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Effective Leadership and Management in Nursing Ninth Edition

Eleanor J. Sullivan PhD, RN, FAAN

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Library of Congress Cataloging-in-Publication Data

Names: Sullivan, Eleanor J., 1938- author. Title: Effective leadership and management in nursing / Eleanor J. Sullivan, PhD, RN, FAAN. Description: Ninth edition. | Boston : Pearson, [2017] | Includes index. Identifiers: LCCN 2016021687 | ISBN 9780134153117 | ISBN 0134153111 Subjects: LCSH: Nursing services—Administration. | Leadership. Classification: LCC RT89 .S85 2017 | DDC 362.17/3068—dc23 LC record available at https://lccn.loc.gov/2016021687

1 17

ISBN-10: 0-13-415311-1 ISBN-13: 978-0-13-415311-7

About the Author

E leanor J. Sullivan, PhD, RN, FAAN, is the former dean of the University of Kansas School of Nursing, past president of

Sigma Theta Tau International, and previous edi- tor of the Journal of Professional Nursing. She has served on the board of directors of the American Association of Colleges of Nursing, testified before the U.S. Senate, served on a National Insti- tutes of Health council, presented papers to international audiences, been quoted in the Chi- cago Tribune, St. Louis Post-Dispatch, and Rolling Stone Magazine, and named to the “Who’s Who in Health Care” by the Kansas City Business Journal. She earned nursing degrees from St. Louis Community College, St. Louis University, and Southern Illinois University and holds a PhD from St. Louis University.

Dr. Sullivan is known for her publications in nursing, including this award- winning textbook, Effective Leadership & Management in Nursing, and Becoming Influential: A Guide for Nurses, from Pearson Education. In addition, Dr. Sullivan has authored numerous professional articles, book chapters, and books, including Creating Nursing’s Future: Issues, Opportunities and Challenges, among others.

Today, Dr. Sullivan is also active in the mystery writing field. She served on the national board of Sisters in Crime, chaired an award committee for the Mystery Writ- ers of America, and is published in Mystery Scene Magazine and Ellery Queen Mystery Magazine.

She has published five mystery novels. Her first three mysteries (Twice Dead, Deadly Diversion, and Assumed Dead) feature nurse sleuth Monika Everhardt. The latter two were bought by Harlequin, reissued in paperback, and are still available as e-books (Deadly Diversion, Assumed Dead).

Her latest series, the Singular Village Mysteries, features 19th century midwife Ade- laide Bechtmann and her cabinetmaker husband, Benjamin. Two books in the series (Cover Her Body and Graven Images) are available in print, e-book, and audio formats. The third book, Tree of Heaven, will be released in the fall of 2017. The series is set in the Ohio village of Dr. Sullivan’s ancestors. Dr. Sullivan’s blog, found on her website, reveals the history behind her historical fiction.

Connect with her at EleanorSullivan.com, Facebook, and LinkedIn.

This book is dedicated to my family for their continuing love and support.

—Eleanor J. Sullivan

iii

Thank You

O ur heartfelt thanks go out to our colleagues from schools of nursing across the country who gave generously of their time, expertise, and knowledge to help us create this exciting new edition of our text. We have reaped the benefit of

your collective experience as nurses and teachers, and this edition is vastly enriched due to your efforts.

Contributors Michael Bleich, PhD, RN, FAAN President, Maxine Clark and Bob Fox Dean and Professor Goldfarb School of Nursing Barnes Jewish College Chapter 2: Designing Organizations

Debra J. Ford, PhD. Program Director, Leadership, and Research Assistant Professor The University of Kansas Medical Center Chapter 10: Communicating Effectively Chapter 13: Handling Conf lict

Rachel A. Pepper, RN, DNP, NEA-BC Senior Director of Nursing The University of Kansas Hospital Chapter 15: Budgeting and Managing Fiscal Resources Chapter 17: Staffing and Scheduling

