organic or  adhocracy structure of organization is an open, free-form system. This system has resulted from behavioral research based on job

Decentralized structure

satisfaction and efficiency. This type of structure is used with specialized teams to complete a specific task. From an organizational perspective, the entire organization consists of specialized teams, each assigned to complete a specific task. The major disadvantage of this type of structure is the lack of a formal chain of command. The teams work together, but when problems are encountered there is no assigned person within the structure on whom they can rely for resolution.


The matrix structure is a combination of two structures, consisting of the product (output) and the function, linked into one structure. The function consists of all of the activities and duties needed to produce an end product, and the product is the result of the function. The structure works to balance the function and service of the organization into one operational outcome. The functions are the tasks required to complete the product. The manager of the product division works with the manager of the function division, creating two lines of authority, accountability, and communication. The team approach is incorporated, and there is a decrease in the number of formal rules for this type of structure. Issues with the matrix structure include the vague chain of command and goal variation between the two structures. This type of structure implements the use of resources efficiently.


As health-care organizations continue to change and reorganize services to meet the needs of the customer, so will the look of the structure. Many services are changing and becoming more accessible for the patient entering the complex health-care arena.

Integrated Health-Care System

Integrated health-care systems can be defined as innovative, patient-centered hospital delivery systems that continuously improve quality and use resources cost-effectively (Effken & Stetler, 1997). This type of system evolved as a result of changes in reimbursement and managed care. An integrated health-care system is a network of structures combined into one to provide better continuity of care for patients in the most applicable setting. The networks share the risks associated with the cost to provide care to the patients (McCarthy, 1997). By providing services in the most appropriate setting, the costs can be contained, which allows for a better patient outcome. The push for an integrated system stems from the need to improve the quality of care within organizations, to reduce costs associated with health care, and to ensure patient/customer satisfaction (Wolf, Hayden, & Bradle, 2004). The single hospital of yesterday is now a component of a much larger system, offering a wide range of services for the consumer. Integrated health-care systems attempt to keep costs down and keep dollars for care within their own systems. This type of consolidation also assists and prepares for managed competition. One example of a cost control measure includes redesigning practice to serve the organizational and patient needs better. Management systems look collaboratively at patient care and outcomes of care. It is important for nurses to know and understand how these systems work and what can be done to enhance them.

The services offered can include a combination of any of the following: hospital, clinics, home health, community health, school nursing, longterm care, and rehabilitation services. When services vary like this, it is known as vertical integration, which provides a range of health-care services across the life span (Newhouse & Mills, 1999). When the integrated system consists of a chain of similar services, such as all hospitals or clinics, this is known as horizontal integration.


There are three types of health-care services on the health-care continuum. Integrated systems often provide all three types. The shift to managed care has also changed the focus from secondary and tertiary care to primary health care. Primary health care prioritizes the importance of health promotion and illness prevention. This is the first line of defense for health care. Examples of health-care services provided in primary care include physician visits, immunization clinics, mammography, and teaching and education for clients. Primary health care covers services that prevent illness. Secondary health-care services focus on treating diseasethrough intervention. The patient has a health alteration and seeks treatment to improve the current state of health. Secondary health-care settings include the acute care setting, such as inpatient hospitals, surgical centers, and birthing centers.

Tertiary health-care services focus on the restoration and rehabilitation services for patients with chronic health-care needs. The goal is to maintain the current state at the best possible level of health. Health-care settings include long-term care facilities, hospice, and rehabilitation centers. Managed care is the umbrella term that is used to address the financing and risk management for services provided in integrated health-care systems. Managed care unites the financing groups with the providers of care. The goal of managed care is to establish programs that benefit all key participants, including the insurance companies and the physicians. The push for managed care was evident as the health-care industry continued to become more complex and difficult for patients to maneuver and understand. Intensifying these concerns was the increase in cultural diversity served by the private sector (Valanis, 2000). The managed care model is the only health-care delivery model formulated from market and customer response, as compared with government and legislative initiatives (Kelly Heidenthal, 2003; Liberman & Rotarius, 2001).

Managed care involves a prepaid mechanism, which means that a predetermined dollar amount is established to cover the cost of the health-care service. Care that is rendered is selective and requires prior authorization. There are many types of managed care products in use currently. The most common is the health maintenance organization (HMO). The HMO plan offers health care for its members for a fixed prepaid amount. An enrolled group of patients participates in the plan, and the provider is considered an employee. The provider receives a fixed payment for the services from the subscriber and assumes the financial risk. The advantage of a managed care program is cost reduction. There is a gatekeeper for the patient, usually the primary care physician. The gatekeeper’s role is to oversee and coordinate services for the patient in the mix of the system. A disadvantage to managed care includes limitations to specialized care needs; some organizations are profit-driven and limit their services. Patients in health care today are discharged quicker and sicker, with only limited services available outside of the acute care setting.

Professional Practice Models

In organizations where nurses are employed and valued, management has developed and implemented opportunities for professional, autonomous nursing practice. Shared governance is defined as “structures… based on a set of principles about the relationship between the worker and the workplace” (Porter-O’Grady, 2003, p. 251). The push was for decentralized nursing leadership and decision making for professional nurses. Such a structure is based on the values of interdependence and accountability for nursing practice. The objective is to empower the nursing staff through involvement in decisions that affect their specific work areas (Erickson, Hamilton, Jones, & Ditomassi, 2003). The outcome from implementation of a professional practice model is that nurses have control of their nursing practice. Nursing staff participates in nursing committees that cover topics such as education, community involvement, research, quality control, and staffing, scheduling, and hiring practices.

The uniqueness of this structure is that nurses gain control and autonomy over their professionalnursing practice. Governance models are designed to link values and nursing practice beliefs to achieve quality care (Anthony, 2004). There are more opportunities to be involved in decision making and have a voice within the organizational structure. As the nursing staff members serve on the various committees, they plan and organize the care of the patients and establish standards for nursing care based on research and evidenced-based practice.


The American Academy of Nursing (AAN) began to review and identify as magnet hospitals those hospitals that had solid organizational structures and a decentralized, open management style. This concept became popular in the 1980s in relation to professional practice model concepts. The goal of the magnet organization was to demonstrate autonomous nursing practice through selfgovernance, appropriate staffing, clinical expertise, and clinical ladder career opportunities (Upenieks, 2003).

To obtain magnet status, hospitals demonstrate that the structure in place is exemplified through a professional practice model that promotes excelence in nursing. Compliance with the identified standards must be demonstrated at all levels of nursing care within the organization (McClure, Poulin, Sovie, & Wandelt, 1983). Multiple days of onsite evaluations to assess organizational magnetism are conducted by the accrediting organization, American Nurses Credentialing Center, to determine if magnet status can be awarded. Status is awarded for 4 years. To achieve magnet status, there must organizational and nursing leadership linkages. There are 14 criteria necessary to obtain magnet status:

1. Quality of nursing leadership

2. Organizational structure

3. Management style

4. Personnel policies and programs

5. Professional models of care

6. Quality of care

7. Quality improvement

8. Consultation and resources

9. Autonomy

10. Community and the hospital

11. Nurses as teachers

12. Image of nursing

13. Interdisciplinary relationships

14. Professional development

Organizational Culture and Climate

All organizations have an informal structure that is not identified on the organization chart. It comprises the social networks and relationships that develop in the work setting. It provides a sense of belonging within the organization, also known as the culture and climate of the organization. These concepts provide insight into the organization and help influence change.


Culture can be defined as the assumptions and beliefs that organizational members have in common. It is the “shared values and beliefs within the organization” (Huber, 2000, p. 437). The culture of the organization contains the norms that characterize the environment (Sleutel, 2000). The culture gives a sense of identity to its members and their commitment to the organization, and it helps to determine the behavior of the organization. It drives the work and the quality of the care within the organization (Gershon, Stone, Bakken, & Larson, 2004).

Culture also means that there are things in the environment that are constant, unspoken, and rarely subject to change. The culture consists of things that are not written down but are known by all members. The organizational culture affects the outcomes of quality for the organization. The culture is learned through the relationship between behaviors and the consequences (Jones & Redman, 2000).


The climate of the organization is the “perception of how it feels to work in a particular environment” (Snow, 2002, p. 393). Components of the climate are specific and easy to measure. Some characteristics of climate include amount of involvement members can have, supervisor support given, amount of responsibility given, commitment of the members, flexibility of the work setting, and standards set for improving practice. The key assessment question to ask regarding the climate of an organization is “Would I want to work here? Why or why not?” The climate comprises the social aspects of the organization that make the members feel like they are a part of the team.

All Good Things…

Health-care organizations face many changes in today’s world. Nurses are a major component of a health-care organization, and it is imperative they understand the structure in which they provide nursing care. The structure of the organization is defined by the organization chart. This chart indicates who reports to whom and who is responsible and accountable for the functions of the organization. The organizational structure defines the arrangement of the work groups. Organizations today that have a strong value set, mission, vision, and philosophy are better prepared to meet everchanging events and the needs of their customers. This chapter defines organizational theories, different types of structures, lines of authority andaccountability, and the components of the organization chart. These are all elements that help members understand their work environment. Nurses need to be knowledgeable and comfortable within the culture and the climate of the organization. Many organizations are improving their work environment through shared governance and magnet status for the nurses. This provides autonomy and demonstrates the importance of a professional practice environment for the registered nurse.


Legal and Ethical Knowledge for Nurses

Understanding the legal and ethical issues involved in nursing practice is critical for all nurses, especially managers and leaders. Legal and ethical issues are intertwined in many ways, but the two entities are distinct bodies of thought and practice. Ethics and laws both derive from societal values. Ethics is a branch of philosophy that involves clarification of the “shoulds” and “oughts” of individuals and society. Ethical decision making entails a distinctive choice between undesirable options. Ethical algorithms help to guide decisions by looking at multiple dimensions of the situation under review. Laws, on the other hand, are set down by the state or federal governments, administrative agencies, or courts, to establish boundaries of behaviors for society. The legal process constantly questions and debates the law on both legal and ethical planes. To clear some of the confusion that often sur-rounds ethics and law, it is important to point out that ethics deals with the “should and should nots” that are related to behavior or actions taken by an individual. Ethics also deals with the questions of why an action is reprehensible or not reprehensible (Fry & Veatch, 1992). The legality of these choices is always a strong consideration when attempting to resolve ethical dilemmas. Ethical dilemmas in health care come up frequently, and they often address life and death issues. Nurse leaders must be prepared to address these issues in order to guide the members of their nursing staff. This chapter considers the aspects of the legal system with which the nurse leader must become familiar and then explores the foundations of ethics and ethical decision making.

The Legal System

The American legal system is based on the early English system of common law. Common law refers to case law that is directed and made by a judge rather than by a governmental legislative body. This type of law is set by precedent or the principles of stare decisis, along with the factual scenario of a given case. These laws build from one case to the next, as each judge’s decision sets the precedent for future cases. In addition to federal law, Pohlman points out that each state court system has it own “case law [emphasis added] based on the interpretation of its respective statutes” (Pohlman, 1990, p. 296). State and federal legislative bodies create statutes according to societal need. Administrative agencies detail the implementation of these statutes, and the courts interpret confusion over the meaning of the statutes.


Federal laws affect nursing practice by setting minimum standards of care for all agencies receiving federal funding. Nurses must become familiar with federal legislation, such as the Health Insurance Portability and Accountability Act, which guarantees the privacy of a patient’s personal health information; the Emergency Medical Treatment and Active Labor Law (EMTALA), and the Americans With Disabilities Act (ADA). According to Moy (2003), EMTALA prohibits refusal of care for indigent and uninsured patients seeking emergency care in the emergency department. It prevents hospitals from “dumping” indigent individuals on other hospitals. The ADA also affects nursing intimately. This law proscribes any discrimination against individuals with disabilities by offering them the same opportunities as individuals without disabilities. For instance, if an individual with disabilities is the most qualified individual for a job but requires reasonable accommodations by the employer in order to take the job, the employer must make these accommodations. See Box 5-1 for others federal laws affecting nurses.


State laws also regulate nurses. Nurse practice acts (NPAs) are created by state legislatures to define, limit, and oversee nursing practice. Nurses must be familiar with the NPA in the state in which they are practicing. NPAs set the requirements for becoming licensed as a nurse in a given state, for renewing one’s license, and for continuing education. They define the duties and responsibilities of nurses in the state and limit the scope of practice. Many NPAs include safe harbor laws, which limit nurses to practicing only in their area of expertise. For example, they prevent a rehabilitation nurse from being pulled into intensive care because of a staff shortage. Other NPAs include good samaritan provisions, which protect nurses from liability for

volunteering to help in an emergency situation. These provisions apply, for example, if a nurse stops at the scene of a car accident to assist victims. If something goes wrong, the victims of the car accident could not sue the nurse for malpractice. NPAs also address charting and physician orders. They specify that nurses must be skillful, correct, timely, and thorough in their charting. With respect to physician orders, most NPAs make nurses responsible for ensuring that orders are clear and accurate. If the nurse needs clarification, she must seek it from the physician giving the orders. The nurse is obligated to follow the physician order, but if she believes that doing so would be dangerous to the health of the patient, she is responsible for contacting her supervisor and following through with the institution’s policy regarding physician orders.


Along with federal and state statutes, common law guides nursing practice. In order to understand how common law works in practice, consider the precedent-setting case of  Utter v. United Hospital Center, Inc. (Giordano, 2003). This case involved a patient developing compartment syndrome after his arm was put in a cast. The nurse caring for this patient failed to acknowledge and recognize the signs and symptoms of compartment syndrome and did not request medical intervention. This case set a legal precedent that is still followed by other courts: nurses are required to exercise independent judgment to ensure patient safety and to prevent harm. Case law touches on a range of issues that involve nursing practice, including nursing malpractice, practicing medicine without a license, wrongful termination, legal challenges to a nurse’s license, and questions regarding collective bargaining and labor laws. Nurse managers must work in collaboration with risk managers to make staff nurses aware of and educated about relevant case law.

There are two major categories of common law that nurses must understand: civil and criminal law. Civil law involves violations between people regarding everyday matters. Criminal law regulates offenses against individuals and society, violations made with criminal intent. Tort law is one of the major branches of civil law. Contracts is the other major branch. According to Hall (1990), a tort is a wrongdoing or injury that is committed against a person’s property or person. The basis of this type of action is the liability by one individual against another. Contracts law revolves around an offer and acceptance of terms between two or more individuals or organizations. The law specifies when these agreements should be upheld and when they should not be upheld.


There are two types of torts: unintentional and intentional.

Unintentional Torts

Unintentional torts include the two types of tort that most frequently affect nurses, negligence and malpractice. Negligence is the failure to act as a reasonable or prudent person would act in the same or similar circumstances. Malpractice is a form of negligence committed by a professional, such as a nurse, by which professional misconduct, unreasonable lack of professional skills, and/or noncompliance with accepted standards of care causes injury to the client (Creighton, 1986).

There are a number of elements involved in both negligence and malpractice (Box 5-2). In order to establish liability for negligence, the existence of a duty must first be established. This duty and/or

obligation from the nurse to the patient is created by law, standards of practice, or contract (Creighton, 1986). For instance, if a nurse is late to shift change, the nurse waiting for the nurse running late may not leave or abandon the clients in their care until the other nurse arrives because that nurse hasa legal duty to the clients. If there is an urgent reason that the nurse on duty must leave, then the manager or supervisor must be notified so that another nurse may fill the position until the late nurse arrives. This leads to the second element needed to establish negligence, a breach of duty by the nurse. If the nurse breaches a duty (i.e., left the clients without waiting for the late nurse to arrive and without finding a replacement), there is evidence of the second element of negligence (Fry & Johnstone, 2002).

The third element needed to establish liability for malpractice is  causation, or proximate cause. Causation means that the nurse’s breach of duty is reasonably close to or causally connected to the injury or damage to the client. Damage or actual harm is the fourth element needed to prove malpractice. Without harm or injury, no cause of action exists. This harm may be physical, emotional, and/or financial (Furrow, et al., 1991). There must be proof of a direct relationship between not meeting a standard and the injury sustained by the client. The fifth and final element of malpractice is the forseeability of an event. Foreseeability in this context means that the damages must be a reasonably expected result from the breach of duty. Nurse executives/managers need to be aware of the current trend toward the criminalization of professional nurses’ negligence. A nurse-attorney shares a personal communication of May 14, 1997, reported by Burkhardt and Nathaniel (1998). The communication is as follows: “Until recently, the risk of criminal prosecution for nursing practice was non-existent unless nursing action arose to the level of criminal intent, such as the case of euthanasia leading to murder charges. However, in April, 1997, three nurses were indicted by a Colorado grand jury for criminally negligent homicide in the death of a newborn. Public records show that one nurse was assigned to care for the baby. A second nurse offered to assist her colleague in caring for the baby. A third nurse was a nurse practitioner working in the hospital nursery. Because the baby was at risk for congenital syphilis, the physician ordered that the nurse give 150,000 units of intramuscular penicillin, which would have required five separate injections. In relation to other problems the same day, the baby was subjected to a lumbar puncture, which required six painful attempts. To avoid inflicting further pain, Nurse Two asked the nurse practitioner if there was another route available for administration of the penicillin. Nurse Two and the nurse practitioner searched recognized pharmacology references and determined that IV administration would be acceptable. The nurse practitioner had the authority to change the route and directed Nurse Two to administer the medication intravenously rather than intramuscularly. Unrecognized by the nurses, the pharmacy erroneously delivered the medication prepared and ready to administer in a dose ten times greater than was ordered—1.5 million units.

As Nurse Two was administering the medication IV, the baby died. The Colorado Board of Nursing initiated disciplinary proceedings against Nurse Two and the Nurse Practitioner, but not against Nurse One. The grand jury indicted all three nurses on charges of criminally negligent homicide, but did not indict the pharmacist” (Burkhardt & Nathaniel, 1998, p. 124). This is a very disturbing example of the criminalization of negligence. The case should be made that the nurses should have double-checked the medication, but there really does not seem to be criminal intent involved. However, recklessness can rise to the level of crimi nal negligence, and in this case recklessness, not intent, became the issue. Extreme cases of negligence that rise to the level of recklessness, however, can sometimes replace the need for criminal intent. Vicarious liability arises when other parties are held responsible for causes of negligence. In these cases, employers become responsible for employees’ actions. Most employees are supervised, so employers, by virtue of their oversight responsibilities, are held accountable for negligent acts employees commit in the course of employment. Employers also tend to have “deeper pockets” than individual employees, so the doctrine of vicarious liability affords injured clients a greater pool of resources from which to draw. There is often the temptation by nurses to believe they are protected by their employer, but they need to keep in mind the principle of  indemnification when practicing.Under this doctrine, the institution may in turn sue the nurses for damages paid out for substandard care. Nurse managers play an important role in avoiding corporate liability problems by ensuring that employees are delivering high-quality care to their consumers. They must recognize the significance of information gathered, reports, implementation of plans, and evaluation of care on an ongoing basis. This includes client satisfaction surveys and/or other tools, which give information on the consumers’ perception of the care they have received in the institution.

Intentional Torts

Intentional torts are “willful or intentional acts that violate another person’s rights or property” (Berzweig, 1996). There are basically three components to intentional torts:

■ The acts are intended to interfere with the plaintiff and/or the plaintiff’s property.

■ The acts are intentional by the defendant.

■ The acts cause the consequences.

There is no legal requirement for the act causing injury or damage, only proof of intention is sufficient for the courts (Fiesta, 1988). Intentional torts include fraud, assault, battery, informed consent, false imprisonment, invasion of privacy, and defamation, which includes slander and libel. This section briefly describes each in turn. Fraud is deliberate deception to gain unfair or unlawful advantage of a situation. Fraud may occur if a nurse falsifies her employment record or any records at her disposal. According to Guido (2001), civil assault is a threat to touch an individual without consent and causing an immediate fear of harm. The touch does not have to take place; the individual just has to be fearful that it will take place. Battery, on the other hand, is the actual and unlawful touching of the individual’s body or clothes or anything attached to the individual without the individual’s consent. The nurse manager must make sure that their employees understand these two intentional torts and the differences. Fiesta (1988) presents an interesting case in which a Christian Scientist client refused medication and treatment. This client was nonetheless forced to take medication, which the courts ultimately ruled was a battery and awarded remuneration.

Interestingly, one of the most common examples of battery in a hospital setting is surgery being performed without informed consent. Informed consent is the process whereby a client is informed of all possible outcomes, risks of treatments, and alternatives in order to be able to consent freely to the recommended procedure. This means the client has the opportunity and the freedom to make choices in health-care treatment. Confusion arises when the patient is not mentally competent to make decisions about treatment, when there is a language or cultural barrier to understanding the explanation of the treatment and risks, when the patient has not reached legal age to consent but is an emancipated minor, in emergency situations, and when patients refuse to consent despite expected dire consequences for refusal. State laws vary on these subjects. Informed consent is an active and complex area of litigation. Nurses should ensure that valid informed consent exists before performing or assisting with any procedure or treatment. Otherwise, nurses risk possible cause of action for battery. According to Creighton (1986, p. 197), false imprisonment is the unjustifiable and unlawful detention of a client within fixed boundaries or an act with the intention to keep the individual in such a confinement. There are many cases involving false imprisonment. In Big Town Nursing Home, Inc. v. Newman (1970), a 67-year-old man was brought to the nursing home by a nephew, and when he tried to leave, the staff restrained him and denied him use of the telephone or his clothes. The court found the reckless actions of the nursing home willful and malicious in detaining him.

Invasion of privacy is the right to be left alone or free from unwanted publicity. Fiesta (1988) describes four types of privacy invasion: the intrusion of the client’s physical and mental solitude, public disclosure of private facts, any type of publicity that puts the client in the public eye under false pretenses, and any type of appropriation that is a benefit due to the client’s name or likeness (p.160). The case of  Bethiaume v. Pratt involved a dying client who had cancer of the larynx and was repeatedly photographed for use by the physician.

The client asked not to be photographed, but these wishes were ignored, and the court found the physician liable for invasion of privacy (Fiesta, 1988, p.160). Nurse leaders and managers must make sure that a client’s privacy is not invaded during their care. This includes ethical as well as legal overtones in client care delivery. Confidentiality is one of the ethical principles that nursing practice upholds via the American Nurses Association Code of Ethics with Interpretative Statements (2001). Nurse managers must make certain that the privileged information regarding clients in their care is kept confidential. Nurses are privy to highly confidential information regarding client care. Information should be disseminated exclusively on a need-to know basis. Nurse managers should also caution their staff not to discuss interesting client cases in open areas. Nurse managers are charged with the maintenance of nursing standards within the ranks of their nursing staff.

Contract Law

The area of contract law most relevant to nurse managers is employment. Most employment relationships between nurses and employers are “at will,” which allows the employees to quit “at will” and the employer to terminate “at will,” for no reason. An actual employment contract between employee and employer is more binding, however. The nurse promises to provide specific nursing services in exchange for financial reimbursement. If either side violates its promises under the contract, the contract has been breached, and the other part may seek damages.

Contracts also come into play in the labor law arena. Many nurses work under the auspices of a union. The Massachusetts Nurses Association (2003) points out that 35% of nurses with union affiliation make a higher wage and work less mandatory overtime than nonunion nurses. This brings into play collective bargaining agreements, which protect the nurse and will not allow the discharge of a nurse without “good cause.” Nurse

Practice to Strive

supervisors are not allowed to participate in collective bargaining.

Ethical Foundations

Ethics is a philosophy based on moral values and reasoning. It contains distinct conduct rules that


regulate particular choices of actions or decisions (Mappes & DeGrazia, 2001). These rules are based on philosophical theories. Ethics and ethical decision making stem from works of major philosophers, such as Immanuel Kant, Rawls, and Mill (Brannigan & DeGrazia, 2001). Deontology, or formalism, is a theory that focuses on an individual’s motives rather than on the consequences of actions.

Deontology encompasses natural law and incorporates dutiful actions of the individual (Hill & Zweig, 2003). Kant further recognized that reasoning is sufficient in leading an individual to moral actions and that these actions should be commenced as ends in themselves rather than as means to an end (Raphael, 1994). For example, a physician asks a nurse to monitor a depressed 40-year-old patient who has been placed on a new, experimental antidepressant medication. The nurse monitors the patient and tells the physician that the patient said,“The medication makes me feel nauseated all of the time,” but the depression has lifted. The physician makes the decision to maintain the patient on the medication because of the need to continue testing on this new medication. The physician is using the patient as a means to an end rather than demonstrating concerns for the patient’s needs and feelings. Kant insisted that moral actions be placed within the boundaries of reason. He further pointed out that an action is not right unless it has the capability of becoming a binding law for everyone. For instance, in truth telling, if the caveat of telling a lie to please a patient exists, then to tell the truth is not a categorical imperative for everyone.

The other major ethical theory is teleology, or consequentialism. Utilitarianism, which is part of teleology and supports the “the greatest good for the greatest number of people,” considers consequences of actions (Beauchamp & Childress, 2001). For instance, if there were to be a flu epidemic and flu vaccine was limited, the decision would be to allow the greatest number of individuals who would be affected to receive the vaccine first. If after their vaccinations, more vaccine became available, then the remainder of the population could be vaccinated. Utilitarianism truly considers real-life and commonsense approaches. John Stuart Mill expressed the view that pleasure and happiness have different qualities. This followed with the distinction that applying the golden rule in one’s conduct takes precedence over immediate gratifications. Mill thought that the greatest happiness must involve everyone concerned, not just an individual. Therefore, the emphasis of this principle is based on groups aimed at producing the most happiness, focusing on utility, consequences, and means to an end (Raphael, 1994).

Another ethical theory is the more contemporary ethics of care. Mappes and DeGrazia (2001) point toaccepting complex circumstances, the people involved must utilize critical thinking within the context of solving or coming to a resolution of the ethical situation.

Mappes and DeGrazia (2001) also considered virtue ethics as part of the ethical picture. Virtue ethics, according to these authors, originated with Aristotle and is based on the character of the individual. Virtue ethics deals with the good or virtuous character traits that may be engendered within the individual. Aristotle named courage as a virtue, striking a balance between excess courage (rashness) and appropriate courage within a situation. The Greek philosophers always strove for balance between two ends of excesses. Balance was always considered the best approach in dealing with virtues. Aristotle also believed that virtues were attained and developed through training and routine practice. In understanding virtue ethics, it would be reasonable to believe that virtuous individuals facing complex ethical dilemmas would make the right decisions due to their virtuous character.

Beauchamp and Childress (2001) laid the foundation for ethical dilemma resolution in their first edition of Principles of Biomedical Ethics. This book is now into its fifth edition and continues to act as a guide for ethical decision making. Nurse leaders/managers need to consider the following ethical principles in their decision-making process or if they are participating on an ethical committee.


The principles listed in Box 5-3 act as a basic foundation for ethical decision making. The first principle is autonomy, which involves the right to self-determination and to make independent personal decisions regarding care. Beauchamp and Childress (2001) imply that the principle of autonomy is sometimes described as respect for autonomy. An example in health care is the patient’s right to refuse treatment. The only restriction on autonomy that may preclude this right would be a com

municable disease, in which case the patient’s autonomy would be restricted. Devettere (2000) points to the Patient Self-Determination Act of 1990 as the first federal initiative that was introduced and designed to educate patients on the use of advance directives. Currently, hospitals and other institutions provide education and paperwork for patients being admitted who have not implemented an advance directive.

Beneficence is a principle that speaks to deeds of charity, mercy, and kindness toward the individual. It also means promoting the welfare of others (Beauchamp & Childress, 2001) or doing good. Nurses, by the nature of nursing practice, perform beneficent acts.

Nonmaleficence literally means to not harm the patient. Munson (2004) believes this is the overriding principle in the care of patients. Aiken and Catalano (1994) declares that nonmaleficence is the other side of beneficence but that the two cannot be considered independent of each other. Nurses may sometimes violate this principle in the short term in order to give a positive long-term result. An example is chest compressions in the event of heart stoppage in an elderly patient; ribs may be broken, and/or sternal fractures may occur that are harmful, but recovering the patient’s life takes precedence over the harm.

The principle of justice is actually the deontological ethical theory. According to Beauchamp and Childress (2001), it encompasses the entire field of ethics and refers to the right to be treated justly, fairly, and equally. Munson (2004) points out that justice in health care often refers to distributive justice and/or the distribution of scarce health-care resources. Social justice becomes a part of this;

Munson continues that it implies fairness in the treatment of individuals. Nurses should be aware that when indigent patients arrive in the emergency department, they must be treated in an equitable way and that if persons require emergency service due to trauma, nurses must proceed to deliver the service as deemed appropriate. This goes along with Rawls’ concept of a  Theory of Justice (1971). Brannigan and DeGrazia (2001) cited Rawls’ two principles of equality and justice: (1) that everyone should be given equal liberty no matter what adversities exist; and (2) that differences among people ought to be recognized by being inclusive of the least advantaged and given their share of improvements. Others have explored this concept in health care, according to Brannigan and Boss, by proposingequitable health-care systems, benchmarks, and accessible points of entry. Fidelity focuses more on the delivery of health care and literally means keeping one’s promises or obligations to an individual. Munson (2004) suggests that keeping these commitments becomes of paramount importance when considering patient care standards that are to be met by the nurse.

Likewise, nurse managers are bound by their commitments to their employees. In particular, a verbal commitment involving a shift change is a contract with the employee and should be considered as such by the manager.

Veracity involves truth telling by all concerned in patient care. The nurse certainly has an obligation to tell the truth, for instance, when a patient asks about his or her condition. This, however, can take on tones of nonmaleficence when, for example, a cancer patient asks the nurse how long he might live. In this instance, it may be the duty of the nurse not to take hope away from the patient and to provide a positive answer to this question. The answer might include the idea that no one is able to predict death and that there is always hope in life. Here again the balancing of beneficence and nonmalfeasance within the boundaries of veracity is important in the nurse’s actions (Munson, 2004).

