1. KEYS TO EFFECTIVE LEADERSHIP AND MANAGEMENT
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:
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.
TRADITIONAL MANAGEMENT METHODS
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.
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 BEHAVIORAL MANAGEMENT MOVEMENT
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).
THEORY Z: JAPANESE MANAGEMENT STYLE
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.
21ST-CENTURY MANAGEMENT THOUGHT
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).
1. Which of the following theorists represents a traditional management viewpoint?
2. The individual recognized as the “father of scientiﬁc management” is:
3. Traditional management theory was designed to provide control and structure to which types of organizations?
B. Scientiﬁc laboratories.
C. Manufacturing industry.
D. Institutions of higher education.
4. Complexity science has developed from the ﬁeldof:
A. Health professions.
D. Quantum physics.
5. In complexity science, the movement of an organization as it changes from one attractor or mission statement to another is known as:
6. Japanese organizations are known for their:
A. Short-term commitment to their employees.
B. Individual approaches to decision making.
C. Rapid promotion of employees.
D. Development of consensus.
7. Fayol’s principle of esprit de corps refers to:
A. Subordination of individual interest to the common good.
B. Development of a high level of employee morale.
C. Encouragement of initiative and risk taking.
D. Emphasis on goal setting.
8. Max Weber is known for the development of which management theory?
A. Bureaucratic management.
B. Scientiﬁc management.
C. Humanistic management.
D. Transformational leadership.
9. Which of the following management theorists conducted the famous experiment at the Hawthorne Electric Plant in which employee productivity increased regardless of the type of intervention implemented at the plant?
10. Dee Hock recommends that managers spend what percentage of their time managing the employees for whom they have direct responsibility?
List of educational literature:
1. Kelly, P. (2008). Nursing Leadership and Management. (2nd ed.). Clifton Park, NY: Delmar Learning
2. Huber, D. (2000), Leadership and Nursing Care Management, (2nd ed.), Philadelphia: W.B. Saunders.
3. Nagelkerk, J. (2000), Study Guide for Huber Leadership and Nursing Care Management, (2nd ed.), Philadelphia: W.B. Saunders.
4. Sullivan, E. J. (2004). Becoming influential: A guide for nurses. Upper Saddle River, NJ: Pearson.
1. See required Websites:
2. Course Website – Log in @ http://www.tdmu.edu.te.ua/ukr/general/index.php
Prepared by Volkova N.M.
Adopted by Department of Medical Bioethics and Deontology sitting
11 June 2012, Minute № 2