Pamela Klauer Triolo, PhD, RN, FAAN Former Chief Nursing Officer (Corporate) and Associate Dean University of Pittsburgh Medical Center Chapter 19: Evaluating Staff Performance Chapter 20: Coaching, Disciplining, and Terminating Staff

Reviewers Wendy Bailes, PhD, RN Associate Director, Undergraduate Programs University of Louisiana at Monroe Monroe, Louisiana

Diane Daddario, MSN, ANP-C, ACNS-BC, RN-BC, CMSRN Adjunct Faulty, College of Nursing Pennsylvania State University University Park, Pennsylvania

iv

Teresa Fisher, MSN, RN, PBT (ASCP) Assistant Professor of Nursing Arkansas State University Jonesboro, Arkansas

Ruth Gladen, MS, RN Associate Professor RN Faculty & Director North Dakota College of Science Wahpeton, North Dakota

Lisa Harding, RN, MSN, CEN Professor Bakersfield College Bakersfield, California

Mary Alice Hodge, PhD, CNL-C, RN Director, Graduate Program The University of South Carolina Upstate Spartanburg, South Carolina

Mona P. Klose, MS, RN, CNE, CPHQ Director of Quality Management Assistant Professor of Nursing University of Jamestown Jamestown, North Dakota

Tara O’Brien, PhD, RN, CNE Assistant Professor The University of North Carolina Charlotte, North Carolina

Jennifer O’Connor, RN, MS, CFCN, CNE Instructor Northeastern State University Tahlequah, Oklahoma

Rose M. Powell, PhD, RN Associate Professor Stephen F. Austin State University Nacogdoches, Texas

Joyce A. Shanty, PhD, RN Associate Professor Indiana University of Pennsylvania Indiana, Pennsylvania

Deborah Smitherman, MSN, RN, CCM Assistant Professor of Nursing Belhaven University Jackson, Mississippi

Thank You v

Preface

N ever have nurses been more important to healthcare organizations than they are today. Passage of the Affordable Care Act (ACA) in 2010 reversed decades of focus on providing quantities of care to emphasize quality of care. Prevent-

ing illness and coordinating care are the cornerstones of the ACA, and nurses are key to its success.

In addition, leading and managing are essential skills for all nurses in this radically changed healthcare environment. New graduates find themselves managing unlicensed assistive personnel, and experienced nurses are managing groups of healthcare providers from a variety of disciplines and educational levels. All need to know how to manage.

This text is designed to provide new graduates or novice managers with the infor- mation they need to become effective managers and leaders in healthcare. In addition, a sidebar in each chapter illustrates how nurses can lead at the bedside. More than ever before, today’s rapidly changing healthcare environment demands highly devel- oped management skills and superb leadership.

Features of the Ninth Edition Effective Leadership and Management in Nursing has made a significant and lasting con- tribution to the education of nurses and nurse managers in its eight previous editions. Used worldwide and translated into numerous languages, this award-winning text is now offered in an updated and revised edition to reflect today’s healthcare arena and in response to suggestions from the text’s users. The ninth edition builds upon the work of previous contributors to provide the most up-to-date and comprehensive learning package for today’s busy students and professionals.

Features of the ninth edition include the following:

• Implementation of the Affordable Care Act

• Evolving models of healthcare organizational structures and relationships

• Expanded content on cultural and gender diversity

• Emphasis on quality management

• Addition of emotional leadership concepts

• Use of social media in management

• Harassing, bullying, and lack of civility in healthcare

• Emergency preparedness for terrorism, disasters, and mass shootings

• Prevention of workplace violence

Two new chapters have been added to this award-winning text. Chapter 7, Under- standing Legal and Ethical Issues, encompasses the myriad of issues confronting nurses and managers today. Chapter 28, Imagining the Future, helps readers contemplate the possibilities inherent in a fast-evolving environment.