The sanctity of life principle is a part of ethical decisions when it comes to withholding or with drawing life-sustaining treatments or assisting sui cide. Sanctity of human life is defined as the obligation not to take human life (Fry & Veatch, 2000). The American Nurses Association (ANA) implies that nurses caring for patients should direct their care toward the relief and prevention of the suffering that is often associated with the process of dying (ANA, 1985, p. 4). This brings into focus the ANA’s position statement (1994) on active euthanasia and its position statement on withholding nutrition and hydration for the patient (ANA, 2001). The latter position should be made by the client or surrogate with the health-care team. Theeducate client family members about the dying process and provision of comfort measures (ANA Ethics and Human Rights Position Statements, April 2, 1992).


Nurses must learn how to make ethical decisions, and nurse managers/leaders must direct and guide nurses in making such decisions. Nurses, in increasing numbers, are being invited to participate on ethical committees. These committees are structured with members of the health-care team, administrators, risk managers, attorneys for the institution, and others. A popular ethical decision model called MORAL was put forward by Thiroux (1977) and Halloran (1982). This model offers a very concise and systematic way of making ethical decisions (Box 5-4). It is most important that ANA carefully considered the benefit-and-harm relationship of withholding nutrition, recognizing that, sometimes, living causes more harm to the individual than dying. The ANA differentiates between artificial nutrition and the individual being able to consume food and water by mouth. The ANA states that only artificial nutrition may or may not be justified. If the individual is unable to make decisions, then the surrogate must be relied upon. Nurses must continue to give good care and

ethical decisions be reached in a timely manner. and the use of this model certainly facilitates the process.

Ethics and ethical decision making have become a thread that is followed throughout the nursing curriculum. The American Association of Colleges of Nursing (AACN) has presented a set of nursing values for nursing students to internalize into their nursing education (Box 5-5). These essential values follow closely the aforementioned ethical principles as a guide for the profession and provide a foundation for future nursing leaders and managers to build upon.

All Good Things…

Legal and ethical issues are moving to the forefront of professional nursing practice. The current societal values are changing, and there is an increasing abundance of litigation in the health-care arena. Along with this, the rapid changes in technological advancement keep health professionals in a constant state of training. Nurse executives and managers must know the law and ethics as well as understand the ramifications of making sure their employees are also knowledgeable of the law and ethical dilemmas. The laws that affect nurses are critical for nurse executives to understand and follow by making their employees knowledgeable about the pitfalls that may arise due to not meeting standards of care in their units and what may happen to them legally due to this failure to meet standards of care. Along with the legalities of practice and care go the ethical issues involved in practice. Understanding ethical foundations, ethical decision making, and ethical committees is an important part of the nurse executive/managerial role.


Regulating Nursing

Nursing practice is regulated on the state and federal level. Nursing regulation “began as a simple registry process to protect the nursing title and the public” (Flook, 2003, p. 160). The primary purpose of nursing regulation today is not only protecting the public through a defined nursing practice but also regulating nursing education and “overseeing the competence of nurses through licensing and disciplinary rules and regulations” (Flook, 2003, p. 160). The authority to license and discipline the nursing profession is granted to each state’s board of nursing, often called the board of nurse examiners (BNE) through state legislation creating a nursing practice act and mechanisms for licensure.

The Nursing Practice Act

At the state level, nursing is regulated by the nursing practice act, which provides for licensure as a registered nurse. A state’s act defines nursing and the standards of care. The nurse is licensed to practice under the state’s act. The act defines specifically what the reasonable nurse is licensed to do to meet the standards of patient care.


The standard of care (Box 6-1) is “that degree of care, expertise and judgment exercised by a reasonable and prudent nurse under the same or similar circumstances [through] use of nursing process” (O’Keefe, 2001, pp. 552–553).

Licensure is the “mechanism by which a state establishes and verifies compliance with [nursing] standards” (O’Keefe, 2001, p. 542). The act regulates nursing through the BNE, which oversees the nurse’s compliance with the nursing standards and grants licensure.

Certification acknowledges nursing competence at an advanced level of practice. Gunn (1999, p. 135) believed that society and patients in general have grown skeptical of the willingness of the nursing profession to police itself. In the 1970s, skepticism coupled with a malpractice crisis forced regulators of nursing practice to move beyond “one-time testing for a lifelong credential, to other alternatives for assuring competency in nursing

practice.” Currently, the focus varies on a state-bystate basis, from voluntary to mandatory requirements for continuing education as a mechanism for either continuing certification or recredentialing. Certification involves “examinations developed by professional organizations which provide certification of a claim to competence at a certain level of practice” (O’Keefe, 2001, p. 532). The graduate nurse must possess the competence to practice independently, a declaration that must be demonstrated and supported by documentation (Texas Board of Nurse Examiners, 2004). A nursing competency is the skill and behavior required to perform the role of a nurse.


By definition, an advanced practice nurse (APN) is “a registered professional nurse who is prepared for advanced nursing practice by virtue of knowledge and skills obtained through a post-basic or advanced educational program of study, [and] acts independently and/or in collaboration with other health care professionals in the delivery of health care services” (O’Keefe, 2001, p. 529).

Regulating Advanced Practice

Advanced nursing practice is regulated by and built upon standards of care for the registered nurse, identified within each state’s nursing practice act. See Box 6-2 for the definition of an APN in Texas. Prior to1971, most states made it illegal for any nurse to perform diagnosis or prescribe treatment. Regulation of APNs and programs for their preparation by boards of nursing vary from state to state. Fenton and Thomas (1998) reported that boards have authority only to regulate advanced practice through: (1) the recognition of the APN and (2) the setting of standards and scope of practice. Fenton (1998, p. 78) noted the “lack of consistent APN educational program standards and experiences and criteria for recognition of APNs was problematic at the levels of accreditation, certification, and regulation.” As a consequence, the Texas Board of Nurse

Examiners developed a model designed to ensure the education and recognition of the APN, emphasizing both professionalism and public safety (Fenton & Thomas, 1998).

For example, APNs practice via protocols or other written authorizations. See Box 6-3 for a definition of these protocols and other written authorizations under the Texas Nursing Practice Act. Roemer (1977) reported that states have been increasingly liberalizing the scope of nursing functions, making it possible for the APN to assume functions formerly not within the nurse’s scope of clinical practice. In some states, some of these advanced practice functions are allowed under doctor’s supervision. In other states, especially in rural areas, the APN may function independently. The independent action, however,  such as dispensing medications, may be limited to a single course of treatment.

Midwives tend to function independently. According to Roemer (1977), nurse-midwives have been accepted as extensions of scarce medical facilities, generally authorized to provide prenatal and postpartum care, handle normal deliveries, and do family planning work, including fitting diaphragms and inserting and removing IUDs. Moreover, courses for family planning nurse practitioners have been set up across the United States. Graduates may, with medical direction: (1) perform bimanual pelvic examinations and breast examinations; (2) prescribe contraception; (3) fit diaphragms, insert IUDs, and examine vaginal secretions microscopically; and (4) refer patients with problems to physicians. Roemer (1977) also reported a California program of both registered and nonregistered nurses trained as women’s health specialists, who make routine examinations in both pregnant and nonpregnant women, to give family planning advice. Non-RN family planning specialists being trained included (1) licensed vocational nurses, (2) baccalaureate degree holders in non-nursing fields, and (3) qualified persons with less formal education. This 24-week course was authorized under the California State Department of Health. According to Roemer, the use of the APN would (1) help make family planning and well-baby services more generally available and (2) conserve valuable physician time for those cases that need greater skill and training.

As standards of nursing care vary from state to state, so does the regulation of the APN. Ponto,

Sabo, Fitzgerald, and Wilson (2002) report that many other state boards of nursing are examining advanced nursing practice to determine a process to recognize and regulate such practice for the purpose of eventual uniformity of the nursing law. For example, in 1999, Minnesota state law was redesigned to define and provide protection for advanced practice registered nurses. The Minnesota Board of Nursing convened to develop (1) recommendations regarding issues of certification, (2) criteria for determining acceptable certifying organizations, (3) procedures in the event of examination failure, and (4) a process for communicating this information to the nursing community (Ponto et al., 2002).

Scope of Practice for Clinical Nurse Specialists

A clinical nurse specialist (CNS) is an APN who has specialized education and training in one clinical area. For example, the psychiatric CNS focuses on treating the patient in the clinical area through patient or staff education, consultation with psychiatric nursing or other staff, and structuring patient therapies. See Box 6-4 for the scope of practice for the APN.

Heitkemper and Bond (2004) believed that the CNS is critical to providing leadership to improve patient care, advancing nursing practice, and strengthening health-care delivery systems.

The scope of nursing practice has been expanded to encompass nursing via various technologies. For example, with the advent of telenursing, states must now extend the scope of practice across state boundaries.

The Effects of Telenursing Upon Expansion of Nursing Practice Acts

Nursing practice acts—developed by the individual states—traditionally have regulated the nurses that practice within the state. Telenursing challenges this boundary-driven regulation. Telenursing is

the “electronic transfer of nursing data, nursing information, and nursing expertise between two points” (O’Keefe, 2001, p. 552). Because nurses are now able to practice outside of their state without actually traveling, telenursing has had a considerable impact on the expansion of nursing practice acts. Hutcherson (2001, p. 4) opined: “During the last century the world has become increasingly reliant on a variety of technologies to manage information needs. Escalation in deployment of remote technology to enhance health care, accompanied by expanded public and private reimbursement for distant care, indicates increasing acceptance of these technologies. Yet many legal and regulatory questions regarding the provision of health care using these technologies remain.”

The age of informatics has opened a new era for nursing practice, taking advantage of advances in telecommunications technology that has allowed nurses to provide patient care in different geographic locations throughout the country (Hardin & Langford, 2001). The state-based system of nursing practice acts is being challenged by this new practice environment.

The Nurse Licensure Compact

To accommodate new technology, states have created the  interstate compact (Hardin & Langford, 2001). An interstate compact “is an agreement between two or more states established for the purpose of remedying a particular problem of multi-state concern” (National Council of State Boards of Nursing, 2005, citing  Black’s Law Dictionary). In this instance, the compact, developed by the National Council of State Boards ofNursing, “allows nurses to practice outside their state of licensure, as long as the nurse adheres to the nurse practice act in the state in which he/she practices” (O’Keefe, 2001, p. 541).

The compact utilizes the  mutual recognition model, which is a model of nursing licensure that “allows a nurse to have one license (in the nurse’s state of residency) and to practice in other states, as long as that individual acknowledges that he or she is subject to each state’s practice laws and discipline. Under mutual recognition, practice across state lines is allowed, whether physical or electronic, unless the nurse is under discipline or a monitoring agreement that restricts practice across state lines. In order to achieve mutual recognition, each state must enter into an interstate compact, called the Nurse Licensure Compact (NLC or Compact)” (National Council of State Boards of Nursing, 2005).

The NLC grants the nurse a multistate licensure privilege, meaning “the authority to practice nursing in any compact state that is not the state of residency,” without the need of an additional license. See Box 6-5 for a listing of states currently participating and/or pending participation in the NLC.

But the NLC also provides that the nurse is accountable for complying with the nursing practice laws, regulations, standards of care, and competencies in the state where the patient is located at the time care is provided (National Council of State Boards of Nursing, 2005). This is a daunting task because the terminology within the nursing practice acts varies from state to state.


The terminology used within the acts differs and varies from state to state. For example, Lavin, Meyer, and Carlson (1999) reviewed the use of the term “nursing diagnosis” in the nursing practice acts in the United States. They divided the nursing practice acts of the 50 states and the District of Columbia into those that did or did not include within a nursing context: (1) the term “nursing diagnosis” or (2) the word “diagnosis.” The findings revealed that 33 of the 51 nursing practice acts used the term “diagnosis” within the nursing context. They concluded (p. 57): “The majority of practice acts now define the practice of professional

nursing as including the diagnostic act, althoughthe manner in which they use the term varies.”Marrs and Alley (2004) conducted a descriptive study to explore related regulatory terminology used in nurse practice acts from the 50 states and Washington, DC. They discovered, for example, that although terms such as moral turpitude, moral character, and morality were used by approximately half of the states, the terms typically were not defined.

They suggested: “Agreement among states on uniform definitions and standards of nursing practice can be a step toward aligning practice acts, bringing consistency to disciplinary actions, and informing the public about the profession’s standards for practice.”


Nursing regulatory boards have the power to take disciplinary action against licensees who have violated the state’s act. Typically, license suspension is a common penalty. For examples of violations of an act and grounds for disciplinary action, see Box 6-6. Disciplinary action in most states is a function of the state board of nursing. But boards also promote rehabilitation for nurses while they regain competence. Lewallen and McMullan (2001) reported that as part of the disciplinary process, the state board of nursing may require licensees to take courses in legal-ethical decision making and/or pharmacology. They indicate that this form of rehabilitative discipline redevelops nursing competence in the following manner: (1) during the courses, the licensees must acknowledge their specific violation and explore the reasons for occurrence and strategies for prevention and (2) on completion of the courses, instructors submit required course materials that are used for consideration of relicensure decisions. These rehabilitation courses, designed to return the nurse to competence, are developed based on nursing standards and required competencies identified in the state’s nursing practice act.

Nursing Competencies

The graduate nurse must possess the competence to practice independently, a declaration that must be demonstrated and supported by documentation (Texas Board of Nurse Examiners, 2004). A nursing competency is the skill and behavior required to perform the role of a nurse. Carlson, Kotze, and van Rooyen (2003, p. 30) have noted “the clinical learning environment creates many opportunities for student learning and the development of critical competencies in the

nursing profession.” They conducted a study that “revealed that the students experience uncertainty due to the lack of opportunities to develop competence in providing nursing care.” Four factors these researchers identified as contributing to the students’ ability to develop essential nursing competencies included (1) availability and accessibility of competent staff; (2) sufficient equipment to fulfill nursing duties and meet the needs of patients; (3) consensus in the expectations of nursing school and clinical nursing personnel in hospitals on the patient standard of care; and (4) awareness among faculty of the needs and problems of first-year nursing students in the clinical health-care environment in meeting standards of care. Unfortunately, students often find that the very nature of the clinical learning experience may interfere with their abilityto develop nursing competencies, as the guidance and support by nursing personnel in the clinical learning environment are often inadequate due to the current critical nursing shortage.

The development, measurement, and documentation of essential nursing competencies will be discussed through exploration of (1) essential nursing competencies, (2) measurement of competencies in clinical practice, (3) competencies critical to nursing management, (4) competencies critical to advanced nursing practice, and (5) competencies in nursing informatics.


Nursing competencies to be developed, documented, and validated in the student’s clinical setting include (1) the core competency of caring, (2) competencies essential to patient care, and (3) competencies in specialty practice.

The Core Competency of Caring

Care is a competency often elusive of measurement and/or validation. But caring in professional nursing has been described as the essence of nursing (Sadler 2003). Woodward (2003, p. 215) postulated: “Human caring, while instinctive, can also be taught, learned, and measured through the nursing education system … suggest[ing] people enter nursing because they value interpersonal relationships, altruism, and a desire to help others.” This “caring ethic” can be built upon. Woodward (2003) believes that nursing students can be professionally trained to develop the competency of caring through the concepts of modeling and role modeling. Modeling is “the process used by the nurse to develop an image and understanding of the client’s world—an image and understanding developed within the client’s framework and from the client’s perspective.” This simply means to “walk a mile” in the patient’s shoes. “Role modeling” was defined as utilizing “the facilitation and nurturance of the individual in attaining, maintaining and/or promoting health through purposeful interventions” (Woodward, 2003, p. 215; citing Erickson, Tomlin, & Swain, 1983, p. 95). But Sadler (2003) measured the self-reported competency of caring in baccalaureate nursing students, using the Coates Caring Efficacy Scale (CES) (2003). Sadler found that “final semester seniors identified their families as making the greatest contribution to their development of caring; only a few reported the influence of the nursing curriculum” (Sadler, 2003, p. 295). Regardless of its origin, the competency of caring appears to be the basis and framework for the development of other essential nursing competencies.

Competencies Essential to Patient Care

Part of the challenge of preparing new graduates for practice is ensuring skill in providing a broad continuum of patient care. Utley-Smith (2004, pp. 166–170) identified six categories of competencies for new baccalaureate graduates in today’s healthcare environment:

1. Health Promotion Competency: involves interventions initiated by the nurse to promote and improve health in individuals, families, and communities. The focus of the intervention “is on assisting clients to maximize their health potential and enhance their well-being.” Therefore, client assessment and intervention are equally important parts of this competency.

2. Supervision Competency: involves the graduate nurse’s ability to coordinate the implementation of a nursing care plan, by ancillary or subordinate members of the health-care team who are responsible for carrying out specific aspects of the health plan.

3. Interpersonal Communication Competency: “encompasses relationship skills that enable the nurse to work effectively on a team … such as communication, negotiating, problem-solving, and collaboration.”

4. Direct Care Competency: encompasses the psychomotor skills necessary to deliver patient care including, for example, medication administration, wound care, and injections. Essentially, these competencies are those skills that “require the nurse to use hands or body to manipulate equipment and the client.”

5. Computer Competency: “refers to the ability of the nurse to use electronic and technological equipment to access, retrieve, and store information that assists in the delivery of effective nursing care.”

6. Caseload Management Competency: concerns the nurse’s ability to coordinate care for a specific number of clients. This may involve direct care as well as time and resource management over a particular period.

These findings identify and encompass critical outcome competencies that define the standards of care for the graduate nurse in both the classroom and clinical settings (Utley-Smith, 2004). Graduate nurse will also have the opportunity to develop specialty competencies within their traditional course work.

Competencies in Specialty Practice

RN-to-BSN specialty courses often move from a traditional model to a competency-based model, according to Foss, Janken, Langford, and Patton (2004). For example, within a psychiatric nursing program, a student may be assigned to work with a probate court as the court’s visitor, assessing the ward’s psychiatric status and need for continuing guardianship. Specialty competencies as a court visitor are then used to measure the student’s course learning outcomes, such as the student’s ability to determine if the psychiatric ward meets the standard of care for the psychiatric patient. Faculty can then document not only student learning outcomes but also mastery of competencies within this specialty area of practice.


Staff development professionals and continuing education instructors have always been concerned with maintaining continued competency of the clinical practitioner in nursing practice. Waddell (2001) reported that the issue of competence reached new levels of significance because of proposals made by the Pew Commission Taskforce on Health Care Workforce Regulation and the National Council of State Boards of Nursing. Waddell (2001, p. 2) believed that these two powerful organizations have forced the nursing profession to re-examine the question, “How do we promote and assure continued competence?” Waddell believed competence should be assessed via (1) mandatory continuing education, (2) peer

review, and (3) practice or process audits used to assess continued competence. But Waddell suggested that the actual measurement involved in the assessment and verification of nursing competence should be established by (1) utilization of appropriate measurement scales; (2) selection of accurate measurement instruments, i.e., a reliable, validated competency scale; and (3) interpretation of the measurement data by nurses qualified in informatics.

Nursing competence may be measured and validated by utilizing a variety of mechanisms to document compliance, including the (1) videotaping, (2) preceptors’ record of competency-based orientation, (3) development of a portfolio of competence in clinical practice, (4) nurse’s self-assessment of competence, and (5) utilization of the hospital intranet.

Videotaping to Assess and Document Competencies and Course Outcomes

The challenge in nursing education, according to Winters et al. (2003, p. 472), is how to develop a mechanism for “effectively teaching competencies and allowing students to safely practice essential nursing skills.” They suggested videotaping, as this medium “offers a safe way … to practice skills and develop confidence prior to actual performance …[it] is a teaching-learning strategy used to help…develop effective communication, physical assessment, and selected psychomotor skills … [and] also provides … a mechanism for detailed instructor feedback to improve performance.” For example, the graduate nurse or registered nurse, both required to attend annual cardiopulmonary resuscitation training exercises, may provide videotaped documentation of either attainment or updating of this competence.

The Preceptors’ Record of Competency-Based Orientation

According to Harper (2002, p. 198, quoting Alspach, 1995): “Competency-based orientation is [a program that is] learner focused … based on the attainment of core [nursing] competencies … that are necessary for new employees to function in their [health care] role at the completion of the orientation period.”

Harper (2002) conducted a research study designed to describe preceptors’ perceptions of a competency-based orientation. The results of a 26-item questionnaire indicated that the majority of preceptors agreed on the following components as necessary to meet standards for a basic nursing orientation: (1) attainment of core competencies that are role- and unit-specific, (2) sufficient time for attainment and completion of core competencies, and (3) a preceptor to ensure that competencies are in fact attained and validated, e.g., via an orientation checklist.

Development of Portfolios of Competence in Clinical Practice

A portfolio is a set of documents that “captures learning from experience, enables an assessor to measure student learning, acts as a tool for reflective thinking, illustrates critical analytical skills and evidence of self-directed learning and provides a collection of detailed evidence of a person’s competence” (Scholes, et al., 2004, p. 595).

The purpose of a portfolio is to document and verify achievement of the clinical competencies required to meet the standard of patient care in the area of practice to which the nurse is assigned. They concluded (p. 595): “To achieve maximum benefit from the portfolio as a learning tool to link theory and practice, there needs to be a clear fit between the model of portfolio and the professional practice that is to be assessed.”

When designing a portfolio, nurses, faculty,and/or nursing students must match learning outcomes and/or competencies to their practice, reconstructing those clinical experiences into the format required for portfolio documentation, such as a skills checklist. Through this process, nursing faculty and students undergo a process of deconstructing learning outcomes/competencies, then fitting this information into their unique practice.

Competencies are then reconstructed to fit the structure of the portfolio. According to the University of Michigan School of Nursing (2005), when comparing a résumé with a portfolio: “A career portfolio … is a much more in-depth document, and supplements—not replaces—your résumé … a key feature is the inclusion of artifacts … [or] tangible objects that demonstrate your work … [such as] care plans, brochures, outlines of training sessions, manuals, spreadsheets, memos, etc., that you created by yourself or as part of a group effort.”

These portfolios can be in many formats, including paper or electronic, Web pages, PDF documents, and even PowerPoint. Included within the portfolio may also be documents addressing the nurse’s good faith self-assessment of competency.

A Nurse’s Self-Assessment of Competence Self-assessment tools can also be utilized to document and measure competence in clinical practice. Meretoja, Isoaho, and Leino-Kilpi (2004, p. 124) reported that “self-assessment assists nurses to maintain and improve their practice by identifying their strengths and areas that may need to be further developed … encourag[ing] them to take an active part in the learning process of continuing education.”

Meretoja, Eriksson, and Leino-Kilpi (2002, p.95) collected descriptive data addressing competent nursing practice in a variety of settings. The data came from staff nurses, head nurses, and nursing directors in an acute 1000-bed university hospital.

The descriptive data obtained were then analyzed to identify a set of clinical indicators for generic competencies that could be applied to all clinical practice environments. The Nurse Competence Scale, an instrument utilized to measure the level of nurse competence, was then designed and developed by Meretoja et al. (2004). The 73 competencies were categorized into the following seven roles and functions: (1) helping role, (2) teaching-coaching role, (3) diagnostic functions, (4) managing situations, (5) therapeutic interventions, (6) ensuring quality, and (7) work role. Categories of the scale were derived from Benner’s From Novice to Expert competency framework. The results revealed that the higher the frequency of using competencies, the higher the nurse’s self-assessed level of competence. Age and length of work experience had a weak positive correlation with level of competence (Meretoja et al.,2004). See Box 6-8. The nurses’ self-evaluation of competence in their own job performance may be conceptualized as an indicator of the standards for the quality of nursing care. Tzeng (2004) clustered nursing competencies into the following three general groups: (1) basic-level patient care skills, (2) intermediatelevel patient care and fundamental management skills, and (3) advanced-level patient care and supervision skills. The results of the study revealed “that nurses’ self-assessment of intermediate

patient care skills, the difference between nurses’ self-assessment and job demands for basic patient care skills, and nurses’ overall satisfaction with their own nursing competencies were three significant predictors of overall satisfaction with nurses’ own job performance. Nurses’ self-assessment on basic patient care skills and advanced patient care skills contributed to nurses’ levels of overall satisfaction with their own nursing competencies. These results suggest a relationship between competency and performance” (Tzeng, 2004, p. 487).

Based on these findings, academic nursing courses and on-the-job training programs may be amended to place emphasis on these competencies required to provide high-quality patient care (Tzeng, 2004). Further, self-assessments demonstrate to nursing regulatory bodies good faith in the nurse’s efforts to either achieve or maintain competencies essential to meet the standard of practice.

Utilization of the Hospital Intranet to validate and document compliance with state competency standards

Currently, regulatory agencies require hospitals to provide evidence that employees are in compliance with state-mandated competencies. Wolford and Hughes (2001, pp. 188–189) identified “Intranetdelivered computer-based training as an effective and efficient method of providing and documenting training to meet regulatory requirements.”

For example, regulatory agencies require competency in adapting nursing care standards to the developmental needs of patients. Although Welton, Nieves-Khouw, Schreiber, and McElreath (2000) suggested that training programs on age-specificcare competencies vary widely in format, content, and method, these authors developed computer based training (CBT) programs on age-specific care competencies, using traditional self-paced learning modules. The authors converted printed modules to CBT and pilot-tested experiences of using CBT with clinical staff, ultimately implementing an organization-wide CBT deployment for age-specific care competency and other mandatory training.


Nursing management has its own set of unique competence functions. Connelly, Yoder, and MinerWilliams (2003) categorized a total of 54 charge nurse competencies within the following four categories: (1) clinical/technical competencies, (2) critical thinking competencies, (3) organizational competencies, and (4) human relations skills.

These researchers believe that these competencies define the standard for leadership and management skills required to function as effective, front-line charge nurses. See Box 6-9. Kleinman (2003) noted, “nurse managers are often less well prepared to manage the business activities than the clinical activities.” The nurse managers and nurse executives who were subjects of this research identified staffing and scheduling, management, and human resources as the three most important competencies for nurse managers.

Based on the results of Kleinman’s research (p. 451), and in an effort to develop and validate knowledge of the regulations and standards of practice for a nurse manager that encompass not only the organizational but also the clinical/technical competencies, the subjects of this research suggested: “Strategies nurse executives may employ to develop nurse manager business knowledge include traditional undergraduate and graduate degree programs, online programs, certificate programs, continuing education, in-service education offerings, seminars, and mentoring activities.”


The level and type of competence and education required in advanced nursing practice depend on the area of specialty practice and vary from state to state. The following section discusses (1) generalist versus specialist nursing competencies and (2) competencies required in critical care.

Generalist Versus Specialist Nursing Competencies

A generalist nurse is one who has a duty to comply with the standards of nursing practice as identified in the nursing practice act of the state of licensure. A specialist nurse has a duty to comply with the state’s standards of nursing practice and a duty to comply with the standards of practice as identified in the specialty area, e.g., psychiatric nursing. This distinction between the standards of practice for generalist versus specialist nursing requires analysis of the “characteristics of knowledge, skills, abilities, values and qualities displayed in the context of professional work for both groups of nurses” (Gibson, Fletcher, & Casey, 2003, p. 591). These authors conducted a research study to determine if there was a difference between the basic competencies of a generalist versus those of a specialist nurse. They ordered 198 competencies into 26 subcategories that were then classified into 12 categories. See Box 6-10.

In conclusion, the researchers noted: “There is a significant common element in these two areas of nursing practice, and generalist preparation in … nursing is the foundation of specialist … nursing practice. Generalist knowledge and skills are 80 Understanding Organizations Box 6-9 Categories of Generalist Versus Specialist Nursing Competencies

expanded in specialist practice and there is also evidence of specialist practice that is beyond the scope of general nursing practice” (Gibson et al., 2003, p. 591).

Competencies Required in Critical Care

Nationally accepted critical care competencies have not been formulated. Therefore, critical care programs in each educational institution tend to redefine the essential competencies necessary to meet the standards of practice in the area of critical care, resulting in variations in accepted practice from state by state basis and within practice. But core critical care competencies can be identified on a national basis. Jones (2002) conducted a research study designed to elicit core critical care competency statements from a sample of nurses working in London, England, in critical care.

According to Jones, a core critical care competency framework can be developed by expert nurses drawing on their own experience and knowledge of critical care nursing. The author suggested that this process would be useful to (1) educationalists designing competency-based curricula, (2) critical care managers as a tool for recruitment and retention and for education and training of staff, and (3) individual critical care nurses to facilitate continuous professional development.

Competencies Required in Nursing Informatics

Informatics is the “application of computer and statistical techniques to the management of information” (University of New Castle upon Tyne, 2004). The standards on which nursing informatics competencies are based are still evolving. Some of the essential nursing informatics competencies will be categorized according to their relevancy to (1) national nursing education strategies designed to  develop nursing informatics competencies, (2) nurses at four levels of practice, (3) risk assessment, and (4) computerization of records

National Education Strategies Designed to Develop Nursing Informatics Competencies

Herbert (2000) proposed that advances in the sophistication of information and communication technologies offer the nurse practitioner opportunities for (1) better information management, (2) more complete documentation of work, and (3) knowledge development to support evidence-based nursing practice. Herbert suggested a shift in emphasis from specialists in nursing informatics (NI) to NI being integrated into all domains of nursing clinical practice, pointing to the need for nursing informatics education strategies on a national level. According to Herbert (2000), steps in developing a plan to implement an education program on informatics competencies and standards must include (1) recognizing the role and history of the NI specialists, (2) defining NI and the required NI competencies, and (3) adapting the educational infrastructure required to support this initiative. A national committee, the National Nursing Informatics Project, was working on a plan to address these competencies in nursing informatics (Herbert, 2000). This project ultimately demonstrated, however, that informatics does not seem to be as successful in providing evidence-based research for establishing standards and competencies for practice as individual nursing researchers, such as Staggers, Gassert, and Curran (2002).

Informatics Competencies for Nurses at Four Levels of Practice

Bickford (2002) noted that, although nurses have always dealt with data, information, and knowledge, the standard for nursing now requires core competencies not only in computer skills but also in data and information management. Informatics competencies differ according to the nurse’s level of skill.

Staggers, Gassert, and Curran (2002, p. 383) conducted a research study designed “to produce a research-based master list of informatics competencies for nurses and differentiate these competencies by level of nursing practice.” The four levels of practice were identified as the beginning nurse, the experienced nurse, the informatics specialist, and the informatics innovator. Based on a comprehensive literature review and item consolidation, an expert panel of informatics nurse specialists defined initial competencies for the beginning informatics nurse. See Box 6-11 for a master list of valid computer competencies for the Level 1 Beginning Nurse.

The results of the research of Staggers, et al.(2002) indicated that: (1) computer skills are only one set of competencies within the larger category of informatics standards, and (2) programming skills or competencies of the third-level informatics specialist nurse are generally not a necessary standard for the first-level beginning and/or secondlevel experienced nurse.

Thus, Staggers, et al. (2002) agreed with Herbert’s (2000) conclusion that general, not specialized, informatics should be the standard for integration into all areas of clinical nursing practice.

Informatics Utilized in Regulating Safety Standards

Nursing informatics may be utilized to design or redesign computerized risk assessment programs that monitor whether patient safety standards have been met. Browne, Covington, and Davila (2004) reported that such computerized tools provide (1) an accurate assessment of the safety risk to each patient; (2) indicators that are embedded into routine assessment documentation, eliminating added charting time and ensuring safety; (3) tailored interventions for specific patient safety risks; (4) an integration of fall-risk information into the care

plan, report sheets, and care conferences; and (5) an interdisciplinary communication network regarding the standards of care for safety.

Informatics Utilized in Establishing the Standard of Care A descriptive study, designed by Scott and Elstein (2004) using the Nursing Home Quality Initiative, found that the standard of nursing care may be achieved, regulated, and maintained through nursing informatics by (1) utilizing quality measurement methods and tools in monitoring patient care, (2) utilizing quality data to ensure desired patient care outcomes, (3) monitoring organizational and cultural factors affecting utilization of quality data in the clinical setting, (4) utilizing informatics systems to gather and implement quality data, and (5) documenting and measuring impact evaluation and research outcomes. The findings of this study may be generalized to establish the standard of care, ensuring quality nursing care. Thus, the nursing standard becomes regulated through evidence-based research.

Evidence-Based Practice: The Standard of Care

Evidence-based nursing practice is an expected part of the nursing standard of care. Evidence-based nursing practice utilizes the best current clinical evidence or research when implementing the nursing process. Evidence-based practice is the basis upon which nursing standards are developed. Thus, evidence-based nursing practice is a clinical decision-making process that is integrated into the nursing process. This scientific, step-by-step process combines (1) the best available research evidence, (2) the nurses’ clinical expertise, and (3) the patient’s preferences for patient care. Nurses integrate evidence-based nursing into the nursing process by doing the following:

1.    Identifying the patient’s care need by assessment, based on analysis using current nursing knowledge, expertise, and clinical practice

2. Researching the literature for best evidence relevant to meeting the patient care need.

3. Evaluating the research, or best evidence, for interventions specific to the patient care need.

4. Choosing the best intervention designed to meet the patient care need, justifying the selection based on valid, reliable research (University of Minnesota, 2004).

Evidence-based practice challenges nurses to develop patient care interventions and expand the relevant knowledge, based on the best research. But van Meijel, Gamel, van Swieten-Duijfjes, and Grypdonck (2004) reported limited literature on the development of evidence-based nursing interventions. They presented a model for developing evidence-based nursing interventions, designed to guide the process of developing and testing complex nursing interventions while incorporating the experience of the client.

The model consisted of four stages: (1) problem definition, (2) accumulation of building blocks for intervention design, (3) intervention design, and (4) intervention validation.

The model allowed for the accumulation of empirical evidence and theory development during the formulation of the evidence-based intervention. The authors suggested (p. 84) that the “use of the model could facilitate effective communication among nurses, researchers and educators when discussing the development and testing of nursing interventions.”

Plouffe and Seniuk (2004) promoted evidencebased clinical practice as the goal of professional nursing. Unfortunately, they reported (p. 14) that “linking research to the clinical realm appears logical and sounds simplistic, yet frequently our preconceived thoughts and ideas of ease of change do not equate with the reality of the situation.” Although relevant research may exist, and the patient care need may be there, the question remains of “how shall the two meet?”

For example, a study was designed by Olade (2004), whose purpose was: (1) to identify the extent to which rural nurses utilize evidence-based practice guidelines from scientific research in their practice, (2) to describe previous and current research utilization activities, and (3) to identify the specific barriers they face in their practice settings. The results of the study revealed that only 20.8% of the participants, nurses with bachelor’s degrees, were involved in research utilization. The two most common areas of research were pain management and pressure ulcer prevention and management. Barriers to research identified by Olade included rural isolation and lack of nursing research consultants.

But Winch, Creedy, and Chaboyer (2002, p. 56) commented that evidence-based nursing practice either will or does direct nursing practice, arguing: “It is possible to identify the governance of nursing practice and hence nurses across two distinct axes; that of the political (governance through political and economic means) and the personal (governance of the self through the cultivation of the practices required by nurses to put evidence into practice.) …

Evidence-based nursing is an emerging technology of government that judges nursing research and knowledge and has the capacity to direct nursing practice at both the political and personal level.”


Best practice is the process through which competence and evidence-based practice lead to the desired health-care outcome. Nursing research is the mechanism to provide evidence-based practice.

Thus, for desired patient outcomes and to ensure cost-efficient and effective best practice, application of nursing research findings is essential to the establishment and regulation of the standard of nursing practice.

Many variables affect regulations and standards that are the subject and/or outcome of nursing research. Olsen (2003) identified Health Insurance Portability and Accountability Act (HIPAA) privacy regulations, which became effective April 14, 2003, as having had the most significant current impact on nursing research. The privacy requirements of the regulations have affected nursing research in (1) the research process, (2) accessing data (including recruitment and using medical records), (3) creating data (including intervention studies, survey, and interview research), and (4) disclosing data to others, such as nursing colleagues at other health-care institutions.

Hodge, Kochie, Larsen, and Santiago (2003) identified a “research-practice gap,” a situation in which research findings that should become best nursing practice are not implemented. In anattempt to diminish the research-practice gap via evidence-based nursing practice, the authors studied ways to implement best practice. A patient care research utilization committee was formed to review and revise each patient care policy and procedure, based on best research evidence. The impetus for the project was a belief that current patient care policies and procedures were (1) based on tradition rather than on science and (2) did not provide best practice in patient care, missing skills required for new equipment, treatments, and research findings. The beneficial outcomes of this research project included (1) a revision of patient care policies and procedures, based on scientific evidence; (2) generation of new research questions, based on gaps in the nursing literature; and (3) an increase in the number of clinical nurses involved in using research to provide best practice. Staff education is another important component of best practice. A research utilization project was designed by Cruz, Abdul-Hamid, and Heater (1997) for the purpose of (1) selecting and implementing a research-based restraint education program, (2) reducing the use of restraints in an acute care setting, and (3) changing the perception about restraints in the direction of decreased importance.

The existing restraint policy and procedure and new restraint products and alternative restraint methods were reviewed by a multidisciplinary team. Based on the evidence provided by a review of the literature on restraint education programs, the multidisciplinary team concluded that education was the key component in promoting best practice.

Education programs could be monitored by risk management and quality assurance to ensure best practice in accordance with nursing regulations.

Accreditation as Nursing Regulation

Accreditation is a voluntary process of compliance with a set of standards established by a nongovernmental organization (University of New Castle upon Tyne, 2004). Accreditation is the process utilized by an organization, such as a school of nursing or health-care facility, to verify a competent educational or health-care program, respectively. For example, the state’s governing board for nursing typically provides accreditation for schools of nursing, providing validation that the educational program is in compliance with the state’s standards of instruction for teaching qualified students how to provide standardized nursing care. Private accrediting agencies like the Joint Commission on Accreditation of Healthcare Organizations  (JCAHO) monitor compliance with state and federal standards, but utilization of these private accrediting agencies is voluntary, not mandatory.


Established over 50 years ago, JCAHO is an independent, not-for-profit accreditation organization. Governed by a board that includes physicians, nurses, and consumers, JCAHO sets the standards by which quality of health care provided in hospitals is measured in the United States and around the world (JCAHO, 2004).

Hospitals and ambulatory surgery centers may voluntarily choose to apply for accreditation through JCAHO or other such organizations. According to Saufl and Fieldus (2003), before accrediting a hospital, JCAHO requires compliance with its standards regarding the environment of care, provision of care, and quality of care. Quality of care is ensured by JCAHO conducting regular surveys of each agency’s performance. The value of the accreditation, according to the authors (p. 152), is that this process “… certifies to the health care community and the community-at-large that the facilities meet nationally accepted standards through a recognized accreditation program.”

JCAHO is committed to improving and regulating safety in patient care by providing (1) standards of patient care, (2) survey evaluations on the healthcare provider’s status in meeting standards of care, and (3) professional consultative and educational services on mechanisms for meeting the standard of patient care (Saufl & Fieldus, 2003). To meet JCAHO standards, nursing standards and operating strategies of health-care organizations must be in a continual state of readiness, including performance improvement practices. Gantz, Sorenson, and Howard (2003) believe that nurses have a unique role in identifying and guiding the nursing process, central to quality care, and the commitment to establishing and maintaining quality care, as identified by JCAHO. They believe that the paradigm of health care must be shifted from just meeting the standards to continual readiness and performance improvement throughout the organization.


A policy is a stated system by which health care is administered. A procedure is a step-by-step process by which a health-care outcome is achieved. The American Nurses Association (ANA) plays a significant role in the development of model policies and procedures on both the state and national levels. Standards of care also affect the development of policies and procedures regulating nursing practice. Policies and procedures must meet or exceed minimum standards of care as set by nurse practice acts and other sources.

For example, the ANA provides a foundation for policies and procedures related to patient safety by (1) developing and disseminating policies and procedures to meet the standard for patient safety, (2) lobbying for legislation and regulations that protect and serve users of nursing services, and (3) advocating for patients and issues that affect a nurse’s ability to meet the standards for safe care.

Policies and procedures are designed to regulate, standardize, and drive nursing practice (Zeitz & McCutcheon 2002). Evidence-based nursing practice is essential in developing policies and procedures. Zeitz and McCutcheon (2003) reported that although evidence-based nursing is the mechanism for achieving best practice in the clinical setting, in reality it has had very little impact on the clinical

practice that nurses deliver on a daily basis. For example, the authors noted that although the collection of vital signs is a ubiquitous component of practice in the postoperative general surgical setting, there is little evidence, in the form of evidence-based policies and procedures, to support this practice. Further, they indicated that nursing policies and textbooks, in general, present traditional, routineregulated clinical practice without an evidence base. Traditional policies and procedures are being used to (1) control rather than support evidence-based practice and (2) limit opportunities for clinicians to make patient-specific decisions. They suggested that evidence-based practice, and ultimately best practice, may be achieved through creation of policies and procedures based on (1) rigorous relevant evidence that supports standardized nursing interventions, (2) the nurse’s clinical expertise, and (3) the changing and expanding environment in which nurses develop and practice. One of the most important environmental factors affecting nursing practice is the level of staffing.

Compliance With Staffing Requirements

Regulation of staffing affects productivity, the delivery of patient care, and thus the standard of nursing care. Bednar, Haight and Street (2003, p. 47) reported that: “… state-mandated staffing ratios, coupled with restrictive nurse practice acts, may be impacting the delivery of care to … patients.” They found that patient-to-staff ratios vary state by state. Mark, Harless, McCue, and Xu (2004) conducted a study designed to evaluate previous research findings exploring the relationship between nurse staffing and quality of care. In evaluating this relationship, they examined the effects of change in registered nurse staffing on change in quality of patient care from 1990 to 1995 They found (p. 279) that “improving registered nurse (RN) staffing unconditionally improves quality of care.” Levels of registered nurse staffing must also comply with state and federal legislative and administrative regulations. Legislative and Administrative

Regulation of Nursing

Nursing practice is regulated through state and federal legislative and administrative laws and agencies. The state and federal legislatures develop and pass laws. Federal administrative agencies, such as the Veterans Administration, oversee compliance with regulations by their agencies. Some examples of federal administrative regulatory agencies include the Centers for Medicare and Medicaid Services (CMS), the Occupational Safety and Health Administration (OSHA), and the Centers for Disease Control and Prevention (CDC). State administrative agencies, such as state boards of nursing, create regulations to accompany, detail, and implement state laws.


The CMS administers the Medicare program and collaborate with states to administer Medicaid, theState Children’s Insurance Health Care Program, and HIPAA. CMS is specifically responsible for simplification of standards for implementation of and HIPAA and maintenance of quality standards for health care through its surveys and certification functions (CMS, 2004).


CMS oversees implementation of HIPAA standards and regulations. Title I of HIPAA is designed to protect health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, The Administrative Simplification provisions, “requires strict security measures to protect the electronic health data of patients” (Follansbee, 2002, p. 42). Consequently, nursing policies and procedures associated with the management of health-care information have changed dramatically (Follansbee, 2002).

Requirements under HIPAA require nursing service to comply with privacy standards by (1) developing appropriate policies and procedures, (2) providing notice of privacy practices and other forms, (3) implementing measures to secure privacy, (4) contracting with business associates to secure privacy, and (5) training all nursing staff involved in patient care (Lucas, Adams, & Wachs, 2004). According to these authors (pp. 178–179):

“HIPAA’s privacy regulations are considered ‘the floor’ or minimum standard for the protection of PHI [protected health information]. As such, it is likely that these privacy regulations will become the ‘industry standard’ to which all health care professionals will be held.”

Research in Long-Term Care: Issues, Dilemmas, and Challenges

Scott and Elstein (2004) reported that as the American population ages, already sizable longterm care expenditures are likely to increase. The CMS, as the largest purchaser of health care for the aging population, is continuously working to improve the standard of long-term patient care through (1) quality monitoring and enforcing of patient care standards, (2) providing information to beneficiaries about the standard of patient care, and (3) enhancing resources to improve standardized patient care.

Medicare and Medicaid also establish program requirements in long-term care facilities. For example, according to regulations created by CMS (CMS, 2003, September), long-term care facilities may, in specific circumstances, utilize paid feeding assistants to supplement the services of certified nurse aides. The training and certification of the feeding assistants must have occurred under standardized guidelines, established by CMS.


The Occupational Safety and Health Administration (OSHA, 2004) is a federal agency whose mission is designed to: “assure the safety and health of America’s workers by setting and enforcing standards; providing training, outreach, and education; establishing partnerships; and encouraging continual improvement in workplace safety and health.” OSHA provides a foundation for understanding workplace health and safety by producing publications, pamphlets, audiovisual programs, computer access programs, and other documents designed to promote compliance with safety standards (Nester, 1996). OSHA works to build partnerships between occupational safety and health-care administration, according to Nester (1996). For example, the Office of Occupational Health Nursing within OSHA is an active advocate for health-care workers, such as nurses, assisting with the establishment of standards that protect and provide for the safety of patients and all health-care providers.

The OSHA Pathogens Standard

In 1991 the OSHA standard designed to protect health-care providers from exposure to blood and other potentially infectious materials became mandatory. According to Goldstein and Johnson (1991), health-care employers were required to institute an infection control plan based upon this OSHA standard, which included universal precautions, engineering and work practice controls, personal protective equipment, and housekeeping. Occupational health nurses (1) coordinated the development, maintenance, and revision of this infection control program, in compliance with the OSHA regulations, (2) educated management about the hazards of blood-borne pathogens, and (3) provided assistance to ensure compliance with theOSHA standard, resulting in a safe and healthy work environment for the health-care provider. Nursing plays an active role in OSHA’s functions. Nurses are not only regulated/protected by OSHA standards but also play an important role in their implementation to meet standards for patient safety.


The Centers for Disease Control and Prevention (CDC, 2004) is the leading federal agency for protecting the patient’s health and safety both at home and abroad. The CDC is responsible for (1) developing and applying disease prevention and control, (2) maintaining environmental health, and (3) promoting health and education activities designed to improve the well-being of the people of the United States. But research has demonstrated that more nursing expertise is needed in the area of disease control, as this environmental concern is a “front line” patient care safety issue in nursing practice.

Disease Control: A Safety

Issue in Nursing Practice

According to Larson and Butterfield (2002), clients often use nurses as their primary contact for expressing concerns about health problems related to environmental disease control. In response to this need, core competencies for nursing expertise in the field of environmental disease control were developed by the Institute of Medicine, Agency for Toxic Substances and Disease Registry, and National Institute of Nursing Research. These core disease control competencies comprise a baseline of knowledge and awareness as well as a standard by which nurses intervene to prevent and minimize environmental disease. Nursing standards for disease control focused on the following four competencies:

1. Basic knowledge and disease control concepts: “Understanding scientific principles [of] basic mechanisms of exposure…prevention and control strategies applied research, and the interdisciplinary nature of environmental health.”

2. Assessment and referral: “Completing a comprehensive environmental exposure history and making appropriate referrals … locating and providing appropriate scientific information for individual patients and communities.”

3. Advocacy, ethics, and risk communication: “Understanding the role of advocacy, principles of environmental justice, and risk communication in addressing environmental health issues.”

4. Legislation and regulation: “Understanding environmental health policy as well as state and national regulations” (Larson & Butterfield, 2002, pp. 301–308; quoting Pope, Snyder, & Mood, 1995).

Establishing Safety Protocols Based

Upon CDC and OSHA Recommendations In 1987 OSHA was petitioned by the ANA and labor unions to issue an emergency infection control standard, subsequent to the first documented reports of occupationally acquired human immunodeficiency virus (HIV) in health-care providers (Miramontes, 1990). OSHA responded by enforcing voluntary guidelines developed by the CDC 4 years earlier. Subsequently, OSHA drafted regulations containing the final set of HIV safety protocols in1991.

According to Miramontes (1990), OSHA established HIV safety standards and protocols to be utilized by all health-care providers, addressing (1) types of protective clothing and equipment, (2) housekeeping and laundry areas, (3) infectious waste disposal, and (4) tracking employees, preand postexposure. In enforcing these standards, hospitals stress continued education and training in order to increase compliance. Miramontes (pp. 561–562) cited a research study that found “after a two-year training/evaluation period, physician compliance with infection control procedures increased from 20% to 80%, and nurse compliance rose from 50% to 86%.”

All Good Things…

Nursing practice is regulated on the state and federal levels. On the state level, nursing is regulated via the state’s nursing practice act, which provides for licensure as a registered nurse. Subsequently

certification acknowledges nursing competence at an advanced level of practice. The nursing practice act establishes the standard of care and scope of practice, which are monitored by the state’s governing board, usually the board of nursing examiners. The nursing practice act also regulates advanced practice; for example, the clinical nurse specialist. The scope of nursing practice has been expanded by telenursing, requiring the development of the Nurse Licensure Compact (NLC). The NLC creates standardization within nurse practice acts that vary and lack uniformity from state to state, providing more standard methods of compliance, discipline, and rehabilitation.

Nursing has been developed upon the core competence of caring, a concept difficult to measure, document, or legislate. Other essential competencies, which appear to be measurable behaviors, include health promotion, supervision, interpersonal communication, direct care, computer, and case load competencies. Competencies may be documented with videotaping, orientation records, portfolios, self-assessment tools, records of mandatory intranet training courses, and continuing education records. Advanced areas of nursing practice have more specialized sets of competencies.

Specific competencies are required in nursing informatics at four levels, consisting of the beginning, experienced, informatics specialist, and informatics innovator nurse. Informatics may be integrated into the nursing standards. Evidence-based nursing practice is the expected standard of care. Nursing research is the mechanism to provide evidence-based practice. The nurse may integrate evidence-based practice into the nursing process, for example, by following a four-step clinical decision-making process. Policies and procedures also establish the standard of care and thus regulate nursing practice.

Independent organizations, such as JCAHO, monitor a health-care provider’s compliance with state and federal laws and regulations. Accreditation is the process utilized by an organization, such as a school of nursing or health-care facility, to verify competency of its educational or health-care program, respectively. Staffing and productivity must also be regulated under these accreditation guidelines to meet the standard of care.

Legislative and administrative regulation of nursing occurs on the federal level; for example, through CMS. CMS oversees the administration of HIPAA, a federal law that regulates confidentiality issues related to patient care. OSHA is a federal agency that promotes standards for patient safety in the health-care environment. The CDC is the federal agency that develops and promotes disease prevention and control.

Economic Influences

Leadership is a challenging job as described by De Pree above. Leaders are asked to be stewards for their organizations’ assets, which range from financial resources and human resources to the overall reputation of the organization. Leaders keep the organization continually moving forward by looking for ways to improve while managing the delicate balance between the goals of the customer and those of the organization. This chapter describes why health economics is important to managers within the health-care industry and some of the unique challenges facing those managers. Health economics has received increased focus in recent years due to the increase in technological innovations, the greater availability of data, and the surge in health-care spending. The need for managers to be effective stewards has never been greater.

Current Status of Health Care in the United States

In order to understand the current turmoil in the U.S. health-care system, a brief review of several dramatic changes that have occurred over the last 40 years is warranted. The emphasis of medical care shifted from diagnosis of the illness to intervention and, now, has shifted to prevention of the illness. New technologies have revolutionized the ways in which health care is practiced. A few examples of these innovations include organ transplants, radiation and chemotherapy treatment plans for cancer, in vitro fertilization, and vast enhancements in drug treatments. The role of health insurance coverage has risen dramatically from less than 10% of the U.S. population in 1940 to more than 84% today (Weisbrod, 1991). In addition, in 1935 when Social Security was enacted as a benefit for older citizens, only 5% of the population lived past the age of 65 years. Social Security did not anticipate life expectancy increases and the resulting need for longer-term use (Cypher, 2003). Finally, health-care expenditures continue to grow in proportion to the gross domestic product, making up 15.3% of total spending in the U.S. economy in 2003, or $1.7 trillion annually, up from 5.3% in the 1960s. Health-care spending is outpacing growth in the overall economy by 3 percentage points (Highlights—National Health Expenditures, 2003). See Figure 7-1.

Why is there so much focus on the increase in health-care spending? One reason is that the United States spends more on health care per person than any other major industrialized country but fares worse on key health indicators such as life expectancy and infant mortality rates. (Anderson, 1997). In addition, the continuing growth in healthcare spending leaves a smaller proportion of national income for other purposes, such as education or defense. This has prompted the federal government and employers to question whether the benefits of this increased spending are warranted, which has spurred the current discussions of how to reform the health-care system. Central to the reform debate is how much to pay for health care. In order to understand the issues fully, an overview of the current payment systems is necessary.


Who pays for medical care? In most industries, the process of obtaining payment for services or products is fairly straightforward. A customer will purchase a product or service and be presented with a bill that represents the quantity of goods or services received, multiplied by an appropriate price.

Discounts may encourage sales of slow-moving inventory; however, the  basic method is a fixed price per unit set by the business. But health care does not follow this simple process. In the United States, there is a complex structure in place for obtaining payment for health-care services, due to various contractual relationships with third parties (Cleverley & Cameron, 2003). As seen in Figure 7-2, 83% of all payments come from third parties. Nevertheless, it is important that managers remember that the consumer is the ultimate payer for health-care services. Although most consumer payments are indirect in the form of insurance premiums or taxes, increases in health-care costs will force consumers to spend less on other goods and services and more on items like insurance benefits. Reactions to increases in health-care costs can vary, such as consumers dropping their health insurance coverage, employers reducing the health insurance benefits offered to employees, or insurance companies reducing payments for services. Even insured consumers are required to make some direct payments for health-care services, often referred to as 96 Understanding Organizations

NOTES: These data reflect Bureau of Economic Analysis Gross Domestic Product as of October 2001. Per capita is calculated using Census resident based population estimates.

National health-care trends in public versus private funding in selected years. (Source: U.S. Bureau of the Census, U.S. Department of Commerce, Bureau of Economic Analysis)

ket payments, co-pays, or deductibles.Some out-of-pocket payments are for services that are not covered by the policy or for services in excess of the policy’s coverage limits. Most health-care organizations have a master price list referred to as the  charge description master (CDM). The CDM has the specific charges for a defined unit of service, such as an x-ray, specific laboratory test, or 1 hour of surgery time. The unique aspect of pricing in the health-care industry is that often the payment for a specific unit of service in no way relates to the charge that actually appears on the patient’s bill from the CDM. This dilemma is discussed in more detail in the review of reimbursement methods.

Uninsured Consumers

Currently, about 16% of the population (45 million people) does not have health insurance (Centers for Medicare and Medicaid Services, 2005). These consumers must pay for their health-care needs from their own resources. Customers without insurance are expected to pay the total billed charges, based on the health-care organization’s price list, while insured customers receive dis

Personal health-care expenditures by source of funds. (Source: CMS Office of Actuary, National Health Statistics Group)

counts for services based on contracts their insurance companies have negotiated with the providers.

When personal resources are not adequate, often the uninsured consumer must rely on charity care or do without the service. The rising share of the population without medical insurance is seen as a major problem in the United States and one of the key issues driving the need for health-care reform. See Figure 7-3. Reimbursement Models Health-care managers need to understand the basic payment methods for customers with insurance. There are two main categories of payment methods: fee-for-service and capitation.

Fee for Service In fee-for-service payment methods, reimbursement increases based on the number of services provided. There are three primary methods of reimbursement: cost-based reimbursement, chargebased reimbursement, and the prospective payment system

Cost-based reimbursement is not frequently encountered in practice today; Medicare reimbursed health-care providers in this manner from 1966 to 1983. Under cost-based reimbursement, the payer agrees to reimburse the provider for the costs incurred in providing services to the insured populations. The payment is limited to allowable costs, which is defined as costs directly related to the provision of health-care services (Gapenski, 2003). For example, if the hospital’s cost to care for a patient delivering a baby included 2 days in the hospital at a nursing cost of $480 per day, medical supplies of $200, drugs of $125, and equipment use of $250, the hospital would be reimbursed the sum of all these costs, $1,535. Charge-based reimbursement was common in the early days of health insurance, when payers reimbursed providers on the basis of billed charges.

The current trend is away from paying on billed charges; however, some payers now reimburse based on a discount of billed charges ranging 20%to 40% (Gapenski, 2003). For example, if the patient bill for the same 2-day maternity stay included charges that totaled $3,500, the hospital would be paid some percentage of this amount under chargebased reimbursement.

In the  prospective payment system (PPS) a predetermined rate is paid for services. Reimbursement of services is based on a per-unit payment, such as diagnosis, procedure, day, or episode. Several common PPS examples follow:

1. Per-procedure reimbursement, which is commonly used in outpatient settings.

2. Per-diagnosis reimbursement, in which diagnoses that require a higher resource utilization have higher reimbursement rates.

“Medicare pioneered this basis of payment in its diagnosis related group system, which was first used for hospital reimbursement in 1983” (Gapenski, 2003). For further discussion, see the Medicare section below.

3. Per-day reimbursement, in which the healthcare provider is paid a fixed amount for each day that service is provided, regardless of the nature of the services.

4. Global pricing, which is a single payment that covers all services delivered in a single episode of care. For example, one payment is made for maternity services, covering physician visits prior to and following delivery and hospital care for the delivery.

* Statistically different at the 90-percent confidence level.

Military health care includes: CHAMPUS (Comprehensive Health and Medical Plan for Uniformed Services)/Tricare and CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs), as well as care provided by the Department of Veterans Affairs and the military.

 Note:  The estimates by type of coverage are not mutally exclusive; people can be covered by more than one type of health insurance during the year.

Coverage by type of health insurance:2002 and 2003. (Source: U.S. Census Bureau, Current Population Survey 2003 and 2004, annual social and economic supplements


The second major category of reimbursement is capitation, in which the provider is paid a fixed number per covered life per period (usually a month), regardless of the number and type of services provided. Although similar to the prospective payment system, a capitated payment system pays a fixed number per month for all services provided to an individual versus per procedure or episode under the PPS. Initially, everyone believed that capitation would become the dominant method of payment; however, the  popularity of capitation plans has declined and became popular only in certain geographic locations. The administrative skills and data demands required to manage risks appropriately are quite substantial. In addition, the financial risks to the insurer are greater under capitation due to the importance of accurately projecting the appropriate payment per member. Currently, feefor-service plans continue to be the most common form of reimbursement (Gapenski, 2003).

Financial Incentives and Risk

Each of the reimbursement methods provides different financial incentives to providers of health-care services. In cost-based reimbursement, for example, providers are paid more if their costs are higher; therefore, no incentive exists to contain costs. In charge-based reimbursement, on the other hand, providers have an incentive to increase their prices because that results in higher payments.

Generally, in a competitive marketplace, consumers will only be willing to pay so much for a service, but because most payments for health-care services come from third parties, providers have limited ability to pass on higher charges. As third-party payers transition to a discount charge-based methodology,providers have an incentive to manage costs to maintain the same level of profit. Additional costs are no longer able to be recouped through increasing charges for services, as only a portion of the charges will be reimbursed.

In all of the prospective payment methods, regardless of the unit of payment (procedure, diagnosis), an incentive exists to reduce costs because the payment is fixed. The overall incentive under the PPS is to work more effectively by managing costs and increasing the utilization of the most profitable services. Under global pricing, for example, one payment is made for an entire episode of services, so a strong incentive exists for the physicians and hospitals to work together to offer the most effective treatment. Finally, under capitation, the key to profitability is to increase efficiency and decrease utilization. In a capitation setting, providers have the incentive to practice preventive medicine rather than just treating the illness so they can limit unnecessary utilization of services.

Health-care providers also face several financial risks created by the reimbursement methods in place. The risks create some uncertainty regarding the profitability of the organization. First, providers now bear the risk that costs will exceed revenues. Due to reimbursement for services being somewhat fixed under current payment methods, providers can no longer increase revenues to offset additional costs. Revenues can be increased, but the reimbursement will be the same, regardless of the charge. A key difference among the reimbursement methods is the ability of the provider to influence the profit of each service by setting the prices above the costs. In the PPS, risk is increased due to the payment being fixed regardless of the charge to the patient. The PPS payment is based on the resource utilization necessary for the average patient, and because some patients need more intensive treatments than others, the health-care provider is at greater risk to manage costs to maintain profitability. It is important to realize that the recent trends in reimbursement represent a shift in risk from the insurers to the providers. By implementing a fixed payment for services regardless of patient charges, the providers are now responsible for managing costs to ensure a profit is made on services.

Major Third-Party Payers

There are two broad categories of third-party payers, which provide insurance coverage to the populations: private insurers and public programs.

Currently, approximately 54% of all hospital payments come from private sources, with the remaining 46% coming from governmental programs such as Medicare and Medicaid. Over the last several decades, the trend has been toward an increase in public sector funding of health-care spending, with public funding projected to be 49% of total funding by 2014 (USA Today, 2005).


The major private insurers include Blue Cross/Blue Shield, commercial insurers, and self-insurers.During the Depression, the Blue Cross/Blue Shield concept emerged as a way for patients to afford care at hospitals and from local physicians. Blue Cross was created by Justin Ford Kimball; 1300 school teachers were allowed to finance 21 days of hospital care by making small monthly payments to the Baylor University Hospital (Flanagan & Kjesbo, 2004). Blue Shield was emerging in the Pacific Northwest as a result of serious injuries and chronic illness in the lumber and mining camps.

“Employers who wanted to provide medical care for their workers made arrangements with physicians who were paid a monthly fee for their services” (History of Blue Cross/Blue Shield, 2006). These organizations developed across the country as independent not-for-profit corporations. Today, the various Blue Cross/Blue Shield plans continue to operate as independent organizations and are members of a single national association that sets standards. In 1986 Congress eliminated their taxexemption status because the organizations were offering commercial insurance. As a result, several plans have converted to for-profit status; due to the complexities involved in converting from not-forprofit to for-profit status, others maintain their not for-profit status (Gapenski, 2003). Because all Blue Cross/Blue Shield corporations operate independently, reimbursement methods vary by state. Just as with Medicare, the trend has been toward a prospective payment methodology. Many private insurers have adopted Medicare’s  diagnosisrelated group (DRG) system and developed their own payment rates based on specific diagnoses.

Several types of organizations, most often forprofit insurance companies, offer commercial health insurance. Traditionally,  commercial insurers have reimbursed providers for health-care services on the basis of billed charges. As health-care costs continue to grow, and as these organizations have begun charging higher insurance premiums, a trend has started toward more cost-effective reimbursement

methods. As for-profits, these organizations have an incentive to maximize their owners’ profits. Another form of private insurance is where companies set aside funds to pay for future health costs of their own employees rather than using an outside organization to provide their health insurance. This form of insurance is referred to as self-insurance and is very popular among organizations with a large number of employees. The next section of the chapter focuses on the two major government insurance programs, Medicare and Medicaid.


The Medicare and Medicaid programs were established through the Social Security Act in the mid1960s. These programs were administered by the Department of Health, Education, and Welfare (HEW). “In 1977, the Health Care Financing Administration (HCFA) was created under HEW to effectively coordinate Medicare and Medicaid. In 1980, HEW was divided into the Department of Education and the Department of Health and Human Services. In 2001, HCFA was renamed the Centers for Medicare & Medicaid Services (CMS)” (Medicare Information Resource, 2005).

CMS is the federal agency that administers the Medicare program. Currently, Medicare provides coverage to approximately 40 million Americans. Medicare is the national health insurance program for:

■ People age 65 years or older

■ Some people younger than age 65, with qualifying disabilities that have been recognized by the Social Security Administration

■ People with end-stage renal disease, which is permanent kidney failure requiring dialysis or a kidney transplant

Medicare coverage is separated into two plans:

■ Part A coverage provides hospital and some skilled nursing home coverage.

■ Part B coverage provides outpatient, physician, ambulatory surgical, and several miscellaneous services.

Most people do not pay a monthly Part A premium because they or their spouses are eligible for Social Security, and it comes as a benefit of Social Security. The Part A premium in 2005 for individuals not eligible for Social Security benefits was $375per month. Part B coverage is optional to all individuals who have Part A coverage. In 2005, the monthly premium for Part B was $78.20 (HHS Announces, 2005).

Until 1983 Medicare reimbursed providers for health-care services based on provider costs. In 1983 the federal government implemented a new reimbursement system for Part A providers called the PPS, discussed earlier. The objective of the PPS was to curb Medicare spending and provide incentives for providers to manage costs. The ultimate goal was to curb growth in health-care spending and to free up funds in the national budget for other services.

Unfortunately, over the years PPS payments have not kept pace with hospital costs. To make matters worse, the Balanced Budget Act (BBA) of 1997 placed significant restrictions on the growth in Medicare spending. The Balanced Budget Relief Act of 1999 restored some of the spending cuts from the BBA, but payment growth is still below the growth in operating costs (Gapenski, 2003).

In the PPS system, providers have an incentive to look for ways to contain costs and maintain profitability. From the early 1980s until 2000, outpatient services continued to be reimbursed at cost while inpatient services were reimbursed under the PPS, so providers shifted services from inpatient to outpatient. As a result, Medicare spending for outpatient services grew quickly and offset some of the expected savings from the PPS. As a result, in August 2000, Medicare implemented a fixed payment system for outpatient services as well.

Inpatient Prospective Payment System

The foundation of Medicare’s inpatient PPS is the DRG assigned to the patient at discharge from the hospital. The DRG provides a way to classify patients based on their primary diagnosis. The diagnosis is influenced by which medical diagnostic category a patient is in. There are approximately 543 DRGs. Each DRG is assigned a relative weight, which represents the average number of resources used in treating the average patient with a certain diagnosis. The average weight of all DRGs is assumed to be 1, so DRGs with a relative weight greater than 1 are more resource-intensive than DRGs with a relative weight of lower than 1. The Medicare case mix index of an institution is a weighted average of all the different diagnoses being treated at a particular organization. For example, a case mix index of 1.5 indicates that a facility’s diagnoses are more complex and resource-intensive than a facility with a case mix index of 0.80. CMS reviews the relative weights of specific DRGs annually and makes adjustments based on changes in resource consumption, treatment patterns, and technology. The DRG payment assigned by Medicare is based on standardized payment rates for labor and nonlabor costs and the relative weight of the DRG. The labor portion of the payment must be adjusted for the local area wage index, which attempts to reflect relative labor costs across the United States.

Local wage indices and standardized payment rates are published annually by CMS. Table 7-1 contains an illustration of this calculation for DRG 106 Cardiac Bypass with a PTCA for a hospital in Atlanta, Georgia. The inpatient PPS works fairly well when patient costs are distributed symmetrically for each DRG, and the payment should be sufficient to cover the costs of an average patient. For example, if within the DRG for pneumonia more patients have a severe rather than a mild case, the charges would be higher for the sicker patients yet the reimbursement will be the same regardless. In the event that certain hospitals treat sicker patients who require more resources for certain DRGs, the PPS payment will fall short in covering the costs of care. To provide some cushion for high-cost patients, the PPS provides an additional outlier payment for patients whose costs exceed certain thresholds.

The regular PPS payment covers only operating costs. Because hospitals have to bear the costs of financing assets necessary to provide services,

Example of Inpatient PPS Reimbursement

Medicare provides additional dollars to assist in covering capital costs. Currently, the capital payment rate is $416.53, which is multiplied by the DRG relative weight, for each Medicare discharge during the year. So hospitals receive additional reimbursement equal to $416.53 DRG weight the number of Medicare patients.

Outpatient PPS

On August 1, 2000, CMS implemented an outpatient PPS based on ambulatory payment classifications (APCs). Services grouped under each APC are similar clinically and in terms of the resources required. A payment rate is established for each APC, and hospitals may be paid for more than one APC for an encounter. Currently, there are approximately 350 APCs that specify surgical and nonsurgical procedures, visits to clinics and emergency departments, and ancillary services. The APC payment calculation is based on a standard national payment rate, the national Medicare payment percentage, and the patient’s co-payment amount. The national payment rate is divided into labor and nonlabor components. Labor represents 60% of the payment rate and nonlabor the remaining 40%. As in the DRG calculations, the labor component of the payment rate is adjusted for the hospital’s local wage index. The calculation of the payment for an individual APC is fairly straightforward. Complications arise, however, when multiple procedures are performed within the same visit for a patient. The procedure with the highest value is paid at 100% of the APC payment, and additional procedures are paid at 50%. Certain outpatient services are paid based on a fee schedule, such as physical, occupational and speech therapy, ambulance services, and diagnostic laboratory services. In addition to inpatient and outpatient hospital services moving to a PPS of reimbursement, nursing homes and home health agency payment methods have also been revised to shift more risk to the health-care provider by capping payments for services.


Medicaid was created under Title XIX of the Social Security Act in 1965 as an entitlement program

Practice Proof

jointly funded by the federal and state governments to provide medical assistance for qualified individuals and families with low income and resources. “Medicaid is the largest source of funding for medical and health-related services for America’s poorest people” (Medicaid: A Brief Summary, 2005).

States have tremendous autonomy in how they structure their Medicaid programs. States decide on:

■ Eligibility criteria

■ Type, amount, duration, and scope of services

■ Payment rates for services

■ Administration

Due to the flexibility each state possesses in structuring its Medicaid programs, considerable variations occur. For example, an individual may be eligible for Medicaid in one state and not be eligible in another state.

The federal government pays a portion of expenditures under each state’s Medicaid program. The percentage the federal government pays is updated annually by comparing the state’s average per capita income level with the national income average. States with higher income levels are reimbursed a smaller percentage. By law, federal payment cannot be lower than 50% or higher than 83% of a state’s Medicaid costs. In 2004, the overall average payment percentage was 60.2%, ranging from 50% in 12 states to a high of 77% in Mississippi (Medicaid: A Brief Summary, 2005). See Box 7-1 for an example.

Basic Economic Theories of Supply and Demand

Based on the current state of health-care spending, there is little argument that resources are limited and consumers (and professionals) are forced to make decisions on how to allocate these resources best. The study of economics helps managers analyze the allocation of scarce resources. Resources are anything useful in the consumption or production of a product or service, such as nursing care, new equipment, surgical supplies and, of course, money. For example, individuals must choose daily how to allocate their resources for food, gas, entertainment, and health care. Basic supply and demand theories help illustrate how this allocation of resources takes place. Managers can use these concepts to make both broad strategic decisions and detailed pricing decisions.

In a market system, price is used to ration goods and services. A price system is easy to operate because the price of a product or service self corrects when the quantity supplied exceeds the quantity demanded. A price system allows individuals with different preferences to make their own choice. In the health-care industry, the market system may appear to work unfairly, as when low income consumers or individuals with preexisting medical conditions are unable to afford needed services (Lee, 2000).


Most organizations begin their annual strategic planning process by projecting demand for their products. In the health-care setting, the focus is on predicting demand for the appropriate level of services to provide, which also results in planning the required staffing levels to meet this demand.

Managers routinely project revenues based on a certain volume of services at a given price. This type of demand forecasting is an essential part of management. It is very important to understand the relationship between price and quantity. The demand curve describes the quantity of goods or services that will be purchased at different prices when all other factors are held constant. Generally, the demand curve slopes downward, which means that a price decrease will reflect more sales of a product. See Figure 7-4. For example, in looking at Figure 7-4, a consumer is willing to buy 80 units at a price of $50 each; however, at a  price of $100, consumers are only willing to buy 60 units. Other factors that may influence demand for health services include consumer income, insurance coverage, perceptions of health status, and changes in the prices of other products (Lee, 2000).

The demand for medical care is more complex than the demand for many products due to the:

1. Influence of insurance coverage on the price of care.

2. Complexity in understanding the relationship between the cost and value of a medical service compared with the likely outcome or benefit of the service. This is in part due to the

lack of information related to these costs and benefits.

3. Difficulty in making informed choices, which leads consumers to turn to health-care professionals for advice. These professionals have significant influence on demand and often make choices that reflect their own best interests.


The supply of services offered is based on how much the producer is willing to sell at each price. This relationship is graphically illustrated in Figure 7-4 by an upward-sloping supply curve, demonstrating that producers are willing to sell more as the price increases. For example, at a price of $150 a provider would be willing to supply 80 units; the consumer is only willing to buy 80 units at a price of $50. Markets generally move toward an equilibrium price at which producers want to sell the amount that consumers are willing to buy. Movements along the demand curve describe the different quantities that consumers are willing to buy at various prices; however, certain circumstances can cause the entire demand curve to shift to the right or left. An example of a situation that would result in the entire demand curve shifting to the right would be the expansion of insurance coverage ( i.e., insurance will pay a larger portion of the bill, more people are covered by insurance, or possibly a reduction in deductibles). The increased coverage of mammograms or colonoscopies for patients of a certain age has created a shift in demand for these services. See Figure 7-5

1.     Supply and demand at equilibrium.

2.     Shift in supply due to change in regulations allowing freestanding ambulatory surgery centers.

A shift in the supply curve to the right indicates that at every price aroducer wants to supply a smaller quantity. A change in regulations might cause such a shift in the supply curve by making care more expensive. For example, recent changes in the approval process for freestanding ambulatory surgery centers in certain states have led to a major shift to provision of services outside the hospital (Lee, 2000). Hospitals saw a decrease in the demand for their services, which caused a reduction in the quantity of services offered. See Figure 7-6.

Health-care managers face many challenges in balancing the supply and demand for services. To illustrate some of the unique challenges, compare an automobile manufacturer with a health-care organization. Prices are set in the competitive marketplace for automotive manufacturers. Consumers have a choice among many suppliers of automobiles, and there is easy access to information to help distinguish between the qualities of competing models, such as Internet Web sites). The assumption is that consumers make a rational decision based on the price and quality of the product. In addition, consumers directly pay for the full price of the purchase. In contrast, health-care organizations often do not provide a wide array of serv

Shift in demand due to expanded insurance coverag of colonoscopies

ices; for example, limited organizations offer open heart surgery or organ transplant services.

Historically, it has been difficult to obtain necessary information to compare services from one facility with those of another. In addition, the information is very complex, and consumers often seek the advice of health-care professionals, which allows the professionals to influence the choice of which service to purchase. Finally, the payment for the service, in the majority of cases, is made by a third party, such as the federal government or private insurance companies. Predicting supply and demand for services is difficult for health-care organizations because of the involvement of multiple third parties in the decision process of where to seek health-care services.

Health-care organizations are currently facing additional pressures because of resource shortages that do not meet demand. Services are constrained by, for example, the current shortage of nurses and the projected shortage of physicians. Consequently, the prices (hourly rates, salaries) to attract nurses and physicians are increasing, reducing profits even further. In addition, the cost of drugs and medical supplies has skyrocketed. Finally, a dramatic increase in demand for health-care services is expected over the next 20 years because of a projected 72% increase in the population over age 65, coupled with technological advances offering more treatment options and extending the life expectancy (U.S. Department of Health and Human Services, 2003).

Maximizing Profits

As evident in the previous discussion of supply and demand, producers of health-care services strive toincrease the demand for their services in hopes of maximizing profits. Even if one is employed in a not-for-profit organization, which does not explicitly seek profit maximization as a goal, it is important to realize that profits are necessary to carry out the mission of the organization.

Profits are dollars that are left over after total costs are subtracted from total revenue. Managers are able to influence profits by reducing costs and/or expanding the quantity of services offered and thereby increasing revenue. Reducing costs generally requires improvements in clinical management, which focuses on how clinical plans are designed and the associated resource usage. Reengineering and quality management are two strategies that some organizations have used to improve the performance of their organization and thereby reduce costs. Reengineering is generally a more radical approach, in which all business processes are reviewed and revised to improve the efficiency of key organizational processes while reducing costs. Quality management often focuses on improving clinical processes and how the delivery of care to the patient can be improved while saving costs. The impact of the changes on the organizational culture is a key factor that must be managed in order for the improvements to be successful.

The second option for maximizing profits is increasing the services offered in order to increase revenue. As a general rule, it is profitable to expand output as long as the additional revenue generated is greater than the additional costs incurred.


Although all firms do not have maximizing profits as a primary goal, profits are necessary to maintain long-term financial viability in the increasingly competitive health-care environment. Traditionally, not-for-profit organizations have dominated the health-care industry. A closer examination of the differences between for-profit and not-for-profit health-care organizations will provide a better understanding of the overall goals and objectives of these organizations.

For-profit organizations are often referred to as investor-owned, which means that investors buy shares of stock in the firm, representing ownership interests. A primary goal of for-profit entities is to maximize profits for their owners, keeping in mind

Practice to Strive

that investors have many choices regarding how to invest their money in today’s competitive marketplace. The investors in the firm are referred to as stockholders and have several basic rights:

1. The right to vote for the firm’s board of directors and on other relevant issues.

2. A claim to the earnings of the firm, primarily through cash or stock dividends.

3. In the case of bankruptcy or liquidation, the stockholders are entitled to any proceeds that remain after all other obligations have been satisfied.

There are two basic types of for-profit organizations: publicly held firms and privately held firms.Publicly held firms are owned by a large number of investors, and the shares of stock in the firm are traded through various mechanisms, such as the New York Stock Exchange, American Stock Exchange, or over-the-counter market. Examples of publicly held health-care organizations include Healthcare Corporation of America and Beverly Enterprises. In contrast, privately held firms are owned by just a few investors and are not publicly traded. In general, for-profits are thought to be more efficient because of the scrutiny by shareholders on financial performance. In addition, for-profits can readily access large amounts of capital by issuing additional shares of stock to modernize their facilities and compete for customers (Marsteller, Bovbjerg, & Nichols, 1998).

An alternative form of ownership is the not-forprofit organization, which is also referred to as a tax-exempt or nonprofit corporation. Unlike the for-profit entities, not-for-profit organizations traditionally had serving the community as their primary goal. The IRS Tax Code Section 501C (3) sets forth the criteria that a firm must meet to qualify for tax exemption as a charitable organization: if it is formed for some defined public good and if none of the net earnings will be disbursed to any shareholder or individual as a “dividend” or share of the net. There are several key characteristics of not-forprofit organizations:

1. Historically, not-for-profit organizations received significant revenues from charitable sources and other donations. Non-profits today receive a small portion of total income from donations; they are being challenged to increase efficiency to gain access to capital and remain competitive (Harrison & Sexton, 2004).

2. Not-for-profit organizations have no shareholders; therefore, a board of trustees, often residents from the local community who are not owners of the firm, exercise control over the organization’s operations (Josephson,1997).

3. Not-for-profit organizations have  limited access to capital because they cannot issue shares of stock. Tax-exempt bond issues are their primary source of funding for capital needs.

4. In the event of liquidation or sale, proceeds must be used for a charitable purpose.

5. Tax subsidies are often provided to not-forprofit organizations through exemptions on local, state, and federal taxes.

6. Not-for-profit organizations are expected to provide free care for poor people, regardless of their ability to pay.

7. Not-for-profit organizations are expected to provide benefits to the community, such as access to services that are not profitable, medical education and research, community education, and health screening (Josephson, 1997; Marsteller, Bovbjerg, & Nichols, 1998). Patients expect that not-for-profit organizations will not reduce quality to increase profits and that earnings above costs will be used for beneficial services or other worthy investments (Marsteller, Bovbjerg, & Nichols, 1998).

8. In many small communities, the very existence of a hospital may be owed to its not-forprofit status as substantial donations of money and time from the community often support the hospital. Local hospitals are a valuable part of the community infrastructure and have fostered community development and civic pride (Marstellar, Bovbjerg, & Nichols, 1998).

Not-for-profit hospitals represent 58% of total hospitals in the United States, according to a recent American Hospital Association Survey (Fast Facts, 2005). Although not-for-profits clearly play a dominant role in the health-care industry, many federal and state policy makers are starting to question the validity of the true differences between forprofits and not-for-profits. With health-care costsgrowing at the state and federal levels, policy makers, looking for additional sources of revenue as a way to balance their budgets, are scrutinizing the current tax subsidies that not-for-profits receive.

Several states, such as Texas and Utah, are now requiring health-care organizations to meet minimum levels of indigent care to maintain their taxexempt status.

All Good Things…

This chapter has provided a broad overview of the unique challenges facing managers in the health care industry today. It is of vital importance formanagers to understand the economic pressures facing health-care organizations and why their role is so important in effectively managing their organizations’ scarce resources. Even with the additional complexities of health care, however, there are several factors that managers can influence. Accurately forecasting demand for services is a very important management task, as is managing the costs of meeting the demand for services. Cost management can be as focused as staffing and supply utilization within a particular unit or as broad as a clinical reengineering project for a certain patient diagnosis. An understanding of the patients who utilize the services is crucial to understanding how the organization will ultimately be paid for the services provided.

Building Teams for Productivity and Efficiency

Delivery of health care is quite complex. Even though nurses may deliver care as individuals, they are usually part of a caregiving team working in concert. Even care delivered to patients by an individual nurse or other caregiver has probably been influenced by others, through diagnosing, planning, referral, or other types of collaboration. The admitting physician provides the initial medical diagnosis, the admitting nurse establishes the initial nursing care plan, and other health-care disciplines, such as social work, physical therapy, diet therapy, and occupational therapy, may influence the plan of care. Treatments, equipment, and medications have been developed over time and studied and tested by unknown numbers of professionals (many working in teams) to develop the best models of care. Many nursing interventions are also the result of nurse researchers working in teams to broaden the repertoire of evidence-based practice. The complexity of both the health-care arena and the nursing profession challenges nurses to become proficient in the skills of collaboration and team building. Most health-care delivery agencies employ nurses with varying credentials and levels of education. The existence of multiple levels of nursing personnel requires that all nurses understand the various roles performed at each level. Doctoral, master, bachelor, and associate degree nurses work along with licensed practical nurses (LPN) and certified nursing assistants (CNA) in large medical centers. In order for patients to receive effective, coordinated optimal care, smooth teamwork must exist. Table 12-1 summarizes the levels of educational opportunities in nursing and the roles associated with each.

As multiple roles have evolved within nursing, so too have the roles within other health-care disciplines. For example, respiratory therapists, physician assistants, occupational therapists and occupational therapy assistants, surgical technologists, radiological technicians, and a myriad of other supportive technicians are likely to be part of the health-care team. Never has mutual understanding, mutual respect, group work, and teamwork been more important and more crucial to the well-being of patients receiving care within the health-care system. Table 12-2 provides examples of the roles played by some of the health-care disciplines likely to be included in the care of hospitalized patients. This chapter will review the importance of teamwork in nursing and health-care delivery. Learning to be an effective team member and/or team leader will serve you, your patients, and their loved ones well. Understanding the dynamics that occur within teams, the roles that members play, and the patterns of communication that develop will help you be an effective team member. Learning about these dynamics will prepare you to ease some of the friction, avoid some of the conflict, and learn from both. You will see that partnerships and collaboration are essential for safe, efficient, and effective health care. Teamwork with other nurses, teamwork with other disciplines, and multidisciplinary teams will help you provide the best possible care for your patients. Good teamwork is essential for good nursing, and good teamwork begins with good group work.

Group Work

Nurses usually work in diverse caregiving groups and are expected to collaborate with others to produce positive patient care outcomes. The popular adage “A camel is a horse designed by a committee” is a reminder how ineffective group work may have unintended and unwanted outcomes. Groups consist of people in relationships. As the size of the group grows, group dynamics become more complex, and the opportunities for misunderstanding, friction, and conflict grow. Those who share a household with their children may recall the simplicity of life prior to parenthood. Similarly, those who are oldest children in the birth order of their family may harbor fond memories of a time when sharing was not necessary or when negotiating was not a daily event. Students expected to work within a study group or required to complete group projects have experienced how group work can be fraught with pitfalls and frustration. Although groups may differ in their purposes, structure, and processes, most groups do have one characteristic in common: the possibility of conflict. Understanding the phenomena associated with good group functioning facilitates good group work and eases frustration and conflict. When group members are aligned about their purpose, work within a well-understood structure, and have a strong and healthy group process, their group is poised to function as an effective health-care team

Levels of Nursing Education


In caregiving agencies, groups (often in the form of committees) exist or are created to fulfill an ongoing function, responsibility, or task within the organization. Managers also create short-term groups (often called ad hoc groups or task forces) to accomplish a specific task or outcome. Long- and short-term groups created and supported by the organization are called  formal groups. Informal groups may also form within caregiving agencies. These groups are not officially designated or supported by the organization but exist because the participants chose to be in a relationship to share a common interest. Effective informal groups that demonstrate a contribution to an organization may become a formal group. Groups containing members who are clear about their purpose and are committed to working toward achieving their purpose have the best potential for success. Some illustrations of formal and informal groups include:


■ A group of nurses assigned to the recovery room or a surgical floor

■ A group of nurses employed by a visiting nurse agency

■ The institutional research board of a community hospital

■ The curriculum committee of a nursing education program

Examples of Team Member Roles

■ The annual dinner ad hoc committee

■ A committee assigned to research the factors related to an increased incidence of patient falls on a nursing home unit


■ A lunch group with an interest in starting a local chapter of a nursing specialty group

■ A mutual support group of new employees

■ A group interested in research on empathy in nursing


Formal and informal groups may be highly structured or have very little structure or few rules that guide their collaboration. Formal groups with longevity are apt to have more rules and provide more guidelines for the expectations of behavior of group members. The amount of structure in a group is reflected by its written guidelines, record keeping, style of leadership, process of decision making, and membership. A highly structured group maintains by-laws or other documents that define expectations of the group’s functions. These documents may address, for example: purpose; goals; roles and responsibilities of members; time, place, and order of meetings; and how minutes will be recorded and filed. The leadership structure and process will be defined clearly as will lines of authority and responsibility. The process of decision making will be clear and consistent. Members of structured groups are usually chosen because of their competence or ability to meet the goals and purposes of the group and are apt to have the same or similar backgrounds and educational levels.

Groups with little structure take a more laissezfaire approach; roles and responsibilities are not spelled out clearly, and group members decide among themselves, often through trial and error, how to proceed. The role of leader may rotate among members, or a leader may evolve. Decision making may be by consensus or fiat by a leader or member. Perhaps little decision making will occur or be needed. Members may not always be the same, and backgrounds and educational levels may vary. The extent of structure within a group has a significant impact on the group’s productivity and effectiveness. For example, groups with clearly communicated guidelines for membership, roles, responsibilities, meeting schedules, tasks, goals, purpose, minutes, and agendas help members understand the expectations of membership. These expectations suggest appropriate and productive group and homework activities. Groups with a purpose but little or no structure are likely to have confused and frustrated members. Productivity and achieving goals become more difficult.


A group usually exists to get a job done a job that is often referred to as the group task. Group process comprises the dynamics that occur between and among group members as they work to complete the group task. Group process encompasses patterns of behavior and issues that occur as a group forms and develops over time. Just as an individual develops from infancy to adulthood and moves with some predictability through patterns of behavior and stages of development, so do groups. Having an understanding of what to expect of an individual’s development helps parents to guide children through each stage and successfully negotiate growth and development. Understanding the dynamics of group process and what to expect as groups grow and develop will help group members function more effectively and more comfortably.

Group Stages of Development

Decades ago, Homans (1950, 1961) proposed a concise and easily understood process that described the predictable progress and process of groups. His thesis has stood the test of time and has been reviewed and expanded by others (Tuckman, 1965; Tuckman & Jensen, 1977; Lacoursier, 1980; Drinka & Clark, 2000). Homans’ theory suggests that groups move through four stages: forming, storming, norming, and performing.


In this initial stage, group members look to the leader for guidance. If there is no designated leader, one may emerge, or several members may take a leadership role at various times. Conversation is polite; the goal is to create a safe environment and find common interests and areas of acceptance.

Members are alert to similarities and differences that they will note for future reference when forming subgroups later. The group avoids controversial or serious subjects. Discussion centers around how to define the scope of the task, how to approach it. See Box 12-1 for some of the thoughts and private concerns that members are likely to be having at this stage.

Characteristics of this stage can include impatience, confusion about group purpose, anxiety, silence and awkwardness, and off-topic chatter. General issues of trust are being considered as the group struggles to find a level of ease. To grow from this stage to the next, each member must relinquish the comfort of nonthreatening topics and risk the possibility of conflict. As members take small steps risking sharing their substantive ideas and begin to experience positive reactions, group comfort will grow, and the group will move to the next stage of development. Consider the following example: During the first week of fall semester, eight members of a new junior-level class of nursing students have agreed to join their college chapter of the Nursing Student Association (NSA). They have been told by the seniors who are the leaders of the NSA that they should meet regularly and work toward enrolling all of their junior-year classmates into the NSA. They are expected to be the “front runners,” who will convince their classmates of the benefits of joining this organization, and they need to learn as much as they can about the organization as quickly as possible so they can be effective mentors for others. The president of the NSA, Kerry, has asked Kathryn to call the first meeting as soonas possible and to take responsibility for leading future meetings. The goal is to enroll at least 75 of the 100 juniors by November 1. Kathryn has assembled the group of eight for the first meeting. Most are chatting quietly about the courses they are taking, the faculty they have, and their concerns about the seniors telling them how difficult the next 2 years will be. Kathryn tells everyone what Kerry expects them to do during the next 6 weeks. All are quiet; sidelong glances are passing through the group as each waits to see who will be the first to speak.

Amy thinks, “There’s no way anyone is going to come up with $20 to join NSA because I ask them to. I am a total failure at selling anything.” She says edgily, “Why do we have to get members? Why don’t the seniors do their own work? They are the NSA officers.” More time passes quietly, and Greg thinks “I know I won’t fit in here because I’m a guy, and they probably don’t even care if guys join or not.” Lindsey thinks, “I never should have come to this school; too many spoiled children will see me as the ‘old lady’ with children of my own and think I have nothing important to say.” Shanna says, “Can anyone tell me where the bookstore is? I haven’t bought my books yet.” Trent says, “Sure, I’ll show you where it is. Where are you from?” Kathryn asks tentatively, “Well, I know we have a big job to do. Is anyone willing to help work on a plan for how to begin?” Jane thinks, “I knew I shouldn’t have come here. I’m already sure I’m going to fall behind in my schoolwork and part-time job, and here I am being asked to do more work. What’s wrong with me?” Superficial remarks go on for the course of the meeting as members learn about each other’s towns, mutual friends, dorms, and so on. Eventually, Greg and Shanna agree to meet with Kathryn the next day and work on a plan of activities to move them toward their goal. All agree to meet at least once a week until November 1, when their list of new members and the money must be turned in. Over the next 2 weeks, there are three meetings of the core group and two more where all eight attend. By then, when all are gathered, there is more comfortable conversation. Some have met for dinner and arrived together; two others have joined an aerobics class together and have arrived energized. Others are trading notes from their leadership class. Some are still shy, but most are ready to talk about the next steps of their plan for approaching new NSA members


As work begins on the job at hand (group task) and the group tries to get organized, competition and conflict develop among personal relations (group process). This conflict occurs because many individuals attempt to contribute, blend, and mold their ideas, feelings, attitudes, and beliefs as they try to find a way to approach the task at hand. As each individual contributes to the group, there may be fear of rejection, fear of failure, tentativeness, frustration, and a growing desire for structure, clarification, and sense of direction. Questions will arise about the rules, who is responsible for what, what the goals are, and how goals will be evaluated. These questions and comments reflect emerging conflicts over leadership, purpose, structure, authority, and influence. As these areas of difference emerge, there will be varying levels of comfort within the group as well as wide differences in behaviors. Some members may become very silent and withdraw; others will attempt to dominate. Cliques and subgroups will develop as agreement and disagreement over issues become apparent. Trivial matters may become the focus of attention but may be masking frustration and an inability to deal openly with larger issues.

In order to progress to the next stage, group members must move from a “testing and proving” to a problem-solving mentality. Leadership and the ability of group members to listen to each other are critical for groups to move on to the next stage of development. An effective group leader will utilize skills of negotiation and consensus building, to help group members develop greater tolerance for diverse views, and the varying roles and contributions of all the members. Think about the NSA group as they continue developing into the storming stage. The group has been experiencing some rocky times. The meetings are often fraught with sullen silences and sarcastic remarks. Frustration and anger seem to be frequent visitors, and members are sometimes missing with no explanation. Some of the remarks heard during the last few meetings include:

“It would be nice if someone would give us the right information once in awhile. Are we supposed to be collecting money from our classmates or not?” “Looks like someone wants to take all the credit for herself” (glancing sidelong at Kathryn, who had just reported on the number of members joined). “Just because someone happens to be dating a senior, he thinks he knows what is going on better than the rest of us.” “I have lots of people who want to join. Why do we have to collect the money and be so strict about keeping a record? Why can’t we just take their word for it and put their names on the new member list?” “I think the four of us who live in Windsor Hall should be a team and not have to keep meeting with everyone every week.”

“If we can’t figure out a better way to work together, we aren’t going to come anymore.” After a couple of such discouraging meetings, Kathryn talks with Greg and Shanna about what to do next. They approach Dr. X, one of the NSA faculty advisors they trust, and explain the situation and ask for help. The advisor explains she thinks the group behaviors may reflect positive group growth and signify that the group is moving out of the “I”-centered forming stage and beginning to test the tolerance of others. Some are showing their frustration with the group’s lack of productivity by angry silences or by angry remarks. Dr. X agrees to try and help. At the next meeting, Kathryn explains they talked with Dr. X and asked her to help the group get better organized. She asks if the group is willing to have Dr. X work with them. The response is lukewarm but, hearing no strong objections, Dr. X thanks the group, hands out an agenda, and explains some ground rules for the meeting. The ground rules ask that all stay focused on the agenda items, agree to speak only when recognized by the leader, promise to make an effort to listen carefully with an open mind to the person who is speaking, to make notes for reference if they have something to add when it is not their turn to speak, and to contribute with serious, thoughtful, suggestions focused on the problem being discussed. All agree to follow the ground rules. Dr. X then shares her impressions of the situation. She acknowledges the group’s frustration. She also notes the commitment of everyone, as reflected by consistent attendance. She tells them that their willingness to voice their frustration is very likely related to their being people who do not like to waste time and who are conscientious and goal-oriented and want to get the job done well. There are nods of agreement. She passes out a feedback form, asking everyone to take a few minutes to write about what they value about this group, what they wish was different, what they would like to accomplish, and what suggestions they have to accomplish the goals. They spend the rest of the evening discussing the collective feedback of the group and brainstorm a list of goals, a list of short-term objectives, a detailed plan of tasks, and a list of volunteers to work on each task. Finally, they develop a time line for the completion of each task. The next few meetings are less chaotic, becoming more focused on the group purpose.


The next stage is called norming because, as the group becomes more cohesive and tolerant of differences, the group process becomes calmer. Members have had time to become more familiar with each other and are better able to predict each other’s reactions and behaviors. This normalcy lessens anxiety and builds trust as group norms begin to develop. Over time and with good group leadership, roles and responsibilities become clearer, and members begin to feel less tension. More productive patterns of behavior develop. Cliques dissolve, and members listen to and value facts, ideas, and opinions brought to the group. Problem solving improves. The group job during this stage entails actively engaging in problem solving, sharing ideas, doing research, and producing facts and information. The group members share feelings and ideas, solicit and offer feedback to one another, and explore actions related to the task. Creativity is high. At this stage, interactions (group process) are characterized by more acceptance, openness, and sharing on both a personal and task level. Consider the NSA group as it embarks on group norming.

Over the next couple of weeks, group members have additional interaction as they compare notes and communicate between classes and in the evenings about how well tasks are being completed. Greg is feeling more comfortable that his classmates appreciate his record-keeping skills, even though he does not share their interest in the shopping trip they are planning. Jamie has experience selling books door-to-door and is teaching the group the art of how to convince others of the value of what you are selling and how to follow through with collecting the money. Amy keeps everyone informed by e-mail of the progress being made. Trent takes responsibility for safeguarding the money collected and issuing receipts. Lindsey plays the role of being the sounding board for the latest gripes, ideas, and suggestions. She strives to keep everyone motivated and encourages those who may be having less than stellar results. Dr. X attends meetings for a few minutes each week to offer her help but observes that the group has shifted its focus from individual needs to the group job. Many good ideas for ways to encourage their classmates to join NSA are generated, and members are often heard complimenting each other for their successes.


Not all groups reach the performing stage. If they do,the capacity of the group members and the depth of their relationships become truly interdependent; the group has established a highly functioning team. Group members can work independently, in subgroups, or as a total unit with equal facility. Roles, authority, and responsibilities easily adjust to the changing needs of the group and of individual members. Members feel secure, and the need for group approval is no longer an issue. Members have become highly task-oriented and people-oriented. Morale and group identity are strong; group loyalty is intense. The group is productive, engages in genuine problem solving, and creates effective solutions. The transformation from being a group of individuals to being a highly functioning team is complete.

November 1 was celebration day for the group. Through the weeks, members produced steady results and rallied around each other to overcome obstacles. As midterm approached, all were challenged by increased demands on time. Greg admitted that he was behind in his research paper for adult nursing; Shanna volunteered to keep records for a week so he could catch up. Lindsey’s father suffered a serious illness that required all her attention. The rest of the group took turns baby sitting each evening for her and involved her two children in stuffing membership envelopes. Trent took on Lindsey’s role of encourager by making a large chart showing progress toward the goals for the week. Jamie invited a different senior to come each week to talk about the fun and professional activities that membership in the NSA offers. At one point, it became clear to the group that several juniors wanted to join NSA but could not afford membership. Kathryn, Jane, and Shanna had an idea that was quickly embraced by the entire group. Kathryn approached the manager of the local music store where she worked, and he agreed to donate a $50 gift certificate to the group. The group organized araffle. Each member committed to sell at least 12 tickets for $2 each, and they raised $200 from students, friends, family, and faculty. With the help of Dr. X, the money was discreetly distributed to 10 qualified students to help them pay membership dues. During this process, it was clear that the group members were willing to work together toward group goals, and each knew he or she could count on teammates for help with tasks and personal support. Not all groups develop to the performing stage, but those that do become highly functioning, highly effective teams. Many groups form and accomplish a task without investing the time and energy necessary to become a team. But when work groups do become teams, they return the highest level of productivity to their employers and the highest level of service to their clients. The difference in effectiveness of teams versus lower-functioning groups that have not negotiated through the group development stages can mean the difference between optimal nursing care and care fraught with inefficiency and error. Consider the level of nursing care that might be delivered by a group at an early stage of development, perhaps at the storming stage, compared with a team at the performing stage. See Table 12-3 (adapted from the Web page of Nondestructive Testing, Teamwork in the Classroom [2004]).

Interdisciplinary Teams

As society has experienced a knowledge and technology explosion, the number of health-care disciplines has increased, and coordination of care has become more complex. A patient entering the health-care delivery system, even for an overnight stay, is likely to be observed, interviewed, examined, tested, treated, discharged, and monitored by a dozen different caregivers representing several medical, nursing, and allied health disciplines. This process offers the patient a breadth and depth of

Group Versus Team Characteristics

comprehensive knowledge and expertise and requires a high level of communication, collaboration,mutual understanding, and respect among the caregivers. Caregivers may include a physician (perhaps multiple specialists); physician assistant; nurses; respiratory, occupational, or physical therapist; social worker; nutritionist; and a myriad of administrators, aides, and technicians. Clerical employees and other support persons may be assisting each discipline. This plethora of personnel presents a serious challenge to effective communication and efficient teamwork. Health-care agencies expect their caregivers to be competent practitioners and effective team members. To be effective, each team member must understand the various roles played by each discipline.Physicians are trained and educated to be the central hub of the health-care team. They are likely to be the first point of contact, and they focus on the disease process or condition that has caused the patient to seek health-care services. Nurses are educated and trained to focus on the holistic needs of the patients as they respond to the stresses associated with their disease or condition. The critical importance of teamwork and communication in health care has been underscored by several published reports in the last decade. These studies document the association between quality patient care and effective teamwork (Firth-Cozens, 2001; Institute of Medicine Study, 1999; Kaissi, Johnson, & Kirschbaum, 2003; Majzun, 1998; Sexton, Thomas, & Helmreich, 2000). The findings suggest that teamwork enhances efficiency, contributes to improved morale and job satisfaction, lowers stress, and improves patient satisfaction. Risser et al. (1999) points out that effective teamwork provides a safety net against patient care errors because it allows for coordinated and integrated clinical activities and gives caregivers more control over their work environment. An earlier study by Williamson et al. (1993) and cited by Kaissi reported that 70%–80% of medical errors are related to interpersonal interaction issues. Communication and teamwork issues have been often cited as shortcomings in the health-care system. Caregiver errors contribute to compromised patient safety and diminish job satisfaction among health-care professionals. A recent report, entitled “Silence Kills,” (2005) published by VitalSmarts in collaboration with the American Association of Critical Care Nurses (AACN), addresses the need for health team members to communicate better.

The study points out the need for professionals to confront each other about detrimental caregiving behaviors that contribute to hundreds of thousands of patients being harmed each year. In addition, it notes that 1 in 20 hospitalized patients will be given a wrong medication; 3.5 million will get an infection due to lack of handwashing or good precautions (Wenzel & Edmond, 2001); and 195,000 will die because of other mistakes made by caregivers (HealthGrades Quality Study, 2004).

Practice Proof

Another significant published work that calls attention to the need for teamwork in the context of patient safety is “To Err is Human: Building a Safer Health Care System” prepared by the Institute of Medicine (1999). This report cites many factors related to health-care errors and makes many recommendations for improvement, including the need for excellent communication among health team members and effective teamwork training. The report calls for health-care organizations to implement patient safety programs that promote team functioning and to train in teams those who are expected to work in teams. Drinka and Clark (2000) support the “training in teams” concept. They recommend that students participate in interdisciplinary courses during college. In their courses, the goal is to develop an appreciation for and an understanding of the differences and similarities among their professions. Students could engage in learning about the theoretical and value orientations of other professions and develop a foundation for continued understanding and collaboration that will transfer to practice. McPherson, Headrick, and Moss (2001) also support educational strategies that prepare learners to collaborate and provide a comprehensive review of recent literature that identifies the issues, examples, methods, and conclusions about “interprofessional education.” Kaissi, Johnson, and Kirschbaum (2003) conducted a survey that explored the attitudes of nurses related to patient safety and teamwork. The nurse respondents were members of teams practicing in high-risk areas, such as operating room, emergency room, and intensive care units. These nurses believed that effective teamwork was as important as clinical competency with respect to patient safety. They also reported the need for clearer team leadership roles, more team input into patient care decisions, and better teamwork relations between nurses in high-risk areas and with anesthesiologists and nurse anesthetists. These reports strongly support the need for health caregivers to be proficient and effective team members and continually to build skills needed to be successful team leaders. Effective teams need the structure of clear  ground rules that all members know, understand, and support. Teams with good structure, good communication, and good leadership will far exceed the accomplishments of an individual. Teams that invest the time and energy to learn and execute team skills will provide uncommon results.

Practice to Strive

Note some best practices based on the work of Larson and LaFasto (1989).

Effective Communication Within Teams

Many of the problems that occur within teams are the direct result of people failing to communicate effectively.  Effective communication takes place only if the receiver understands the exact information or idea that the  sender intended to transmit. Most literature about effective communication agrees that the communication process begins with the sender having information in his or her mind. It may be a thought, a conceptual idea, technical information, or a feeling. The sender “sends” this communication, using observable behaviors, to the receiver, and the receiver “gets it” using senses, and translates the words or message into information in the receiver’s mind. This could be described as a “mind to mind” transmission. During the process, the receiver will receive a message about both the content and the context of the message. Content is the actual spoken or written language that can be understood by those who speak the same language.

Misunderstandings or confusion may occur when senders and receivers apply different interpretations or usage to the same words.  Context, sometimes referred to as paralanguage, includes the additional messages that may be sensed or perceived through nonlanguage behaviors. Context may include tone of voice, the look in the sender’s eyes, body language, hand gestures, or real or perceived state of emotion (anger, fear, uncertainty, confidence, etc.). These multiple variables of paralanguage can easily cause misinterpretation of or confusion about what may appear to be clear content. Individuals believe what they see over what they hear and tend to trust the accuracy of nonverbal behaviors more than verbal behaviors (Schuster, 2000, p.13). Several nonverbal contextual behaviors that have a significant influence on the way messages are received are described in Box 12-2 (Arnold & Boggs, 1995; Burgoon et al, 1996; Riley, 2000; Schuster, 2000). In the process of communication, there are many opportunities for a message to become distorted or altered between the sending and receiving. For example, many team leaders think they have communicated once they have told someone to do something (“I don’t know why it did not get done, I told Jim to do it.”) Perhaps Jim did not hear or understand the message. The message has not been communicated unless the receiver has received and understood it exactly as the sender intended it to be understood. Communicators can validate if a message has been properly received by engaging in twoway communication (feedback). Communication is an exchange, not just a one-way give, and both parties must participate in the feedback process to be sure nothing was “lost in translation.” One excellent way to ensure effective two-way communication is with  active listening and feedback.

Active listening is listening with full attention with the intention of understanding. It requires a conscious focus of energy and concentration and full engagement of the listener. It requires listeners to listen as if they will be asked to repeat every word they have heard. Not only will this level of attention promote effective communication of the message, it will also nonverbally communicate full attention and interest back to the sender. Some signs of active listening appear in Box 12-3 (Arnold & Boggs, 1995; Burgoon et al, 1996; Riley, 2000). Feedback is another powerful communication tool because it helps to verify that the message received was the one sent. Providing feedback may entail the receiver paraphrasing or restating what was perceived, such as “This is what I understood you to say” or “This is what I understand you are feeling. Am I correct?” The feedback process can identify the need for further discussion to prevent misunderstanding. Communication “in a hurry” and without feedback can lead to errors, hurt feelings,

wasted time, and an inefficient and ineffective work environment. When providing feedback, it is important to stay positive and  nonjudgmental. Being nonjudgmental requires conscious effort on the part of the listener. The listener must attempt to resist being distracted by inner thoughts and judgments that arise in reaction to the message being heard. Attending to these inner thoughts and judgments, instead of giving full attention to the message, distracts the listener and may create misunderstanding. For example, if the listener experiences anger at what is being said during the first part of the message, it is likely that the feeling of anger will become the focus of the listener, and the rest of the message may be distorted or lost. If the listener can make a conscious effort to wait until the entire message is heard before attending to any emotions that may be associated with the message, it will improve the effectiveness of the communication. Dr. Carl Rogers, a noted psychologist during the first half of the 20th century, was an advocate for nonjudgmental communication. He advocated using several deliberate techniques to provide feedback. He recommended paraphrasing, interpreting, providing supportive statements, probing for more information, reflecting back the same words and/or feelings, and sharing feelings. He advised that the techniques be practiced and utilized with genuineness by the communicators. He cautioned that utilizing feedback techniques in a mechanical way or as manipulations would likely be recognized as such by the communicators and interfere with clear communication and trust building. Effective communication is a cornerstone of effective teamwork, and it works best when those involved are committed to utilizing excellent communication skills, attempt to suspend personal judgments, and extend respect and positive regard for their teammates. Good communication is a rare and precious talent and requires practice. Nurses working together must apply best practices of good communication to minimize opportunities for errors or omissions in care based on misunderstandings. Communication skill is foundational to professionals being able to share, collaborate, delegate, and integrate their knowledge, expertise, and experiential wisdom. Professional expertise that is shared and blended among colleagues optimizes benefits to patients. Each discipline must understand its own roles as well as the roles of other team members so that appropriate referrals can be made and specialized expertise applied.

Team Leading

Effective team leaders must understand the concepts and theories that explain how teams function so they can meet the challenges inherent in this complex leadership role. Adjusting to the complexities of caregiving settings, negotiating development through group stages, facilitating effective communication, and maintaining patient safety is work to be guided by the team leader. In fact, one of the most important factors in overcoming these challenges and rising to the opportunities is having a

competent team leader. LaFasto & Larson (2001) note “Your purpose as a leader is to add value to your team’s effort” (p. 99). The team leader’s primary job is to stay focused on the results that the team has been charged to produce. As tasks are shared, different points of view are expressed during planning, or conflicting feelings are shared about group events, and the leader must react appropriately. The challenge will be to interpret and react while keeping the ultimate goal of the team in mind. The best leaders will consistently monitor the progress towardthe goal and plan actions accordingly. The leader must “keep an eye on the prize” and rally team members to do the same. Some skills to assist the leader to stay focused on the goal include:

■ Define the goal often to the team and ask the team to do the same.

■ Provide visual reminders of the goal.

■ Explain how tasks or assignments will contribute to accomplishment of the goal, and ask members to do the same.

■ Keep the goal alive by discussing it frequently and in different ways.

■ Use frequent examples of how all contributions are moving toward the goal.

■ Share examples of reports/stories/literature of how others reached similar goals.

■ Help all to understand how/why difficult tasks may be the key to creating the change.

■ Value team members, and trust them.

Team leaders must also invite active participation of all team members and make it clear that all members’ input is valued. Team leaders should be honest when providing feedback to members. Ground rules must call for the expectation of honest communication delivered in a respectful manner. The leader must set the tone and example for communicating honestly and respectfully and must calmly and respectfully confront others not observing this rule. In most circumstances, the leader should expect, acknowledge, and reward collaboration over competition (see Chapter 21). Providing guidance in using a methodical and clear problem-solving method is essential. A balance between tending to the need for technical knowledge and expertise and tending to interpersonal group process needs must be met. There will be times that team effectiveness is blocked because a deeper level of knowledge is needed or times when progress is impeded because team members are not working well together. The good team leader will constantly monitor the team’s progress toward its goals and provide the skill and support that are needed to help the team progress. This may take the form of exposing the team to new information, or it may require mediating a disagreement between team members who are not working well together. Providing effective leadership will require diligent monitoring and holding high expectations of team members. Encouraging task assignments that have high expectations but are doable will stretch the team’s ability. Success with stretching will build confidence and create the opportunity to experience a “win.” A leader who is fair and impartial, shows no favoritism, and facilitates inclusiveness will create a team that is willing to take greater and greater risks. Building confidence will create more motivation for positive action. A good leader says “thank you” in as many verbal and nonverbal ways as can be imagined. Effective leaders are mindful of the need for good technical expertise. Teams need to have the necessary knowledge, experience, and background necessary to reach the goal. Hard work goes a long way toward success, but without the right knowledge in the right areas effective problem solving is unlikely. A team leader who recognizes that a team has knowledge deficits will search for assistance. Possible solutions include adding more knowledgeable team members or providing the team with strong consultation to assist members with building the competence needed.

While keeping the team’s ultimate goal in mind, a wise leader will also develop interim steps designed to move toward goal achievement and will assist members with prioritizing each step. To focus energy and ensure efficiency, leader and members must be clear about what work is essential and what is not. Effective leaders set priorities by asking, “What are the three most important steps for us to achieve today (or by our next meeting)?” Teams can not reach goals, work collaboratively, build confidence, or apply their expertise if they are not clear about the priorities or if they have too many priorities. The team leader must consistently communicate the priorities to be met and help envision how the step-by-step priorities fit within the big picture of goal attainment. Finally, the team leader must apply management skills to facilitate effectiveness and productivity. Nonperformers must be managed in a positive way. The leader must communicate concern to nonperformers and provide clear descriptions of expected performance. Nonperformers must be made aware of expected time lines and the  rewards and consequences that will be applied for improved or continued lack of performance. Lack of response by nonperformers will create deterioration of team morale and will soon affect team productivity. Nonperformers will likely appreciate guidance toward better performance or will welcome the opportunity to acknowledge they would prefer not to be part of the team. Team leaders who guide their team to stay focused on the goal, stay in a collaborativerather than competitive mode, maintain confidence, provide or build the necessary technical knowledge for goal attainment, set priorities, and manage performance will find themselves in constant demand for service. They will also be appreciated by their team members and will make a lasting contribution to the safe and effective care of health-care consumers.

All Good Things...

This chapter has explored the value of team building and teamwork in health care. The innumerable numbers and types of health-caregivers create potential for chaos and require coordination of care for patient safety. Coordination of care occurs best with teamwork, and the elements of good teamwork include good communication and good group work. Effective communication is based on intentional application of good sending and receiving techniques. Effective group work occurs when group members understand group structure and process and are committed to achieving group goals. Groups grow through stages of development; those that are highly developed become productive teams. The best teams have effective leaders, excellent communication, group loyalty, clear goals, flexibility, competence, and members who care about each other. Teams are the cornerstone of high-quality patient care and satisfying work environments.

Career Development

In nursing, even more so than in other fields, leaders will need to think creatively to conceive new ways of working in today’s cyberworld. It is critical to recognize one’s personal joys and to take advantage of (and to seek) opportunities as they develop during the course of your  career. Developing a nursing career extends through a lifetime and is not limited to the institution in which you work; be in tune with opportunities that arise within a changing environment.

Opportunities emerge while one assesses future health-care needs. Equally important is for the nurse to be ready to take action when opportunity knocks by positioning herself educationally and experientially to meet health-care needs. Selecting mentors, seeking a supportive working environment, networking successfully, and positioning yourself strategically will require having people skills. Whether the goal is to become a valued member within the organization as an intrapreneur or to branch out as an entrepreneur, the nurse will need the skills to predict people’s reactions and needs and the ability to interact with different populations and personalities. Thus begins the process of building or rejuvenating oneself, recognizing what gives joy, breaking away from old beliefs and assumptions, reassessing strengths, networking to open new doors, seeking mentors to learn new skills and, most important, taking a risk. Opportunities arise outside and inside the organizations and outside and within one’s position. So tailoring or refining personal career goals requires the nurse to keep abreast of the world’s economic and political forces while keeping attuned to the health-care organization.

This chapter focuses on nurses, from early career to later. The aim is to help guide nurses who desire to take charge of career development and shape their careers and themselves more intentionally within the dynamic world in which they live.

Building a Nursing Career: A Chance to Grow

Given today’s health-care environment, what does an individual nurse do to continue in nursing, yet manage job frustrations and achieve satisfaction at the end of the day? Building a career of enduring depth, breadth, and growth is a lifelong process, not unlike growth in one’s personal intellectual development. With the advent of advanced practice, higher education in nursing, and the economic necessity of full-time employment, most nurses have come to realize that nursing is a career and profession, not just a job. The evolution of your career should not be left to chance; when you do not plan a direction for job movement, the stage is set for stagnation and inertia. Haphazardly moving from one position to another based on intangibles and whims negates the ability to achieve career goals. Although nursing positions are still plentiful and the need for nurses promises to increase, today’s nurse wants more than a paycheck. For too long, nursing placed importance on the way nurses worked and the tasks they completed, not on what they do to bring about successful patient outcomes. In reality, satisfaction with the employment environment, commitment to patient care needs, and enjoyment of pertinent activities and patient-nurse interactions are requisites for career enhancement and stability.


Nursing, as a profession and a career, is founded upon principles of science, arts, and the humanities (Chinn & Kramer, 1999). Its education and practice are accredited by the various nursing education organizations and accrediting bodies that ensure the quality and integrity of the profession and its educational curriculum (Bellack & O’Neil, 2000). Characteristics of a profession are described by the American Nurses Association (ANA, 1975, 1991) as attaining a common body of knowledge, practicing with agreed performance standards and a code of ethics, having an agreed certification procedure, having a representative professional organization, and having an external perception as a profession. Nursing’s core value is centered on people and serving the good of society (Strader & Decker, 1999); these values are timeless, but the nature of the nursing practice evolves with the times and environment. ANA (1975) described nurses as having “specialized skills essential to the performance of a unique professional role” (p. 3). The specialized skills, unique to the professional, are sensitive and responsive to the dynamic environmental forces and to the future advancements (Williams-Evans & Carnegie, 2002). Hence, the profession of nursing melds its timeless core values with its ability to adapt to the needs of the dynamic environment. Career development is a dynamic, growing, and continuous process requiring ongoing contemplation and planning. Not unlike a development of a life skill, it involves sets of steps or phases of development whereby there are markers to ensure achievement to its maximum potential. There are various permutations of the career developing or building process. It can be viewed from a perspective of mapping (Ellis & Hartley, 2005); mobility (Hall, 2002; Riverin-Simard, 2000); staging (Broscio, Paulick, & Scherer, 2005); patterns (Super, 1980); and styles (Coombs, 1987; Driver, 1979a; Gardner, 1992; Orr, 1991). Current literature on career models has moved away from static views; whereas earlier career models, such as career mapping, helped to keep the vision of a career alive, this merely provided a snapshot of what direction to go in terms of career goals. It did not provide a road map that reflects changing environmental conditions, such as “detours ahead” or “alternate routes” to take “due to inclement conditions.” Likewise, linear career mobility, which once had natural “up the ladder” promotions, does not reflect today’s careers, which are more fluid and unstable.

Today’s career development tends to be more fluid, dynamic, and sensitive to socioeconomic forces and requirements of family household needs. Therefore, careers reflect more complex trajectories and work patterns, typical of today’s two-career family households (Hall, 2002). When it comes to career trajectory, it is more apt to appear jagged with erratic turns rather than linear. Brown and associates (cited in Hall, 2002) found in their interviews of career experts that an average person will change careers (not jobs) five to seven times within his or her lifetime. In nursing, although there does not seem to be such a dramatic exiting of the profession, there does appear to be greater “entrance and exit” mobility to parallel family needs and commitments (Gardner, 1992; McLees, 1988). Nurses have become more accustomed to tailoring their career mobility to their family stage and personal needs (Gardner, 1992; Hall, 2002; McLees, 1988; Moen, 1998). Nicholson (1996) noted that careers that do not follow a steady pattern of continuous service and regular and steady promotion are likely to be considered “imperfect,” when in fact they can be a creative way of negotiating the potentially incongruent goals of a successful career and a successful family life. Typical of a two-career family with children, nurses may enter, exit, and reenter the job market multiple times within their career development, thus maintaining a fluid, flexible work schedule. Even later in their careers, as a prelude to retirement preparation, nurses are apt to reenter the job market, not solely for financial supplement but purportedly due to career identity and career satisfaction (Riverin-Simard, 2000) and personal and family needs (Gardner, 1992; Hall, 2002, McLees, 1988; Moen, 1998). Berg (2004) noted that, after retiring, many nurses either remain in the workforce or later return to it and/or return to society what Erikson (1997) termed “generativity.” Quietly advocating for patients/families as they provide care, retired nurses find a variety of job opportunities to fit their needs of retirement, financial situations, and interests. Part-time work is becoming increasingly common among retirees, with a third working part-time for “interest and enjoyment” (Roper, 2002). The flexible hours, no commitment to grown family, and unique jobs across country and abroad are opening up virtually all possibilities. Many retired nurses,viewing their personal values as integral to their professional values, find creative means to share this with the community. There are numerous stories about retired nurses, with a wealth of lifetime experience, who use their integrated knowledge and skills to volunteer and work part-time in various settings: teaching in classrooms and hospitals, being involved in ministries abroad, leading community groups, recruiting new nursing students, lobbying for political causes, and helping professional organizations. Some take leadership positions, volunteering for a local hospital board of trustees, fundraising for scholarships, working with inner city grassroot organizations. It is ironic that as nursing shortages worsen, the pool of Baby Boom retired nurses may become the “safety net” for our overworked profession.

Innovative Opportunities: Entrepreneurship and Intrapreneurship

Scientific and technological advances occur by quantum leaps. They are creating a complex landscape that futurists caution will be vastly different from our present or past. In terms of the health-care system, how the care will be delivered and what will be required of its providers and consumers will differ (Kressley, 1998; Porter-O’Grady, 2000; Porter-O’Grady & Wilson, 1999). The work of providing care will also be altered, especially for nurses (Porter-O’Grady, 2000). Neuhauser, Bender, and Stromberg (2000) described today’s world and its pace of the employment environment as “a jump to warp speed.” Organizations are predicted to coalesce more on short-term teams of experts to accomplish specific goals and to deliver results. This new consultative way of working requires work to be channeled expediently through technological communications, which paradoxically will result in a greater demand for relationship building (Neuhauser, Bender, & Stromberg, 2000). Also in an era that points to the national and global nursing shortage, organizational leaders will need to seek nurses to fulfill organization capacity. They will need to attract nurses who can build top-notch teams and who are clinically advanced, technologically smart, and relationship advanced.

Supply and demand shortages lead to demandbased pricing. More now than ever, the nursing shortage brings the highest priority to nursing leaders and educators to retain those experts in the profession and to attract the brightest and best into the field. This calls for leaders with innovative product/service ideas and an eclectic repertoire of people skills who can make, have, and address more critical decision making and conceptualized ideas.

Equally important will be to attract nurses who are politically astute, have negotiating skills, are wellversed in the art of compromise, and are tuned into the values of a growing culturally diverse nation. These qualities are present in the people with entrepreneurial and intrapreneurial spirit. Motivated by opportunities and driven by increasing consumer power, the promise of genetic research (Human Genome Program, 2005) and new drug and medical advancement, global trade and investment in system technology, today’s RNs work in an

Practice to Strive

incredible environment to enrich their professional development and carve out their niches in professional practice.

Career Planning and Development: Phases

Career planning follows a carefully designed, stepby-step method, whereas career development is a repetitive, continuous, and evolving nonlinear process. Both begin with an assessment of where the nurse has been experientially as well as a look at the current work environment. Donner and Wheeler (2001) described these bidirectional influences of self and environment as a “life skill, one that nurses can apply in their workplace, and in their personal life” (p. 8). Relating it to a series of phases of selfassessment, the career development process integrates the knowledge of self with the existing environmental opportunities. Donner and Wheeler broke these two basic interactive forces into five phases, “scanning your environment, completing your self-assessment and reality, creating your career vision, developing your strategic career plan, and marketing yourself”(p. 9). These discrete and yet fluid processes can be expanded relative to the process of becoming an entrepreneur or intrapreneur. For example, it is important to build personal characteristics that promote the entrepreneurial mindset, take control of self-knowledge gained, become aware of the dynamic forces that may ultimately shape your career, integrate the knowledge of self with the existing environmental opportunities, and then to take the risk and take action. Finally, the nurse is ready to use critical thinking and decision making to build a strategic plan that includes self-marketing.


Career assessment as a part of career development is key to finding career satisfaction while maintaining ethical integrity. Nurses need to take a SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis of their job situations and their individual characteristics and values to ascertain if they are congruent or divergent. Why do they like their chosen areas of work? What are the strengths and weaknesses of their professional areas? When and where are there opportunities? What are the threats to success? Assessing your current status is the first step of planning a career. Remember the adage, “If one fails to plan, one plans to fail.” Perhaps there is still a chance to maintain ties within the organization yet meet career goals. McGillis-Hall, et al. (2004) noted, “Nurses who are committed to the organization in which they work and have the skills and flexibility to link personal effectiveness and satisfaction with achievement of the organization’s strategic objectives” (p. 232) may continue to prosper. Currently, viewing supply and demand economics of nurses willing to work within an institution, nurses can see that this can work in their favor. Contino (2001) noted, “Accepting that hospital revenues are somewhat fixed, nurses need to find ways to help hospitals control costs, increase profitable service lines, and meet staff’s scheduling and income needs.” (p. 21). To assess the career development process, you need to ask the following questions:

■ What are the basic values in nursing?

■ How do nurses merge these core values to address the environmental needs?

■ What forms of nursing bring greatest satisfaction in meeting the needs of their patients and society?

Answering such questions can help the nurse determine whether it is possible to continue to work within the status quo or go in the direction of change. Two areas that many nurses identify as basic career needs are the ability to feel in control of their practice and to have flexibility in their work.

Autonomy in decision making, as long as it is within the scope of the organization’s policies and procedures, allows nurses the flexibility to individualize care, think critically, and set patient priorities according to established standards of practice.

Comparing one’s own practice standards with those observed in the work environment will supply vital data that the nurse can use to decide whether to continue to practice in that setting.


Bellack and O’Neil (2000) described nursing as being at its “crossroads” with a chance to grow and develop its own vision of its professional practice. As entrepreneurial “free agents,” notable nursing leaders such as Florence Nightingale, Lillian Wald, and Mary Breckinridge all carved out their own missions beyond their immediate  callings to help patients or address community needs. They took

action to reach beyond their usual practice, to create nontraditional nursing roles, to publish, to use epidemiological methods to address populations at risk, to lobby for health-care reform, to raise philanthropic funds, and to bring awareness of the plight of the poor and their lack of access to health care. These quests all stemmed from personal values about which they felt passionate, and they all channeled their voices through their professional practice (Carper, 1978). These entrepreneurial spirits pushed their goals and stirred up the social, political, and policy status quo to bring new standards to health care and nursing practice (Bellack & O’Neil, 2000). Not unlike our predecessors, today’s cyberworld requires nurses to challenge their old beliefs and assumptions of the way the nursing profession is envisioned. It will require nurses to break loose from worn-out thinking and to dream of new ways of practicing the profession. Porter-O’Grady (2000) noted the difficulties of change; however, humans naturally prefer the familiar and resist change. The greatest challenge for nurses will be to leave the familiar industrial era model of task-oriented nursing care, which served organizations well but left nurse/patient interactions to suffer. Roy (2000) illustrated the power of entrenched minds and the strength of resistance: A major hospital chain in the 1980s hired a futurist firm to envision what changes the hospital should make by the 1990s, given the changing trends in society. The futurist predicted accurately, but with the hospital operating at its peak of financial growth the hospital administration failed to respond and so missed opportunities that would have benefited the organization. The lesson to be learned here is two-fold: what may be working today will not necessarily work in the future, and the time to change is when things are going well. Pushing the envelope necessitates getting out of your comfort zone and being proactive rather than reactive to change.


Donner and Wheeler (2001) urged “nurses to be proactive, to assert more control over their careers” (p. 80). Yet traditionally nurses have not articulated their expertise well, especially in health-care settings where high levels of accountability and evidencedbased practice were concerned (Hardy, et al., 2002). Whereas nurses are people-skilled and interface with a large network of disciplines, such as medicine, business, policy, and government, their core competencies in communication and group interactive skills have gone unrecognized. Furthermore, beyond their expert clinical skills in delivering patient care, their role in successes in patient outcomes has also not been acknowledged. As a result, nursing has allowed others to direct its own job redesign whenever hospital chief executive officers (CEOs) have sought operation efficiency or costcutting tactics; nurses have been treated as no more than dispensable production task-oriented workers. Such lack of recognition has suppressed nurses’ ability to contribute actively to the goals of improving patient care. Short-term downsizing business tactics have phased out lifelong employment tenure and ignored the benefits of nurses’ contributions and loyalty to institutions. These trends have damaged nurses’ morale, led to shortages of nursing supply through professional attrition, and threatened patient safety.

In response to skyrocketing costs of health care in the United States over the last three decades, various forms of structural funding and payment mechanisms evolved, fundamentally changing treatment of patients. With decreasing length of costly hospital stays and a shift toward treating more acute care in the ambulatory and home settings, the need for experienced, highly skilled nurses dramatically increased outside hospital settings. Many nurses who remained committed to in-hospital settings found themselves unemployed and having to shift toward community-based care. Even for those who deemed themselves lucky to remain employed within their chosen setting, the heavy demands began to take a toll.

For nurses to take control of their careers, they will need to steer away from the old assembly-line shift-work mentality and to take active responsibility in managing their careers and actively marketing themselves. This will require nurses to identify their core competencies and to gain confidence in articulating to others (and to themselves) what they can market beyond their tenured process-oriented care. Regularly, nurses are faced with complex decision making, both in managing acutely ill patients and working collaboratively with multidisciplinary professionals and business organizations. Yet for nurses to take credit for their innovative care, they will need to show evidence that such interventions are proven to bring successes, especially when it comes to patient outcomes. This will be a challenge, as nursing care has traditionally been viewed as an extension of medicine, a tool in which medical care is provided, and not as a distinct profession in which the art of caring is founded on empirically based scientific principles.

Asoh, et al. (2005) noted, “Nursing presents an excellent opportunity for entrepreneurial activities since they (nurses) are trained in a holistic manner to care for patients rather than treat specific diseases” (p. 218). Beyond nurses’ expertise in caring for patients, Roggenkamp and White (1995) found that nurses exhibited entrepreneurial characteristics of “commitment to service, desire to stay close to their customer, and had risk-taking, assertive and strong leadership skills” (p. 8). Above all other factors, the most dominant motivating factor was their “love for nursing” (p. 8). The biggest challenge in this visionary transformation may be the process of change in the image of self and instilling the image of nursing as innovative intrapreneurs. The first step toward gaining control of your career is becoming aware of one’s valued contribution in bringing successful patient outcomes. Once the transformation has begun, nurses need to identify the value of their product (their expert ability), to take control of their careers, to shape them, and actively market so that other professionals and consumers will recognize nursing’s unique knowledge base and innovative care. Only then can nurses expect to become valued players and be invited into the circle of caregiver experts.

Gaining control of your career entails defining the value of your product in the marketplace. To build a valued product line (or career specialty), nurses will need to recognize what knowledge and specialty skills they can offer to either fulfill or create a market demand so as to create career opportunities that will grow. Finally, for nurses to develop their careers and identify marketable expertise, they will need work environments and leaders who will be supportive of the nurse’s intrapreneurial ventures. In selecting where the nurse will market her wares, it will be important to select organizations that promote a culture that rewards shared and creative ideas, translates creative ideas into action, acknowledges successes, and puts failures into perspective. Failures are lessons that improve ideas and help build an even better product. Therefore, gaining control requires an environment that is supportive of your professional practice and career goals and personal goals. Broscio, Paulick, and Scherer (2005) warn that careers will need to be more responsive to the freemarket ideology; there will be a need to employ free agents with specialized skills. Paradoxically, working in a virtual world, what one presumes as a greater emphasis for autonomous and independent work will actually require greater emphasis on interconnected relationships and communication (Neuhauser, Bender, & Stromberg, 2000). Moreover, effective communication is strongly influenced by previous experiences, culture, and relationships. For example, as in a global interface, without face-to-face contact, without language fluency, more emphasis is placed on communication in both the transmission and feedback loop. There will need to be a check and balance between parties in communication and a greater reliance on the nonverbal communication that requires being sensitive to diverse human beliefs, values, and modes of communication. Nurses are people-skilled and interface with a variety of multidisciplinary teams, regularly implementing and utilizing collaboration, negotiating, and building partnerships in their collaborative interactions with a highly educated network of professionals.

Complex environments require complex decision making; therefore, a bureaucratic hierarchy model of top-down communication does not fit the needs of today’s dynamic, unstable environment. Where environmental boundaries have become blurred, our response to such complex dynamic forces requires decentralized decision making that is flexible and rapid-response. Popularized by the profit center concept developed during World War II, decentralized decision making allows for those who are closest to the operations to exert greater freedom to take control. Decisions need to be made closer to the operational level or at the point of patient care. Whereas physicians and other health professionals have expertise in the disease management or various elements of the human body, it is the nurse who has the greatest patient contact in hospitals and in the home. Knowledgeable about human responses to illnesses during the most vulnerable times in people’s lives, nurses have unique caring ways to bring patients back to health through their expert clinical skills and human interactions. Again, nurses’ expertise in “knowing the patient”brings unique skills that help motivate clients with their self-care; thus, nurses have a unique ability to carve out patient education niches within the marketplace.


Amidst the optimism of scientific and technological advances, health care is under the shadows of a growing socioeconomic crisis: issues of the growing uninsured and entitlement costs of the soon to retire  Baby Boomers (Robert Wood Johnson Foundation, 1999). Such opposing forces create a complex landscape, vastly different from that of the past. In terms of the health-care system, how the care will be delivered, what will be required of its providers and consumers, and what provider roles will be expected to address in terms of institutional capacity needs will also differ (Kressley, 1998; Porter-O’Grady, 2000; Porter-O’Grady & Wilson, 1999). For nurses, the work of providing care will be greatly altered as well (Porter-O’Grady, 2000). Clearly, nurses’ skills and career paths will need to mirror the changing health-care environment (Porter-O’Grady, 2000). Taking stock of the world in which we live is the first step to shaping our careers. Porter-O’Grady (2000) outlined three major converging forces that are changing our health-care landscape, which directly and indirectly affect nursing: economic, sociopolitical, and technological forces.

National Forces: Economic and Sociopolitical

Today’s U.S. health-care system is faced with some daunting challenges. Economic forces drive the health-care delivery system to monitor its service use and patient health outcomes. Closely related to economics are sociopolitical forces as the health-care industry shifted its focus of care from costly curative hospital-based care to a less costly preventive consumer-accountable community-based care. The change from cost-based to prospective pay has brought managed care to its third decade of maturity; yet the great hope of curbing escalating health-care costs has still not been fully realized. To improve U.S. health-care shortfalls, U.S. health-care leaders are now rethinking forms of funding and mechanisms for health-care alternatives, even learning from other countries.

Accompanying such sociopolitical forces is the change in America’s demographic topography in terms of age and ethnicity: fewer young productive citizens to support aging Baby Boomers, increased ethnic diversity, with growing economic gaps leading to even greater disparities. The “wide-angle image” shows inadequate insurance coverage that is inching up toward middle class Americans, along with an insecure entitlement reimbursement for the retired. In the next decade, our nation is projected to have one of the highest dependency ratios of younger ethnically diverse underemployed to older retired citizens.

The close-up brings to view images of the plight of the nursing and labor shortages, which create a patient dependency ratio that exceeds that of hospital capacity. The current nursing shortage is said to be unlike that in the past; it is deemed more dire and enduring (Nevidjon & Erickson, 2001). Fueled by the aging demographics, its primary shortfall is the result of attrition, both in nurses and nursing educators. According to Nevidjon and Erickson, “from an economic perspective, this shortage is being driven more by the supply side of the supply/demand equation” (p. 1). Adding to the nursing shortfall are the shortages in allied health professionals and ancillary staff, such as secretaries and support staff. Thus, this is a more complex shortage, which promises to worsen during the next decade as more health-care professionals and educators retire. Such shortages all adversely affect the health-care delivery system. Early in the 1990s, for cost-cutting reasons, hospital executives increased the use of unlicensed assistive personnel; however, these models failed due to increasing patient acuities, higher patient nurse ratios, concerns over medical errors, and the declining numbers of ancillary personnel. The impact was felt by the patients as well, as nurses are deemed to have the most continuous contact and develop the closest relationships with the patients and their families.

Global Forces: Sociopolitical Economy, Nursing Shortage, Unintended Consequences With globalization, today’s world has become interdependent, yet highly competitive. International boundaries have become more fluid, especially in terms of U.S. interdependency in global trading. The blurring of domestic and international boundaries has shaped the environment in which we work and live. Its impact has filtered down to everyday American lives and work (Hall, 2002; RiverinSimard, 2000). Our social sphere is growing smaller, with tightly interwoven diversity, both racially and ethnically. Partly the result of the American’s insatiable consumerism, our link with foreign labor markets is much more visible. The 2000 U.S. Census indicated that, between 1990 and 2000, 33 million people were added to the total U.S. population, with the fastest and second fastest racial/ethnic groups being Hispanics and Asians, respectively. Such dramatic demographic change can be viewed positively as an enriched cultural mix for our society, or it can be viewed by others as a menacing mix of clashing values that threaten our society. In our country’s efforts to assimilate our newcomers into society quickly, there is a demand not only for bilingual nurses but also a greater demand for employees who are sensitive to the nuances of working within a racially/ethnically mixed culture. Culture has a significant impact on how people interpret health and illness (Spector, 2000). This provides nurses greater career opportunities. Nurses are inherently peoplesensitive, which fits the required portrait of the type of leader that is needed for tomorrow’s culturally diverse employees (Vicere, 2004). Indeed, nurses are not only advocates and  care experts to individuals, families, populations, and communities, but their leadership skills often include mentoring employees of diverse cultures. So in terms of expertise, nurses have a wealth of possible career development options that could be carved into a specialty niche to fit the needs of a growing international community.

With the increasing size and mobility of the human population, there are direct and unintended consequences of emerging diseases that pose a continuing threat to global health. Historically, the United States had come to see open trading as “a means not only of advancing its own economic interests but also as a key to building peaceful relations among nations” (Garrett, 1998, p. 787). Yet even with economic incentives and peaceful motivations, there are subtle political ideologies promoted. This can create ideological clashes between diverse nations, which can surface as trade disputes and power struggles. Ideological clashes have caused America (and other nations) to be targeted for terrorist attacks as protests against American policy.

Global unrest and international instability can have overreaching effects on countries and their people. The global outreach in nursing is extensive, and it encompasses a full spectrum of expertise and services, from policy-making, capacity-building efforts to point-of-service primary health-care delivery. International organizations, such as the World Health Organization (WHO) and the International Council of Nurses (ICN), provide opportunities for nurses to work abroad and to mix their expertise with their love of travel and learning about diverse populations. With growing global disputes, traveling outside the United States has become increasingly risky for Americans, especially to the most severely economically depressed, war-torn countries. Such global unrest has curbed the activities of many nurses and medical volunteers who otherwise would reach out with humanitarian efforts to serve where the nursing (and medical) shortages are the greatest.

International trade agreements have transformed the capacity of governments to monitor and to protect public health by regulating occupational and environmental health conditions, exporting and importing food products, and ensuring affordable access to medications (Shaffer, et al., 2005).

Proposals are under way for the World Trade Organization’s General Agreement on Trade in Services (GATS) and the regional Free Trade Area of the Americas (FTAA) agreement to seek coverage of a wide range of health services, health facilities, sanitation services, and clinician licensing. Linkages among global trade, international trade agreements, and public health will no doubt open new opportunities for global exchange, especially for nurses to participate overseas in a wide spectrum of entrepreneurial-type services. Linkages among global trade, international trade agreements, and public health deserve greater attention. The effects of interdependency in trade of products can be seen in human resources as well. Shortages in the health workforce, especially nurses, present a major challenge for health-care policy makers nationally and internationally. The nursing shortage is worldwide, even in developed countries such as the United Kingdom, Canada, and Sweden. International exchanges, especially in nursing resources, could become an area of dispute. Working under North American Free Trade Agreement (NAFTA) status, current trade of foreign market is keenly felt in the area of nursing shortages; recruitment continues from various foreign countries such as the Philippines, Canada, Mexico, and others. But while there has been an increasing trend to recruit foreign-born nurses to increase the U.S. labor market, the shift in supply to the United States does little for the global shortage of nurses and the demand it creates within the countries they left (Booth, 2002; Zurn, Dolea, & Stilwell, 2005). More recently, South Korean nurses have been proposed as an answer to the current shortage of nursing educators. Living in a highly competitive Korean job market, many Korean faculties are already doctorally prepared nurses and English-proficient and have taken the NCLEX International (2005) examination administered by the National Council of State Boards of Nursing (NCSBN). In the Western Pacific, Korea is among three nations that have reported a surplus of nurses at present (SocioEconomic News, 2003).

With the potential influx of nurses into the United States from diverse countries, the most poignant question that U.S. nursing professionals ask is, “Do foreign nurses hold similar professional nursing values and practice models as nurses in the United States?” Flynn and Aiken (2002), in their secondary analysis of nearly 800 nurses surveyed (with nearly a third from 34 other countries), challenged the prevailing sentiment that foreign nurses would have different nursing values and professional practice models compared with U.S. nurses. The findings also revealed that in the absence of a professional practice environment, foreign-born nurses would experience similar high levels of burnout as U.S. nurses. Although one answer to the nursing shortage might be to recruit from foreign countries, health-care administrators will still need to ensure that organizational and leadership attributes are congruent with a professional nursing practice environment. With blurred boundaries, the world has become increasingly vulnerable to both (re)emerging infectious diseases, once thought controlled or never experienced before, and to natural disasters, such as earthquakes and hurricanes. Given the current size and mobility of the global community, the world is at risk for pandemic outbreaks and increasing climatic disasters. For example, increasing contact between humans and animal disease reservoirs contributed to the emergence of severe acute respiratory syndrome. Ecological changes, such as habitat fragmentation by deforestation, may increase the contact between people and reservoir species, all contributing to zoonoses (e.g., hemorrhagic fever virus). Early recognition of cases and application of appropriate infection control measures will be critical in controlling future outbreaks. Moreover, global warming has been identified as contributing to the spread of dengue beyond tropical regions and possibly contributing to the global climatic and typological turbulence.

Technological Forces and Unintended Consequences

Scientific and technological advances promise revolutionary changes in the health-care system. Yet such promises of technology and its ability to fix human ills may need to be balanced with cautious optimism. Beyond the impact on global communication capabilities, technology promises to offer resources to improve the quality and length of people’s lives. It promises to transform the way diseases are diagnosed and treated. The technology presents new possibilities to design innovative methods for (1) preparing future generations of nurses, (2) addressing the issues of medical errors and the nursing shortage, and (3) satisfying and extending the requirements for entry-level RN practice in terms of knowledge, skills, and abilities. One exciting example for nursing education and practice is the ability “to practice” low-frequency high-risk patient events through the use of simulation technology. Such technology has multiple applications in helping to reduce nursing and medical errors, advancing nursing skills, and improving teamwork without putting real patients in harm’s way. Not unlike the military field training for combat, the simulation laboratories can be created as virtual hospital rooms and clinical settings with physiologically/verbally responsive mannequins for nurses, students, and other medical teams to act out realistic scenarios that simulate actual events. The impact of this technological training tool is enormous as it addresses multiple educational, nursing, and organizational issues. It provides a safe environment in which novice nurses and students can train; allows for errors to take place without putting an actual patient in harm’s way; permits organizations to gather data and develop system changes to protect patients and adjust policies to improve patient safety; provides new possibilities for preparing novice nurses to expert level in a shorter time; promotes teamwork by helping the health-care team to communicate with each other (where the majority of medical errors occur); and trains nurses and other medical members to improve their communication with patients/families (Institute of Medicine, 2000).

The flip side of technology is its unintended consequences. With any new technological advances,we need to scrutinize and critically think through what the unintended effects might be on the greater whole: the world. Without getting into the philosophical debate about the benefits/risks of reliance on technology, William Barrett (1979), in his classic The Illusion of Technique, warned about placing such high reliance on technology to solve human problems. Similarly, Ehrenfeld (1981) critiqued society’s reliance on humanistic power to solve the world’s problems. Some questions that need to be asked are:

■ How is the technology to be applied?

■ Who will be applying it?

■ To whom is it being applied?

■ What are alternate uses of such technology?

■ How and whom might it harm?

The Human Genome Program (2005) is an example that illustrates the cost of technology. It affects myriad social and clinical applications, but there are a number of ethical dilemmas attending its use, ranging from ensuring privacy to informed consent.


Rollo May (cited in Driver, 1971b) wrote, “out of the creative act is born symbols and myths. It brings to our awareness what was previously hidden and points to new life. The experience is one of heightened consciousness—ecstasy.” Creative expression is vital to quality life, and everyone has the creative potential if they follow their interests. Although “creativity” continues to elude empirical measurement, we can see creativity in a person’s affective “act of doing,” seeing their spark through their being in the world/nature-at-large, and discovering their interactions with us and exploring their effect on us. Because creativity is an intrinsically motivating trait, its action may be associated with nonconformity, independence, persistent questioning, and persistent in-depth inquiry. This internal drive is what pushes entrepreneurs and intrapreneurs toward excellence. The adage, “time flies when you’re having fun” can be applied to the process and outcomes of creativity. Csikszentmihalyi (1997) identified the spark as the heightened consciousness, or the creative flow, an energy that is not necessarily an isolated experience but can result as a synergy working with others. To learn how creativity worked, Csikszentmihalyi (1995) interviewed 90 leaders in various disciplines and discovered that they regularly experienced this state of  flow, a heightened state of pleasure experienced when one is engaged in physical or mental challenges that absorb us and give us joy. Based on these interviews with some of the most creative people in the world, Csikszentmihalyi (1995) listed the steps that individuals could take to cultivate one’s creativity. Furthermore, he recommended (1995) that one needs “to acquire many interests, abilities, and goals and to use them in such a way they harmonize with one another” (p. 30).

Creativity and innovation reflect “thinking and producing” respectively; both share in creating something new. Merriam-Webster (2005) describes creativity as a reflection of these two parts: creativity as “the ability or power to create something new” and innovation as “the power that puts the creative inspiration into action.” The three key personality elements required to build a new vision of oneself as creative include having a high tolerance for ambiguity, being comfortable with the unknown, and having faith in yourself to handle any outcome.


Sister Callista Roy (2000), renowned theorist on adaptive nursing theory, wrote that nursing faces a great challenge: to create a visionary change within its own profession. However, Carper, Chinn, and Kramer (cited in Roy, 2000) revealed that nurses all too often struggle to find effective strategies for developing integrated knowledge, defined as a way of knowing that comes with synthesizing “the personal, ethical, aesthetic, and sociopolitical knowledge” (p. 118). Self-reflective thinking brings the “invisible” knowledge of self into clearer view. This process requires a nurse to assess what in his current position gives him joy and what he believes and values about life and the people around him (White, 1995). Guided by the Professional Standards of Nursing Practice, nurses’ core values and practice of nursing are centered on people and serving the good of society, which is unchanging and timeless (Strader & Decker, 1999; White, 1995). Conversely, nursing skills evolve to reflect the context of the time and environment (Williams-Evans & Carnegie, 2002). Specialized skills evolve over time, as one can see with many nurse practitioner skills. Their skills of assessment, diagnosing, and prescribing medications evolved from both the greater push for nursing practice and to fill the need of the primary care physician shortage. Yet the core of nursing values remains immutable, to advocate for the needy populace and to promote the good of society; thus, these values are embedded in each nurse’s personal values and beliefs. Creating the vision for career necessitates self reflective thinking, a process that requires nurses to assess what in their position gives them joy and what they believe and value about life and the people around them. Nurses can then bring this self-reflection and compare it with how others perceive them (Donner & Wheeler, 2001). This process helps to identify the “invisible” personal and professional values (Roy, 2000). This vision of self is then linked to how you fit into the environment, how your values fit with the organization and whether the organization fits with your values, a reality check. This begins the “self-reflective” process of wondering and thinking:

■ Where am I?

■ Where do I want to be?

■ Where have I been?

■ How can I use my experience, and what else do I need to know?

■ Who do I go to for more information and direction?

■ How do I get there?

■ How can I salvage what I already know?


Nurses too often struggle to find strategies for integrating the self into the environmental opportunities (Carper, et al., 1978; cited in Roy, 2000). After completing a career self-assessment, you need to repeat the environmental assessment discussed earlier in the chapter. Through this repetitive process of self-assessing and seeking feedback from colleagues, the level of self-awareness deepens. With an accurate picture of your values, strengths, and desires, you can immerse yourself in the offerings within and outside the health-care field. It is vital to scope the environment and keep abreast of the surrounding marketplace, to view the trends in business and organizations, both related and unrelated to the health-care system. Scanning the environment means following the technological development and immersing yourself in the global news and local and national current events: identifying the sociopolitical and economic issues that directly or indirectly affect our nation and our profession. For example, topics of importance to hospital industry, business, and global news can easily be identified and collected by simply typing in the subject of interest through a search engine, such as Google. For example, a search of hospital CEOs concerning the financial outlook for health care resulted in a survey of hospital CEOs done by Deloitte and Touche, USA (2005). It reported that the industry was taking a more optimistic outlook of its financial future (Deloitte and Touche, USA, 2005). With a consumer-empowered market, it reported that the United States offers a more interconnected economy, which offers consumers greater advances in new drugs and medicine, promises of genetic research and its potential curative application to chronic diseases, greater investment in telemedicine, and new cyber- and biomedicine technology (Deloitte & Touche, USA, 2005). Sources of information need to be widespread and diverse. Both online and library sources can bring a wealth of literature information. Also important is networking with a variety of people both inside and outside the field of nursing. Attending national conferences to learn about the national and global trends and ongoing issues and to meet others within and outside the field can be energizing and valuable. Information can be gathered easily online by signing up on a listserv, such as, which provides continuous legislative and policy information and updates relevant to one’s interest area. Other access to information may be through a live or archival recorded Webcast of national and international conferences. Searching professional journals within and outside nursing, and even searching popular magazines,would give insight into current events and what the public is reading. Once the environmental search is completed, sift through the materials identifying similar, related, and dissimilar issues within diverse disciplines. Analyzing the dissonance and the interconnectedness between various disciplines allows one to bring the pieces together, the parts brought together to bring a new whole, a synthesis of new ideas. Pulling this together, one can begin to identify the gaps, view the needs within the environment, and bring one’s strength of expertise to develop a strategic plan, a blueprint of actions.


Taking the “entrepreneurial leap” is the same for the intrapreneur as it is for the entrepreneur. Taking the leap requires the entrepreneur and intrapreneur to view themselves as opportunity seeking (Gordon, 1985; cited in Hisrich, 1990) and as having the ability to recognize opportunity (Paterson, 1985; cited in Hisrich, 1990). For the entrepreneur, that means seeking the opportunity outside the current employment; whereas, for the intrapreneur it means seeking an opportunity within the current workplace. In fact, many budding entrepreneurs arise from having evolved as intrapreneurs (Manion, 2001). Brugleman (cited in Hisrich, 1990) integrated these two traits of seeking opportunity and recognizing opportunity to describe entrepreneurship as “seeking to find and recognizing when opportunity knocks.” These traits give entrepreneurs and intrapreneurs the leading edge in developing and diversifying their businesses. For the nurse entrepreneur and intrapreneur, this can mean developing new skills to create a new role outside and inside of nursing. It is the discovery of something new, the creativity that ignites the entrepreneur’s (and intrepreneur’s) innovative ideas and propels her forward to the opportunity (Gordon, 1985; Paterson, 1985; cited in Hisrich, 1990). Beyond the risk-bearing attributes, entrepreneurs and intrapreneurs themselves are known to have other unique personality attributes. They quest for quality, a willingness to move beyond the standard solution in preference for creating a new “original idea.” McClelland (1965) noted that entrepreneurs had a need for high achievement, and Roscoe (cited in Bird, 1989) found they had a strong drive for independence and an exceptional belief in themselves. Smilor (cited in Baum & Locke, 2004) suggested that passion is “perhaps the most observed phenomenon of the entrepreneurial process” (p. 342). Locke (cited in Baum & Locke, 2004) identified, in a qualitative analysis, core characteristics of famous wealth creators, such as Bill Gates and Michael Bloomberg: their zeal and their love for their work. Moreover, Lackman (cited in Bird, 1989) found that entrepreneurs held the personal values of honesty, integrity, duty, responsibility, and ethical behavior constant and applied them toward their life and work. Consistent with these values, Cunningham and Lischeron (cited in Bird, 1989) deemed high self-esteem as a notable characteristic of entrepreneurs. As leaders, they were found to be more flexible and adapted their leadership style to the needs of the people (Katz and Brockhaus, 1995).


As discussed earlier, one of the first steps for a nurse considering the role of an entrepreneur or intrapreneur is to look within herself to see whether she has the ambition, fortitude, and inner strength needed to venture outside the role definitions that have been used in the past. As nurses begin to imagine what their professional lives could be, they need to do some critical thinking about their present environment. Can their goals and professional achievements be fostered from within their current organization, or must a break be made? A nursing process model, combined with critical thinking, is an excellent framework to use as a problem-solving method of career analysis. Nurses are expert at assessing, planning, synthesizing data to form diagnoses, setting goals, creating interventions, and evaluating. Nurses can immediately evaluate a plan of action according to its riskbenefit probability and can use critical thinking to develop a short-term evaluation of the consequences, both positive and negative. The assessment includes looking at the organization in which nurses are employed; the organizational structure and leadership style should support decentralized decision making. As they survey their present organization, nurses should make judgments regarding its culture of human respect, its value of autonomy, and its ability to accept new ideas and discard old ones. Another important point to consider is whether the organization will thrive and grow or stagnate. The question that needs to be answered is whether to stay in the present organization, move to another one, or move outside of any organization. Or even whether to remain in the role of a nurse. McLees (1988) stated, “Former nurses developed careers in other professions that offered them greater outlets to express their individuality, creativity and freedom.” The intrapreneur can work effectively within an enlightened organization, whereas an entrepreneur is destined to work from the outside, often with many different organizations. After the decision for a role change has been reached, the nurse needs to look at what needs to be done and what advantages can be gained from a strategic plan for marketing the idea or product. The environment needs to be assessed relative to the networking possibilities and the availability of potential mentors.

Marketing, Networking, and Mentoring

A nurse considering a move to intrapreneur or entrepreneur must become familiar with the concepts of marketing, networking, and mentoring; these are vital to a successful intraprise or enterprise.


Marketing lets potential users know about a product’s existence and advantages. The dictionary defines marketing as “the process or technique of promoting, selling, and distributing a product or service” (Merriam-Webster, 2005). For nurses, marketing often becomes indistinguishable from selfmarketing, which involves promoting who they are and what they do. Having a business plan will allow the nurse to answer objective questions about the product or service as to what it is, the advantages of it relative to its competitors, the innovation of it in relation to the status quo, the worth or value in monetary terms, the break-even point, the potential buyers, what might motivate them to purchase, and what the contractual obligations should entail. In order to sell the product or service, the nurse needs to become an expert on the needs of the organization. This involves research and tapping into people who may be able to help within the pertinent network as well as soliciting the advice of a mentor. Nurses are experts in picking up on behavioral cues and applying them to outcome criteria for their patients. Many of the same skills are useful in negotiating with potential clients. Reading books on selling and practicing with others who might agree to pose as “buyers” will help to bolster confidence and allow the nurse to anticipate questions and formulate confident answers beforehand. Competition and the task of constantly proving one’s worth to organizations can be emotionally draining. The independent contractor must be politically savvy within his current organization and able to apply these skills to new situations and people. Even though the nurse entrepreneur can, in theory, choose his own clients, when one is just beginning to get established this is usually not a reality. The nurse needs to please as many new clients as possible and follow up on other potential clients while they are still interested. The role of nurse entrepreneur brings the potential for increasing income, but at first there is often meager remuneration. Many unpaid work hours will be necessary to get the business started. Sometimes the fledgling entrepreneur must provide services and consultation almost for free just to get started Once the nurse has an established a reputation, fees can be increased and cancellation clauses introduced into written contracts. The business plan will include some of the start-up costs; typical needs are a computer with fax and color printer, file cabinets, and copier. Also important are business cards describing the nurse and the services available as well as a mailer or cover letter that can be given to prospective clients. Mailings and Web-site design may become eventual investments. Keeping the overhead down can do a lot to keep a fledgling business afloat. The nurse entrepreneur may need to borrow money to compensate for business setbacks or to fulfill orders that are not affordable within the current budget. Much depends on the type of service or product that the nurse entrepreneur intends to provide.


Another important concept to consider in order to become a successful intrapreneur or entrepreneur is networking. The word “network” literally means a framework of nets. It has recently been used as a verb, referring to meeting people for the purpose of establishing links or contacts to further a goal. Hisrich (1990) found that “the density of the entrepreneur’s business contacts or linkages” was important to start a new business and that “maintaining contacts were a significant predictor for early profit” (p. 6). For the nurse, it means becoming visible, getting to know people in other areas of the job site, finding out what they do and who they know. A more formal definition is offered by Benton (1997): “a way of establishing and using contacts for information, support and other assistance to further career goals, or as a way of building relationships” (p. 58). Most networks are made up of people who are receptive to communicating with one another. Benton sees the benefit of networks as a vehicle to gather “feedback” on a particular issue or on the nurse’s performance. It may be a way for the nurse to “influence” or be influenced by a particular point of view. One of the more traditional reasons to network is to act on or procure a “referral” (p. 59). A network can also act as an excellent advertising vehicle (Hisrich, 1990): “satisfied customers help establish a winning business reputation and promote goodwill” (p. 6). Many individuals network to test the job market or to help secure a position outside of the organization. For the intrapreneur or entrepreneur, it may help to locate an area of need within the organization. This can serve as a springboard to fill the vacancy either permanently or temporarily as a consultant.

Some nurses are afraid to network because they think that it will involve small talk and taking advantage of a colleague or friend. Networking should be mutually advantageous for both parties involved. It is important that this give-and-take be implied at the outset. It may be difficult to see the immediate monetary or career rewards to networking because some contacts take more than one meeting in order to cultivate useful information. But at the very least a foundation has been formed. Beck and Utz (1996) sees the benefits as “increasing contacts, sharing resources, and gaining peer support to contribute to an ultimate goal”. Networking is also “an effective means of fulfilling [the] responsibility of collegiality, while at the same time achieving personal and professional goals”. Benton (1997) advises that successful networking is a “dynamic process,” so it is important to strike a balance, keeping in touch with contacts but not becoming a nuisance. Follow up promptly on a promise of information or help, as reciprocity of a favor may be important in the future. It is important not to ask for favors or information that the person is unable to provide. Discretion is also extremely important as comments made to one person about another are bound to reach the ears of the one discussed, especially if the network is small. It is always advantageous to carry a good supply of business cards. Some nurses carry more than one type; one may describe the current job, and another highlights the nurse’s intrapreneurial or entrepreneurial abilities. Obviously, this is also a good way of marketing one’s skills or product. Within an organization, it is important to approach people who work in unfamiliar areas and get information on what their jobs entail and how their departments function. The nurse can approach a staff member whom she would like to know better and offer to treat the person to lunch in exchange for some information about how that person does an assigned job. The colleague will probably be flattered if the nurse is diplomatic. Benton (1997) recommends getting on mailing lists of professional organizations so that follow-up is possible with members related to newsletter submissions and advises the nurse to write or e-mail journal authors to establish contact and “open up a new network connection”. West (1997) offers many useful networking strategies, particularly if a new position is sought. When attending a large professional conference, circulate and meet as many new contacts as possible, disseminating business cards and collecting them from all. When a new contact asks, “What do you do?” it is best to describe it in behavioral terms to highlight particular skills. It is advisable to write notes on the back of the person’s business card so that pertinent information is not forgotten. Even if a new permanent position is not being sought, finding out from contacts and nursing journals about vacant jobs will give useful information about where professional expertise may be needed and consultation opportunities exist. Whenever there is a chance to meet new people, it is also a good idea to have an updated résumé. Sometimes, a potential client is so enthusiastic that he will ask for one. It is beneficial to join professional organizations and volunteer to serve on committees or task forces (Benton, 1997). West (1997) advises “diversification of the networking group by adding social acquaintances, college classmates, alumni, professors, church ministers, church members, and local business and social club officials. Even the family lawyer, doctor, dentist, insurance agent, and banker may be in a position to help”. Web logs, known as blogs, are an emerging writing tool that is easy to use and that can enhance health professionals’ communication, collaboration, and information-gathering skills and help to manage information, diminish medical error, and support decision making (Maag, 2005). Nurses can read and comment on others’ blogs as well as starting blogs themselves. Maag noted that “Daily blogging will enhance positive writing skills, instill selfconfidence in voicing personal opinions, and promote reflective thinking that, in turn, will allow the writer to appreciate his or her personal opinions or ideas” (p. 2). Bloggers must be careful about what they write online; a number of bloggers have been fired for criticizing their employers or presenting themselves in an unprofessional way online. Getting in touch with a wide range of global information and insight will facilitate knowing and becoming known. Having a perspective on worldwide nursing issues gives the professional an ability to interpret situations with greater accuracy.


The other concept that is vital to a successful career as an intrapreneur or entrepreneur is mentorship. The term “mentor” is originally from the Greek legends and “refers to Mentor, the loyal friend and wise advisor to Odysseus and the teacher and guardian of Odysseus’ son Telemachus” (MerriamWebster, 2005). The individual needs a personal moral support and a morale-building system and a professional network of contacts and advisors. A role model who will agree to give counsel and act as a sounding board for potential career plans and activities is an invaluable resource, particularly at the inception of a new business venture or even at the beginning of a nursing career. Byrne and Keefe (2002) describe a shift “in the nursing literature from an early emphasis on mentoring primarily for executive leadership roles to a current emphasis on special mentorships for clinician, researcher and other roles”. Recommendations for mentoring of clinicians include support of new RN graduates (Andrews and Wallis, 1999; cited in Byrne and Keefe, 2002), novice nurse practitioners (Hayes, 1998, and Hockenberry-Eaton & Kline, 1995; cited in Byrne and Keefe, 2002), and nurses making specialty transitions (Esper, 1999; cited in Byrne and Keefe, 2002). Byrne and Keefe noted, “Within nursing the experience of mentoring has sometimes been perceived as a learning continuum which extends from peer support and role modeling, through instructive preceptorship, selfinitiated and guided networking, and finally the intense and personal occurrence of focused mentorship”. Nursing is unique in that newly acquired knowledge, whether evidence-based or hypothesis-related, can almost immediately be put into practice. Nurses can immediately evaluate a plan of action according to its risk/benefit probability and, by using critical thinking, develop a shortterm evaluation of the consequences, both positive and negative. If new nurses burn out because of the lack of available support and advice, they will not survive the rigors of the initial practice environment to become advanced practitioners, intrapreneurs, and entrepreneurs. Nurses are cognizant of the need to support, encourage, and teach new graduates and novice practitioners and are committed to helping them become competent, self-confident, and enthusiastic nurses. Having a mentor within an organization can help a budding intrapreneur to gauge the advisability of assuming a new role. Finding someone who has worked in the same place for a number of years is a bonus; he knows the history of various programs and people. He can give a synopsis of what has been tried and why it was dropped or changed. This is vital information for the nurse who is planning to offer a “unique” and important service in order to occupy a niche within the hospital, healthcare center, or community facility. A mentor can give helpful feedback on ideas and proposals before they are presented. Temporary setbacks can be analyzed and a new plan theorized. For the nurse entrepreneur, it is advisable to seek a mentor with a business background as well as another within the health-care sector.

Nurse Intrapreneurs

A comprehensive perspective on the development of intrapreneurs and entrepreneurs in nursinginvolves looking at the qualities, roles, options, and successes of each designation.


As described by Gifford Pinchot in 1986 relating to the corporate sector, “intrapreneur” refers to a person who wants to be entrepreneurial but does not want to change his/her workplace. “Behind most successful nurse leaders, executives, and entrepreneurs winds a long road of successful intrapreneurship, or innovation within an organization” (Manion, 2001, p. 5). The  nurse intrapreneur develops skills that are needed by the organization, thus creating a visible, marketable, talent niche. “These professionals are continually seeking and recognizing opportunities for personal growth and development and are undeterred by typical organizational barriers to innovation” (Manion, 2001, p.5). Because many of the intrapreneur’s skills and internal innovations save the facility money, the organization directly benefits from the service. Intrapreneurs are loyal to the organization andwant to be useful and feel appreciated. They are also confident, assertive, and willing to speak up when they see a situation that could be ameliorated or made more efficient. They are open to exploring new ideas, not mired in traditional mindsets or bound by convention. They can take two “old” environmental objects and synthesize a new one that becomes more than the sum of its parts. This nurse is also typically talented, innovative, and proactive; the facility wants to keep this valuable nurse on its payroll rather than lose the intrapreneur to a competitor.


How can a nurse become an intrapreneur? Having a creative outlook is the first step. “The greatest obstacle to workplace creativity is the we-alwaysdo-it-this-way mentality” (Cohen, 2002, p. 10). Intrapreneurs may recognize systems that need changing, skills that will become necessary to master new equipment, better ideas for organizing or sorting data or personnel—the possibilities are endless. By becoming a valued contributor to an organization, the nurse can build job security and increase professional and personal satisfaction with her career trajectory. One of the first steps is to get to know people in the organization and find out what they do. Having a network of individuals will help to identify problems and how they may have been solved in other departments. Finding multiple mentors is also important; they may all have expertise in different areas and may offer many possibilities for innovation. It is also important to look at the strategic plan and see where the organization will go in the future. An important tactic involves volunteering for task forces and committee assignments. It is both a good way to meet people and will acquaint the budding intrapreneur with the way the organization solves problems with its people and who has the power to make change. It is also important to adopt a philosophy of lifelong learning, to stay current in the newest innovations in nursing, and to be aware of what is happening in other fields. The intrapreneur needs to research what therapies are innovative and how they are being implemented at the facility; the next step would be to write an article for publication or make a presentation to other facilities. Entrepreneurs may be competitive with an established company, but the nurse intrapreneurs can maintain their security within the facility. Koch (1996) noted intrapreneurs “capitalize on the reputation of the organization and can readily access a diverse network of professionals who are crucial for answering questions, giving assistance and helping make ideas become realities” (Koch, 1996, p. 2). Nurse intrapreneurs can also utilize the facilities’ meeting areas, copying, and Internet services, saving them the financial outlay that entrepreneurs must absorb as part of the cost of doing business on their own. Intrapreneurs have the relative safety to discuss new ideas as a means to a possible “intraprise” without worrying that someone from within the organization will steal their innovation.

What kind of culture would welcome the nurse intrapreneur? There must be a dynamic mindset with “networking, teamwork, sponsors, and mentors abounding; trust and close working relationships where tasks are viewed as fun activities (not chores) with participants gladly putting in the amount of hours necessary to get the job done. Instead of building barriers to protect turf, advice and cross-fertilization freely occur within and across functional areas and even divisions” (Hisrich, 1990, p. 7). The environment, including top management, needs to be open to new ideas and willing to experiment. Of course, some hypotheses do not work, and failure needs to be tolerated.


For the umbrella organization, the nurse intrapreneur is visible as a change agent and a role model for other staff members who may also have good ideas, inspiring and influencing others to become innovators “while advancing the science of nursing through clarifying, refining, and expanding the nursing knowledge base” (Koch, 2004, p. 9). One example is an operating room nurse who designed the “first hospital-based surgical recycling program in the country, a newly-created position of waste reduction specialist, and eventually into a national consulting business” (Manion, 2001). A nurse with demonstrated excellence in sterile technique and wound management might float from one hospital unit to another, helping nurses change complicated dressings or manage wound vacuum systems. Keeping before-and-after pictures and showing how patient days and money were saved may make the hospital realize that a wound care nurse is an asset. The hospital pays to send this nurse for an advanced certificate or to become a wound care specialist. Similarly, a nurse with experience with colostomies or ileostomies might become an enterostomal therapist. A nurse with a combination of computer and clinical expertise can become the in-house informatics consultant, responsible for orienting new staff, troubleshooting system glitches, and formulating new ways to use technology at the bedside. Some health-care facilities will have computers with Internet capabilities available at the bedside. It will be important for a nurse with computer expertise to help patients select and navigate the many health-care consumer Web sites for information, to be someone who can integrate the education according to the disease and wellness needs of the patient. Nursing job niches are only limited to the imagination of the nurse intrapreneur. A nurse with children may create a job where there is the possibility of working at home or at an adjacent day-care site. Perhaps self-staffing began with nurses deciding that they could do it better. Traveling nurses, with experience in many cities and job sites, may bring new ideas about doing things to each site, making them very desirable as permanent hires should they decide to stay. A nurse who enjoys animals may volunteer while a pet visits its owners who are hospitalized or living in a rehabilitation center and may eventually convince her supervisor that a resident dog or cat needs her constant services as a petpatient liaison. Facilities are always looking for an idea that they can promote to capture a particular market and become more competitive. It may just take a nurse intrapreneur to point them in a promising direction.

Nurse Entrepreneurs

It is important to compare the previously discussed qualities, roles, and options of the nurse intrapreneur with those of the nurse entrepreneur. There are many similarities but also some marked differences.


It is important to look at the component parts of the nurse entrepreneur definition and assess whether the individual has what it takes to become self-made and successful. The definition speaks to a talented, independent, and experienced nurse who sees an available health-care business niche and decides to fill it. Consider what the individual does well professionally as well as what she likes and wants to do. Many entrepreneurs were once intrapreneurs with a particular talent that was recognized within an organization; subsequently, they embellished and magnified this talent so that other organizations would find it valuable also. Sullivan and Christopher (1999) describe many of the characteristics that are desirable in order to become a successful nurse entrepreneur. It is important to be a creative thinker and be willing to assume the leadership role to get an idea from concept to reality. Being a decision maker who is action-oriented rather than deliberative is essential to make change happen quickly. Having a high tolerance for ambiguity and knowing that there is always a transition period from the inception of an innovation until it finally takes a cohesive shape are integral to the role of entrepreneur. It is important to include nurse entrepreneurial activities as a part of the educational curriculum for management courses (really at any level) to foster innovative ways to approach traditional patient care activities (Sullivan & Christopher, 1999). Sullivan noted, “Thus, it is possible to learn the basics of entrepreneurship while studying management, including strategic planning, continuous quality improvement, business plan development, marketing, management information systems, leadership, and financial management”. Although it is vital to practice nursing according to principles and care standards, it is also important to forgo rigidity and a procedural mindset.


Merriam-Webster defines entrepreneur as a “person who organizes and manages a business undertaking, assuming the risk for the sake of profit” (MerriamWebster, 2005). The term commonly refers to a self-made individual with a good idea who, despite many setbacks, perseveres and becomes successful and wealthy. The term has been used often in the business community. The number of successful entrepreneurs and new companies has steadily increased, despite the high rate of failure for a fledgling business. The American culture is particularly supportive of the process. Hisrich (1990) noted, “Although dissatisfaction with various aspects of one’s job—challenge, promotional opportunities, frustration, and boredom—often motivates the launching of a new venture, previous technical and industry experience is important once the decision to launch has been made”. Whether a person possesses the qualities necessary for success in this venture may be determined by family support, education, personal motivation and, to some extent, age. Hisrich (1990) noted, “Generally, male entrepreneurs tend to start their first significant venture in their early 30s whereas female entrepreneurs tend to do this in their middle 30s.” Although independence is usually the primary motivating factor, “money is the second reason for starting a new venture for men, whereas job satisfaction, achievement, opportunity, and money are the reasons in rank order for women”.

If the job that an entrepreneur desires is not attainable with current skills, then it is necessary to find out what is needed and acquire it. Sometimes education will open the door to a new market. Education does not have to occur in a traditional manner, but having a baccalaureate, master’s degree, or doctorate will open doors to previously unattainable positions or establish the credibility necessary for consulting. This will obviously be a longer-term goal, but with careful planning, the present company or hospital may actually pay for that credential as part of its employee benefits. One or more certifications and practice in another area may pave the way for a different career path. Accomplishing these things while still employed is time-consuming but may allow the nurse time to save money; extra startup money may be necessary later when beginning to work as an entrepreneur. Perhaps a degree or certificate in law, hospital management, marketing, or business would complement the assets of a health-care background. The nurse must consider what will make her unique and sought as an entrepreneur. Sometimes working in the desired area parttime or in an entry-level position will help identify what is needed and how it can be supplied. Working with or observing a person who already has the desired type of job will supply invaluable experience, especially if it can be used as an apprenticeship. Often a lack of experience is a stumbling block to moving into a new job. Orientation and training are expensive for any organization, and if nurse entrepreneurs can “hit the ground running” they will have an advantage over the competition.


There are many ways in which a nurse can make the leap to an entrepreneurial role. For instance, a nurse who demonstrated excellence as a patient educator could become a corporate wellness coordinator. The nurse who had a position as an educator could subcontract to other health-care agencies without educators. Some hospitals and geriatric facilities have eliminated their educator positions as cost-cutting measures and now find that an educational consultant is cheaper than paying one fulltime. A nurse manager who has coordinated care for multiple units has proven leadership ability; would-be coordinators might prove a marketable commodity. “Current research on complementary therapies, such as music therapy, guided imagery, and relaxation, can provide a springboard for the nurse entrepreneur who wants to apply research to practice and/or education” (Sullivan & Christopher, 1999, p. 332). A  care manager or case manager may deliver registry or agency services to insurance companies or health-care management agencies. “With the aid of videoconferencing, fax, and e-mail transmission, practitioners can participate in operations, review laboratory data, and even perform a virtual physical exam. Telehealth is a major factor [that is] forcing state and federal regulatory bodies to reexamine their antiquated regulatory systems” (Shaffer & Sheets, 2001, p. 40). The nurse considering multistate consulting or giving advice via health-care information hotlines that cross state lines or country borders must consider the necessity and impact of multistate licensure.

Nurses have succeeded in their own businesses as business and health-care writers; educational consultants to hospitals, universities, and corporations; legal nurse consultants; health care and nursing Web design; state board examination tutoring; and home care nursing. Bensing (2005) illustrated a story about Richard C. Thompson in “How I Became a Nurse Entrepreneur”. Thompson started an agency that supplied nurses to hospitals and extended care facilities and guaranteed that shifts would be covered; if necessary, he replaced the ill nurse scheduled at the facility himself. This made his agency very attractive to hospitals. He also paid more money to his nurses than his competitors did, which made his agency very popular with his employees. There are many other opportunities for nurse entrepreneurs. Many nurses have begun agency staffing services for hospitals and home health. Other nurses have acted as their own brokers of services to hospitals and traveling nurse agencies. A nurse who found publishers unwilling to print submissions from nurses started her own publishing company (Lowder, 1997; cited in Bensing, 2005). Another nurse organized educational cruises. Still another became a financial consultant specializing in the nursing market. Some became cost-containment experts, able to market their services to facilities and families. Many nurse practitioners have set up independent practices in rehabilitation services and in as many areas as there are specialties.

In the last 10 years, as the “sandwich generation” has had to deal simultaneously with raising children and arranging for services for aging parents, nurse-run businesses have sprung up in the popular retirement states. These businesses arrange for extended care or nursing home placement of aging parents of children living at opposite ends of the country. They also make sure to provide followup care and regular updates if the adult children are unable to visit frequently. Nurses have also invented and patented useful products. Downey and Freidin (1997) invented communication vehicles for ventilator patients. Dr. Laura Gasparis Vonfrolio is a well-known nurse entrepreneur who began her first business with corporate cardiopulmonary resuscitation and professional education and eventually owned many businesses. Dr. Leslie Nicoll is an RN who has written “The Nurses’ Guide to the Internet” and is editor-in-chief of CIN: Computers, Informatics, Nursing and the  Journal of Hospice and Palliative Nursing. She is also “the principal and owner of Maine Desk, an entrepreneurial venture that helps nurses become published” (Bensing, 2005, p. 12).

All Good Things...

The future of nursing is largely unexplored; the required expertise and what the new roles will be are vastly different from how we envision nursing and its practice today. It will be increasingly important for nurses to develop and articulate their expertise in a growing global health-care environment. To develop this expertise, nurses will first need to be firmly grounded with their core values; second, they will need to be vigilant in scouting the dynamic environment; and third, they will need to merge their core values with environmental needs to bring together an expertise, a marketing niche. Developing new models of care will require nurses to craft themselves creatively and then take action to sell their product. Taking it to action will require nurses to articulate their nursing expertise in terms of unique care models and as “value of their product” and to speak a common language to market, to partner with other sellers, and to trade with buyers. In an ever-expanding trading market, nurses will interface with a variety of people, locally, nationally, and internationally. Thus, one no longer can view nursing in isolation or within one setting; the impact of one’s action is now felt worldwide. Therefore, any action taken must be within nursing’s social consciousness, considering the unintended consequences. The focus on the process of nursing care rather than the outcome of nursing care has buried nurses’ contribution in bringing successful patient outcomes. The current importance we place on evidence-based practice promises to link the nursing delivery process to its successful client outcomes. In turn this “product-line designing” advances nurses toward developing standards of practice and moves nursing toward greater competency. Nurses will need to learn a new way to measure their successes; no longer will professional satisfaction be gained through traditional hierarchical advancement. The vertical structure that supports promotion of one administrative step at a time no longer fits the expert nursing model of care. Such a bureaucratic decision-making structure does not allow for that quick decision making required in the fast-paced, dynamic environment in which we live. Decision making will need to be streamlined to bring authority to those care experts who are at the point of care. Recently, nurses have begun to advance laterally within organizations as care experts and care managers and even through advanced practice into expanded roles as  nurse practitioners and clinical nurse specialists. The future of nursing and the work of providing care will be greatly altered and open doors to many new opportunities. Matched to keep pace with tomorrow’s environment, the opportunities for practice will open from local to global. Organizations will coalesce to gather teams of experts, to accomplish specific goals and deliver results quickly. If nursing is to gain membership within this team of experts, it will need to articulate clearly its expertise to others on the health-care team. In addition to clinical knowledge, nurses offer expertise in top-notch team building, technological savvy, and the ability to foster many different types of relationships. This new consultative way of working offers nurses great entrepreneurial and intrapreneurial opportunities within an unstable environment. The phases in career development offer nurses ways to develop a clearer vision of their expertise as they develop expert practice models that fit a unique marketing niche. Expert models of care will provide nurses greater autonomy, respect, and career satisfaction.


There are five dysfunctions of team. These can be mistakenly interpreted as five distinct issues that can be addressed in isolation of the others. But in reality they form an interrelated model, making susceptibility to even one of them potentially lethal for the success of a team. A cursory overview of each dysfunction, and the model they comprise, should make this clearer.

l. The first dysfunction is an Absence of trust among team members. Essentially, this stems from their unwillingness to be vulnerable within the group. Team members who are not genuinely open with one another about their mistakes and weaknesses make it impossible to build a foundation for trust.

2.    This failure to build trust is damaging because it sets the tone for the second dysfunction: fear of conflict. Teams that lack trust are incapable of engaging in un- filtered and passionate debate of ideas. Instead, they resort to veiled discussions and guarded comments.

3.    A lack of healthy conflict is a problem because it ensures the third dysfunction of a team: Lack of commitment.

Without having aired their opinions in the course of passionate and open debate, team members rarely, if ever, buy in and commit to decisions, though they may feign agreement during meetings.

4. Because of this lack of real commitment and buy-in, team members develop an A voidance of accountability, the fourth dysfunction. Without committing to a clear plan of action, even the most focused and driven people often hesitate to call their peers on actions and behaviors that seem counterproductive to the good of the team. Failure to hold one another accountable creates an environment where the fifth dysfunction can thrive.

5. Inattention to results occurs when team members put their individual needs (such as ego, career development, or recognition) or even the needs of their divisions above the collective goals of the team.

And so, like a chain with just one link broken, teamwork deteriorates if even a single dysfunction is allowed to flourish.

Another way to understand this model is to take the opposite approach—a positive one—and imagine how members of truly cohesive teams behave:

1. They trust one another.

2. They engage in unfiltered conflict around ideas.

3. They commit to decisions and plans of action.

4. They hold one another accountable for delivering against those plans.

5. They focus on the achievement of collective results.

If this sounds simple, it's because it is simple, at least in theory. In practice, however, it is extremely difficult because it requires levels of discipline and persistence that few teams can muster.

Before diving into each of the dysfunctions and exploring ways to overcome them, it might be helpful to assess your team and identify where the opportunities for improvement lie in your organization.



The questionnaire on the following pages is a straightforward ward diagnostic tool for helping you evaluate your team's susceptibility to the five dysfunctions. At the end of the questionnaire there is a simple explanation of how to tabulate the results and interpret the possible conclusions. If possible, have all members of your team complete the diagnostic and review the results, discussing discrepancies in the responses and identifying any clear implications for the team.


Instructions: Use the scale below to indicate how each statement applies to your team. It is important to evaluate the statements honestly and without over-thinking your answers.

3 = Usually 2 = Sometimes 1 = Rarely

1. Team members are passionate and unguarded in their discussion of issues.

2. Team members call out one another's deficiencies or unproductive behaviors.

3. Team members know what their peers are working on and how they contribute to the collective good of the team.

4. Team members quickly and genuinely apologize to one another when they say or do something inappropriate or possibly damaging to the team.

5. Team members willingly make sacrifices (such as budget, turf, head count) in their departments or areas of expertise for the good of the team.

6. Team members openly admit their weaknesses and mistakes.

7. Team meetings are compelling, and not boring.

8. Team members leave meetings confident that their peers are completely committed to the decisions that were agreed on, even if there was initial disagreement.

9. Morale is significantly affected by the failure to achieve team goals.

10. During team meetings, the most important—and difficult—issues are put on the table to be resolved.

11. Team members are deeply concerned about the prospect of letting down their peers.

12. Team members know about one another's personal lives and are comfortable discussing them.

13. Team members end discussions with clear and specific resolutions and calls to action.

14. Team members challenge one another about their plans and approaches.

15. Team members are slow to seek credit for their own contributions, but quick to point out those of others.





Trust lies at the heart of a functioning, cohesive team. Without it, teamwork is all but impossible.

Unfortunately, the word trust is used—and misused— so often that it has lost some of its impact and begins to sound like motherhood and apple pie. That is why it is important to be very specific about what is meant by trust.

In the context of building a team, trust is the confidence among team members that their peers' intentions are good, and that there is no reason to be protective or careful around the group. In essence, teammates must get comfortable being vulnerable with one another.

This description stands in contrast to a more standard definition of trust, one that centers around the ability to predict a person's behavior based on past experience. For instance, one might "trust" that a given team-mate will produce high-quality work because he has always done so in the past.

As desirable as this may be, it is not enough to represent the kind of trust that is characteristic of a great team. It requires team members to make themselves vulnerable to one another, and be confident that their respective vulnerabilities will not be used against them. The vulnerabilities I'm referring to include weaknesses, skill deficiencies, interpersonal shortcomings, mistakes, and requests for help.

As "soft" as all of this might sound, it is only when team members are truly comfortable being exposed to one another that they begin to act without concern for protecting themselves. As a result, they can focus their energy and attention completely on the job at hand, rather than on being strategically disingenuous or political with one another.

Achieving vulnerability-based trust is difficult because in the course of career advancement and education, most successful people learn to be competitive with their peers, and protective of their reputations. It is a challenge for them to turn those instincts off for the good of a team, but that is exactly what is required.

The costs of failing to do this are great. Teams that lack trust waste inordinate amounts of time and energy managing their behaviors and interactions within the group. They tend to dread team meetings, and are reluctant to take risks in asking for or offering assistance to others. As a result, morale on distrusting teams is usually quite low, and unwanted turnover is high.

Members of teams with an absence of trust…

   Conceal their weaknesses and mistakes from one another

   Hesitate to ask for help or provide constructive feedback

   Hesitate to offer help outside their own areas of responsibility

   Jump to conclusions about the intentions and aptitudes of others without attempting to clarify them

   Fail to recognize and tap into one another's skills and experiences

   Waste time and energy managing their behaviors for effect

   Hold grudges

   Dread meetings and find reasons to avoid spending time together


Members of trusting teams...

   Admit weaknesses and mistakes

   Ask for help

   Accept questions and input about their areas of responsibility

   Give one another the benefit of the doubt before arriving at a negative conclusion

   Take risks in offering feedback and assistance

   Appreciate and tap into one another's skills and experiences

   Focus time and energy on important issues, not politics

   Offer and accept apologies without hesitation

   Look forward to meetings and other opportunities to work as a group


Suggestions for Overcoming Dysfunction I

How does a team go about building trust? Unfortunately, vulnerability-based trust cannot be achieved overnight. It requires shared experiences over time, multiple instances of follow-through and credibility, and an in-depth understanding of the unique attributes of team members. However, by taking a focused approach, a team can dramatically accelerate the process and achieve trust in relatively short order. Here are a few tools that can bring this about.

Personal Histories Exercise In less than an hour, a team can take the first steps toward developing trust. This low-risk exercise requires nothing more than going around the table during a meeting and having team members answer a short list of questions about themselves. Questions need not be overly sensitive in nature and might include the following: number of siblings, hometown, and unique challenges of childhood, favorite hobbies, first job, and worst job. Simply by describing these relatively innocuous attributes or experiences, team members begin to relate to one another on a more personal basis, and see one another as human beings with life stories and interesting backgrounds. This encourages greater empathy and understanding, and discourages unfair and inaccurate behavioral attributions. It is amazing how little some team members know about one another, and how just a small amount of information begins to break down barriers. (Minimum time required: 30 minutes.)

Team Effectiveness Exercise This exercise is more rigorous and relevant than the previous one, but may involve more risk. It requires team members to identify the single most important contribution that each of their peers makes to the team, as well as the one area that they must either improve upon or eliminate for the good of the team. All members then report their responses, focusing on one person at a time, usually beginning with the team leader. While this exercise may seem somewhat intrusive and dangerous at first glance, it is remarkable how manageable it can be and how much useful information, both constructive and positive, can be extracted in about an hour. And though the Team Effectiveness Exercise certainly requires some degree of trust in order to be useful, even a relatively dysfunctional team can often make it work with surprisingly little tension. (Minimum time required: 60 minutes.)

Personality and Behavioral Preference Profiles Some of the most effective and lasting tools for building trust on a team are profiles of team members' behavioral preferences and personality styles. These help break down barriers by allowing people to better understand and empathize with one another.

The best profiling tool, in my opinion, is the Myers-Briggs Type Indicator (MBTI). However, a number of others are popular among different audiences. The purpose of most of these tools is to provide practical and scientifically valid behavioral descriptions of various team members according to the diverse ways that they think, speak, and act. Some of the best characteristics of tools like the MBTI are their nonjudgmental nature (no type is better than another, although they differ substantially), their basis in research (they are not founded upon astrology or new age science), and the extent to which participants take an active role in identifying their own types (they don't simply receive a computer printout or test score that alone dictates their type). Many of these tools do require the participation of a licensed consultant, which is important to avoid the misuse of their powerful implications and applications. (Minimum time required: 4 hours.)

360-Degree Feedback These tools have become popular over the past twenty years and can produce powerful results for a team. They are riskier than any of the tools or exercises described so far because they call for peers to make specific judgments and provide one another with constructive criticism. The key to making a 360-degree program work, in my opinion, is divorcing it entirely from compensation and formal performance evaluation. Rather, it should be used as a developmental tool, one that allows employees to identify strengths and weaknesses without any repercussions. By being even slightly connected to formal performance evaluation or compensation, 360-degree programs can take on dangerous political undertones.

Experiential Team Exercises Ropes courses and other experiential team activities seem to have lost some of their luster over the course of the past ten years, and deservedly so. Still, many teams do them with the hope of building trust. And while there are certainly some benefits derived from rigorous and creative outdoor activities involving collective support and cooperation, those benefits do not always translate directly to the working world. That being said, experiential team exercises can be valuable tools for enhancing teamwork as long as they are layered upon more fundamental and relevant processes.

While each of these tools and exercises can have a significant short-term impact on a team's ability to build trust, they must be accompanied by regular follow-up in the course of daily work. Individual developmental areas must be revisited to ensure that progress does not lose momentum. Even on a strong team—and perhaps especially so— atrophy can lead to the erosion of trust.

The Role of the Leader

The most important action that a leader must take to encourage the building of trust on a team is to demonstrate vulnerability first. This requires that a leader risk losing face in front of the team, so that subordinates will take the same risk themselves. What is more, team leaders must create an environment that does not punish vulnerability. Even well-intentioned teams can subtly discourage trust by chastising one another for admissions of weakness or failure. Finally, displays of vulnerability on the part of a team leader must be genuine; they cannot be staged. One of the best ways to lose the trust of a team is to feign vulnerability in order to manipulate the emotions of others.

Connection to Dysfunction 2

How does all of this relate to the next dysfunction, the fear of conflict? By building trust, a team makes conflict possible because team members do not hesitate to engage in passionate and sometimes emotional debate, knowing that they will not be punished for saying something that might otherwise be interpreted as destructive or critical.


All great relationships, the ones that last over time, require productive conflict in order to grow. This is true in marriage, parenthood, friendship, and certainly business.

Unfortunately, conflict is considered taboo in many situations, especially at work. And the higher you go up the management chain, the more you find people spending inordinate amounts of time and energy trying to avoid the kind of passionate debates that are essential to any great team.

It is important to distinguish productive ideological conflict from destructive fighting and interpersonal politics. Ideological conflict is limited to concepts and ideas, and avoids personality-focused, mean-spirited attacks. However, it can have many of the same external qualities of interpersonal conflict—passion, emotion, and frustration—so much so that an outside observer might easily mistake it for unproductive discord.

But teams that engage in productive conflict know that the only purpose is to produce the best possible solution in the shortest period of time. They discuss and resolve issues more quickly and completely than others, and they emerge from heated debates with no residual feelings or collateral damage, but with an eagerness and readiness to take on the next important issue.

Ironically, teams that avoid ideological conflict often do so in order to avoid hurting team members' feelings, and then end up encouraging dangerous tension. When team members do not openly debate and disagree about important ideas, they often turn to back-channel personal attacks, which are far nastier and more harmful than any heated argument over issues.

It is also ironic that so many people avoid conflict in the name of efficiency, because healthy conflict is actually a time saver. Contrary to the notion that teams waste time and energy arguing; those that avoid conflict actually doom themselves to revisiting issues again and again without resolution. They often ask team members to take their issues "off-line," which seems to be a euphemism for avoiding dealing with an important topic, only to have it raised again at the next meeting.

Suggestions for Overcoming Dysfunction 2

How does a team go about developing the ability and willingness to engage in healthy conflict? The first step is acknowledging that conflict is productive, and that many teams have a tendency to avoid it. As long as some team members believe that conflict is unnecessary, there is little chance that it will occur. But beyond mere recognition, there are a few simple methods for making conflict more common and productive.

Teams that fear conflict...

· Have boring meetings

· Create environments where back-channel politics and personal attacks thrive

· Ignore controversial topics that are critical to team success

· Fail to tap into all the opinions and perspectives of team members

· Waste time and energy with posturing and interpersonal risk management


Teams that engage in conflict...

· Have lively, interesting meetings

· Extract and exploit the ideas of all team members

· Solve real problems quickly

· Minimize politics

· Put critical topics on the table for discussion


Mining Members of teams that tend to avoid conflict must occasionally assume the role of a "miner of conflict"— someone who extracts buried disagreements within the team and sheds the light of day on them. They must have the courage and confidence to call out sensitive issues and force team members to work through them. This requires a degree of objectivity during meetings and a commitment to staying with the conflict until it is resolved. Some teams may want to assign a member of the team to take on this responsibility during a given meeting or discussion.

Real-Time Permission In the process of mining for conflict, team members need to coach one another not to retreat from healthy debate. One simple but effective way to do this is to recognize when the people engaged in conflict are becoming uncomfortable with the level of discord, and then interrupt to remind them that what they are doing is necessary. As simple and paternal as this may sound, it is a remarkably effective tool for draining tension from a productive but difficult interchange, giving the participants the confidence to continue. And once the discussion or meeting has ended, it is helpful to remind participants that the conflict they just engaged in is good for the team and not something to avoid in the future.

Other Tools As mentioned earlier in this section, there are a variety of personality style and behavioral preference tools that allow team members to better understand one another. Because most of these include descriptions of how different types deal with conflict, they can be useful for helping people anticipate their approach or resistance to it. Another tool that specifically relates to conflict is the Thomas-Kilmann Conflict Mode Instrument, commonly referred to as the TKI.

It allows team members to understand natural inclinations around conflict so they can make more strategic choices about which approaches are most appropriate in different situations.

The Role of the Leader

One of the most difficult challenges that a leader faces in promoting healthy conflict is the desire to protect members from harm. This leads to premature interruption of disagreements, and prevents team members from developing coping skills for dealing with conflict themselves. This is not unlike parents who overprotect their children from quarrels or altercations with siblings. In many cases, it serves only to strain the relationships by depriving the participants of an opportunity to develop conflict management skills. It also leaves them hungry for resolution that never occurs.

Therefore, it is key that leaders demonstrate restraint when their people engage in conflict, and allow resolution to occur naturally, as messy as it can sometimes be. This can be a challenge because many leaders feel that they are somehow failing in their jobs by losing control of their teams during conflict.

Finally, as trite as it may sound, a leader's ability to personally model appropriate conflict behavior is essential. By avoiding conflict when it is necessary and productive— something many executives do—a team leader will encourage this dysfunction to thrive.

Connection to Dysfunction 3

How does all of this relate to the next dysfunction, the lack of commitment? By engaging in productive conflict and tapping into team members' perspectives and opinions, a team can confidently commit and buy in to a decision knowing that they have benefited from everyone's ideas.


In the context of a team, commitment is a function of two things: clarity and buy-in. Great teams make clear and timely decisions and move forward with complete buy-in from every member of the team, even those who voted against the decision. They leave meetings confident that no one on the team is quietly harboring doubts about whether to support the actions agreed on.

The two greatest causes of the lack of commitment are the desire for consensus and the need for certainty:

Consensus. Great teams understand the danger of seeking consensus, and find ways to achieve buy-in even when complete agreement is impossible. They understand that reasonable human beings do not need to get their way in order to support a decision, but only need to know that their opinions have been heard and considered. Great teams ensure that everyone's ideas are genuinely considered, which then creates willingness to rally around whatever decision is ultimately made by the group. And when that is not possible due to an impasse, the leader of the team is allowed to make the call.

Certainty. Great teams also pride themselves on being able to unite behind decisions and commit to clear courses of action even when there is little assurance about whether the decision is correct. That's because they understand the old military axiom that a decision is better than no decision. They also realize that it is better to make a decision boldly and be wrong—and then change direction with equal boldness—than it is to waffle.

Contrast this with the behavior of dysfunctional teams that try to hedge their bets and delay important decisions until they have enough data to feel certain that they are making the right decision. As prudent as this might seem, it is dangerous because of the paralysis and lack of confidence it breeds within a team.

It is important to remember that conflict underlies the willingness to commit without perfect information. In many cases, teams have all the information they need, but it resides within the hearts and minds of the team itself and must be extracted through unfiltered debate. Only when everyone has put their opinions and perspectives on the table can the team confidently commit to a decision knowing that it has tapped into the collective wisdom of the entire group.

Regardless of whether it is caused by the need for consensus or certainty, it is important to understand that one of the greatest consequences for an executive team that does not commit to clear decisions is irresolvable discord deeper in the organization. More than any of the dysfunctions, this one creates dangerous ripple effects for subordinates. When an executive team fails to achieve buy-in from all team members, even if the disparities that exist seem relatively small, employees 'who report to those executives will inevitably clash when they try to interpret marching orders that are not clearly aligned with those of colleagues in other departments. Like a vortex, small gaps between executives high up in an organization become major discrepancies by the time they reach employees below.

A team that fails to commit...

   Creates ambiguity among the team about direction and priorities

   Watches windows of opportunity close due to excessive analysis and unnecessary delay

   Breeds lack of confidence and fear of failure

   Revisits discussions and decisions again and again

   Encourages second-guessing among team members


A team that commits...

   Creates clarity around direction and priorities

   Aligns the entire team around common objectives

   Develops an ability to learn from mistakes

   Takes advantage of opportunities before competitors do

   Moves forward without hesitation

   Changes direction without hesitation or guilt

Suggestions for Overcoming Dysfunction 3        

How does a team go about ensuring commitment? By taking specific steps to maximize clarity and achieve buy-in, and resisting the lure of consensus or certainty. Here are a few simple but effective tools and principles.

Cascading Messaging One of the most valuable disciplines that any team can adopt takes just a few minutes and is absolutely free. At the end of a staff meeting or off-site, a team should explicitly review the key decisions made during the meeting, and agree on what needs to be communicated to employees or other constituencies about those decisions. What often happens during this exercise is that members of the team learn that they are not all on the same page about what has been agreed upon and that they need to clarify specific outcomes before putting them into action. Moreover, they become clear on which of the decisions should remain confidential, and which must be communicated quickly and comprehensively. Finally, by leaving meetings clearly aligned with one another, leaders send a powerful and welcomed message to employees who have grown accustomed to receiving inconsistent and even contradictory statements from managers who attended the same meeting. (Minimum time required: 10 minutes.)

Deadlines As simple as it seems, one of the best tools for ensuring commitment is the use of clear deadlines for when decisions will be made, and honoring those dates with discipline and rigidity. The worst enemy of a team that is susceptible to this dysfunction is ambiguity, and timing is one of the most critical factors that must be made clear. What is more, committing to deadlines for intermediate decisions and milestones is just as important as final deadlines, because it ensures that misalignment among team members is identified and addressed before the costs are too great.

Contingency and Worst-Case Scenario Analysis A team that struggles with commitment can begin overcoming this tendency by briefly discussing contingency plans up front or, better yet, clarifying the worst-case scenario for a decision they are struggling to make. This usually allows them to reduce their fears by helping them realize that the costs of an incorrect decision are survivable, and far less damaging than they had imagined.

Low-Risk Exposure Therapy Another relevant exercise for a commitment-phobic team is the demonstration of decisiveness in relatively low-risk situations. When teams force themselves to make decisions after substantial discussion but little analysis or research, they usually come to realize that the quality of the decision they made was better than they had expected. What is more, they learn that the decision would not have been much different had the team engaged in lengthy, time-consuming study. This is not to say that research and analysis are not necessary or important, but rather that teams with this dysfunction tend to overvalue them.

The Role of the Leader

More than any other member of the team, the leader must be comfortable with the prospect of making a decision that ultimately turns out to be wrong. And the leader must be constantly pushing the group for closure around issues, as well as adherence to schedules that the team has set. What the leader cannot do is place too high a premium on certainty or consensus.

Connection to Dysfunction 4

How does all of this relate to the next dysfunction, the avoidance of accountability? In order for teammates to call each other on their behaviors and actions, they must have a clear sense of what is expected. Even the most ardent believers in accountability usually balk at having to hold someone accountable for something that was never bought in to or made clear in the first place.


Accountability is a buzzword that has lost much of its meaning as it has become as overused as terms like empowerment and quality. In the context of teamwork, however, it refers specifically to the willingness of team members to call their peers on performance or behaviors that might hurt the team. The essence of this dysfunction is the unwillingness of team members to tolerate the interpersonal discomfort that accompanies calling a peer on his or her behavior and the more general tendency to avoid difficult conversations. Members of great teams overcome these natural inclinations, opting instead to "enter the danger" with one another.

Of course, this is easier said than done, even among cohesive teams with strong personal relationships. In fact, team members who are particularly close to one another sometimes hesitate to hold one another accountable precisely because they fear jeopardizing a valuable personal relationship. Ironically, this only causes the relationship to deteriorate as team members begin to resent one another for not living up to expectations and for allowing the standards of the group to erode. Members of great teams improve their relationships by holding one another accountable, thus demonstrating that they respect each other and have high expectations for one another's performance.

As politically incorrect as it sounds, the most effective and efficient means of maintaining high standards of performance on a team is peer pressure. One of the benefits is the reduction of the need for excessive bureaucracy around performance management and corrective action. More than any policy or system, there is nothing like the fear of letting down respected team-mates that motivates people to improve their performance.

Suggestions for Overcoming Dysfunction 4

How does a team go about ensuring accountability? The key to overcoming this dysfunction is adhering to a few classic management tools that are as effective as they are simple.

A team that avoids accountability...

   Creates resentment among team members who have different standards of performance

   Encourages mediocrity

   Misses deadlines and key deliverables

   Places an undue burden on the team leader as the sole source of discipline

A team that holds one another accountable ...

   Ensures that poor performers feel pressure to improve

   Identifies potential problems quickly by questioning one another's approaches without hesitation

   Establishes respect among team members who are held to the same high standards

   Avoids excessive bureaucracy around performance management and corrective action

Publication of Goals and Standards A good way to make it easier for team members to hold one another accountable is to clarify publicly exactly what the team needs to achieve, who needs to deliver what, and how everyone must behave in order to succeed. The enemy of accountability is ambiguity, and even when a team has initially committed to a plan or a set of behavioral standards, it is important to keep those agreements in the open so that no one can easily ignore them.

Simple and Regular Progress Reviews A little structure goes a long way toward helping people take action that they might not otherwise be inclined to do. This is especially true when it comes to giving people feedback on their behavior or performance. Team members should regularly communicate with one another, either verbally or in written form, about how they feel their teammates are doing against stated objectives and standards. Relying on them to do so on their own, with no clear expectations or structure, is inviting the potential for the avoidance of accountability.

Team Rewards By shifting rewards away from individual performance to team achievement, the team can create a culture of accountability. This occurs because a team is unlikely to stand by quietly and fail because a peer is not pulling his or her weight.

The Role of the Leader

One of the most difficult challenges for a leader who wants to instill accountability on a team is to encourage and allow the team to serve as the first and primary accountability mechanism. Sometimes strong leaders naturally create an accountability vacuum within the team, leaving themselves as the only source of discipline. This creates an environment where team members assume that the leader is holding others accountable, and so they hold back even when they see something that isn't right.

Once a leader has created a culture of accountability on a team, however, he or she must be willing to serve as the ultimate arbiter of discipline when the team itself fails. This should be a rare occurrence. Nevertheless, it must be clear to all team members that accountability has not been relegated to a consensus approach, but merely to a shared team responsibility, and that the leader of the team will not hesitate to step in when it is necessary.

Connection to Dysfunction 5

How does all of this relate to the next dysfunction, the inattention to results? If teammates are not being held accountable for their contributions, they will be more likely to turn their attention to their own needs, and to the advancement of themselves or their departments. An absence of accountability is an invitation to team members to shift their attention to areas other than collective results.


The ultimate dysfunction of a team is the tendency of members to care about something other than the collective goals of the group. An unrelenting focus on specific objectives and clearly defined outcomes is a requirement for any team that judges itself on performance.

It should be noted here that results are not limited to financial measures like profit, revenue, or shareholder returns. Though it is true that many organizations in a capitalist economic environment ultimately measure their success in these terms, this dysfunction refers to a far broader definition of results, one that is related to outcome-based performance.

Every good organization specifies what it plans to achieve in a given period, and these goals, more than the financial metrics that they drive, make up the majority of near-term, controllable results. So, while profit may be the ultimate measure of results for a corporation, the goals and objectives that executives set for themselves along the way constitute a more representative example of the results it strives for as a team. Ultimately, these goals drive profit.

But what would a team be focused on other than results? Team status and individual status are the prime candidates:

   Team status. For members of some teams, merely being part of the group is enough to keep them satisfied.

For them, the achievement of specific results might be desirable, but not necessarily worthy of great sacrifice or inconvenience. As ridiculous and dangerous as this might seem, plenty of teams fall prey to the lure of status. These often include altruistic nonprofit organizations that come to believe that the nobility of their mission is enough to justify their satisfaction. Political groups, academic departments, and prestigious companies are also susceptible to this dysfunction, as they often see success in merely being associated with their special organizations.

   Individual status. This refers to the familiar tendency of people to focus on enhancing their own positions r career prospects at the expense of their team. Though all human beings have an innate tendency toward self-preservation, a functional team must make the collective results of the group more important to each individual than individual members' goals.

As obvious as this dysfunction might seem at first glance, and as clear as it is that it must be avoided, it is important to note that many teams are simply not results focused. They do not live and breathe in order to achieve meaningful objectives, but rather merely to exist or survive. Unfortunately for these groups, no amount of trust, conflict, commitment, or accountability can compensate for a lack of desire to win.

Suggestions for Overcoming Dysfunction 5

How does a team go about ensuring that its attention is focused on results? By making results clear, and rewarding only those behaviors and actions that contribute to those results.

A team that is not focused on results...

   Stagnates/fails to grow

   Rarely defeats competitors

   Loses achievement-oriented employees

   Encourages team members to focus on their own careers and individual goals

   Is easily distracted

A team that focuses on collective results...

   Retains achievement-oriented employees

   Minimizes individualistic behavior

   Enjoys success and suffers failure acutely

   Benefits from individuals who subjugate their own goals/interests for the good of the team

   Avoids distractions

Public Declaration of Results In the mind of a football or basketball coach, one of the worst things a team member can do is publicly guarantee that his or her team will win an upcoming game. In the case of an athletic team, this is a problem because it can unnecessarily provoke an opponent. For most teams, however, it can be helpful to make public proclamations about intended success.

Teams that are willing to commit publicly to specific results are more likely to work with a passionate, even desperate desire to achieve those results. Teams that say, "We'll do our best," are subtly, if not purposefully, preparing themselves for failure.

Results-Based Rewards An effective way to ensure that team members focus their attention on results is to tie their rewards, especially compensation, to the achievement of specific outcomes. Relying on this alone can be problematic because it assumes that financial motivation is the sole driver of behavior. Still, letting someone take home a bonus merely for "trying hard," even in the absence of results, sends a message that achieving the outcome may not be terribly important after all.

The Role of the Leader

Perhaps more than with any of the other dysfunctions, the leader must set the tone for a focus on results. If team members sense that the leader values anything other than results, they will take that as permission to do the same for themselves. Team leaders must be selfless and objective, and reserve rewards and recognition for those who make real contributions to the achievement of group goals.


As much information as is contained here, the reality remains that teamwork ultimately comes down to practicing a small set of principles over a long period of time. Success is not a matter of mastering subtle, sophisticated theory, but rather of embracing common sense with uncommon levels of discipline and persistence.

Ironically, teams succeed because they are exceedingly human. By acknowledging the imperfections of their humanity, members of functional teams overcome the natural tendencies that make trust, conflict, commitment, accountability, and a focus on results so elusive.


Kathryn understood that a strong team spends considerable time together, and that by doing so, they actually save time by eliminating confusion and minimizing redundant effort and communication. Added together, Kathryn and her team spent approximately eight days each quarter in regularly scheduled meetings, which amounts to fewer than three days per month. As little as this seems when considered as a whole, most management teams balk at spending this much time together, preferring to do "real work" instead.

Though there are actually many different ways to run a management team, Kathryn's methods are worth considering. Following is a description of how she ran her staff after her initial team-building off-sites and the significant investment in time that it required: Annual planning meeting and leadership development retreats (three days, off-site).

Topics might include budget discussions, major strategic planning overview, leadership training, succession planning, and cascading messaging Quarterly staff meetings (two days, off-site) Topics might include major goal reviews, financial review, strategic discussions, employee performance discussions, key issue resolution, team development, and cascading messages Weekly staff meetings (two hours, on-site) Topics might include key activity review, goal progress review, sales review, customer review, tactical issue resolution, cascading messages Ad hoc topical meetings (two hours, on-site) Topics might include strategic issues that cannot be adequately discussed during weekly staff meetings



As I was nearing the completion of this book, the horrible events of September 11, 2001, occurred. Amid the unfathomable tragedy of the situation and the amazing triumph of the country's response, a powerful and inspiring example of teamwork emerged—one that must be acknowledged here.

The men and women of the fire, rescue, and police departments in New York City, Washington, D.C., and Pennsylvania demonstrated that groups of people working together can accomplish what no assembly of mere individuals could ever dream of doing.

In emergency services professions like these, team members live and work together, developing bonds of trust that only families can rival. That allows them to engage in focused, unfiltered debate over the right course of action to take when every second is precious. As a result, they are able to commit quickly to unambiguous decisions under the most dangerous of circumstances, when most other human beings would demand more information before taking action. And with so much on the line, they don't hesitate to push their colleagues and hold them accountable for carrying their loads, knowing that even one team member slacking could cost lives. And finally, they have only one end in mind: protecting the lives and liberties of others.

The ultimate test of a great team is results. And considering that tens of thousands of people escaped from the World Trade Center towers in New York City and the Pentagon in Washington, D.C., there can be no doubt that the teams who risked, and lost, their lives to save them were extraordinary.

May God bless them all, as well as the victims and survivors they worked together to save.




This book is the result of a team effort, not only during its writing but throughout my education and career. I would like to acknowledge those people who have been instrumental in my life.

First, I thank the head of my own first team, my wife, Laura. For your unconditional love, and your unwavering commitment to me and our boys, I cannot adequately describe my appreciation. And I thank Matthew and Connor, who will soon be able to read one of my books, though they'll certainly prefer Dr. Seuss. You give me so much joy.

Next, I offer sincere gratitude to my team at The Table Group, without whose ideas, editing, and passion this book would not have come to be. For Amy's graceful judgment and intuition, Tracy's extraordinary and unending diligence, Karen's kind support, John's stylish wisdom, Jeffs optimistic intelligence, Michele's insightfulness and humor, and Erin's youthful authenticity. I am constantly amazed and touched by the depth and quality of your commitment. You have helped me learn more about real teamwork than any group I have ever known, and I thank you for that.

I want to acknowledge the support and love of my parents. You have always given me the emotional safety net I needed to take risks and chase dreams. And you have given me so many things that you never had yourselves.

Thanks to my brother, Vince, for your passion, intensity, and concern.

And to my sister, Ritamarie, for your wisdom, love, and patience that mean more to me with every passing year.

And to the hundreds of cousins, aunts, uncles, and in-laws of mine—the Lencionis, the Shanleys, the Fanucchis, and the Gilmores. Thank you for your interest and kindness, which mean a lot to me even though I am far away from many of you.

Thanks to Barry Belli, Will Garner, Jamie and Kim Carlson, the Beans, the Elys, and the Patchs for your interest and friendship over the years.

I thank the many managers and mentors I've had during my career. Sally DeStefano for your confidence and graciousness. Mark Hoffman and Bob Epstein for your trust. Nusheen Hashemi for your enthusiasm. Meg Whitman and Ann Colister for your advice and counsel. And Gary Bolles for your encouragement and friendship.

I thank Joel Mena for your passion and love. Rick Rob-les for your coaching and teaching. And so many of the other teachers and coaches I had at Our Lady of Perpetual Help School, Garces High School, and Claremont McKenna College.

I thank the many clients whom I've worked with over the years for your trust and commitment to building a healthier organization.

I want to give special thanks to my agent, Jim Levine, for your humility and insistence on excellence, or as my wife says, for being "a humble butt-kicker." And to my editor, Susan Williams, for your enthusiasm and flexibility. Thanks to everyone at Jossey-Bass and Wiley for your persistence, support, and commitment.

Finally, and certainly most important of all, I give all thanks to God the Father, the Son, and the Holy Spirit for all that I am.




Patrick Lencioni is the author of the best-selling books The Five Temptations of a CEO and The Four Obsessions of an Extraordinary Executive. In addition to his work as an author, Pat consults and speaks to thousands of people each year on topics relating to leadership, teamwork, management, and organization development. He currently serves on the National Board of Directors for the Make-A-Wish Foundation of America.

Pat is also the president of The Table Group, a San Francisco Bay Area management consulting firm that specializes in executive team development and organizational health. The Table Group offers the following professional services:

   Executive Team Workshops

   Consulting Services

   On-line Assessments

   Speaking Services

Pat lives in the San Francisco Bay Area with his wife, Laura, and their three sons, Matthew, Connor, and Casey.

To learn more about Pat and The Table Group, please visit If you'd like to contact Pat directly, he can be reached at 510-596-9292 or


Oddsei - What are the odds of anything.