Most notably, this text is available for the first time with a suite of digital resources to enhance your learning. This digital program includes the MyLab Nursing program

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that lets you review the chapter materials, decision-making cases that allow you to apply your learning, and the E-Text 2.0 digital text that is easy to navigate and gives you tools for highlighting, note taking, and more.

Student-friendly Learning Tools Designed with the adult learner in mind, the text focuses on the application of the con- tent presented and offers specific guidelines on how to implement the skills included. To further illustrate and emphasize key points, each chapter in this edition includes these features:

• A chapter outline and preview

• A complete audio version of each chapter

• Key terms in pop-up boxes linked to their first appearance and defined in the glossary at the end of the text

• Flashcards to self-test knowledge of new vocabulary

• What You Know Now summaries at the end of each chapter

• A Tool Box with a list of tools, or key behaviors, for using the skills presented in the chapter

• Questions to Challenge You in an interactive journal format to help students relate concepts to their experiences

• Up-to-date references

• Case Studies to demonstrate application of content, with discussion board questions

Organization The text is organized into five sections that address the essential information and key skills that nurses must learn to succeed in today’s volatile healthcare environment and to prepare for the future.

Part 1. Understanding Nursing Management and Organizations Part 1 introduces the context for nursing management, with an emphasis on chang- ing organizational structures, ways that nursing care is delivered, the concepts of leading and managing, how to initiate and manage change, providing quality care, and how to use power and politics—all necessary for nurses to succeed and prosper in today’s chaotic healthcare world. A new chapter addresses how to weigh legal and ethical issues,

Part 2. Learning Key Skills in Nursing Management Part 2 delves into the essential skills for today’s managers, including thinking critically, making decisions, solving problems, communicating with a variety of individuals and groups, delegating, working in teams, resolving conflicts, and managing time.

Preface vii

Part 3. Managing Resources Knowing how to manage resources is vital for today’s nurses. They must be adept at budgeting fiscal resources; recruiting and selecting staff; handling staffing and sched- uling; motivating and developing staff; evaluating staff performance; coaching, disci- plining, and terminating staff; managing absenteeism, reducing turnover, and retaining staff; and handling disruptive staff behaviors, especially harassing and bul- lying behaviors. In addition, collective bargaining, preparing for emergencies and pre- venting workplace violence are included in Part 3.

Part 4. Taking Care of Yourself Nurses are their own most valuable resource. Part 4 shows how to manage stress and to advance in a career.

Part 5. Looking Toward the Future New to this edition, this chapter provides ways to consider the future, societal predic- tions about the future, the future of healthcare, and the future of nursing.

Instructor Resources The assignable and gradable assessments in MyLab Nursing provide educators with insight into students’ preparation for class, students’ understanding of the material, and clarity around areas in which additional instruction may be needed.

Additional Instructor Resources can be accessed by registering and logging in at www.pearsonhighered.com/nursing and include the following:

• TestGen Test Bank

• Lecture Note PowerPoints

• Instructor’s Resource Manual

viii Preface

Part 1 Understanding Nursing Management and Organizations

1 Introducing Nursing Management 1

2 Designing Organizations 13

3 Delivering Nursing Care 33

4 Leading, Managing, Following 43

5 Initiating and Managing Change 60

6 Managing and Improving Quality 75

7 Understanding Legal and Ethical Issues 94

8 Understanding Power and Politics 110

Part 2 Learning Key Skills in Nursing Management

9 Thinking Critically, Making Decisions, Solving Problems 125

10 Communicating Effectively 145

11 Delegating Successfully 163

12 Building and Managing Teams 178

13 Handling Conflict 198 14 Managing Time 211

Part 3 Managing Resources

15 Budgeting and Managing Fiscal Resources 224

16 Recruiting and Selecting Staff 241

17 Staffing and Scheduling 260

18 Motivating and Developing Staff 271

19 Evaluating Staff Performance 283

20 Feedback and Coaching, Disciplining, and Terminating Staff 296

21 Managing Absenteeism, Reducing Turnover, Retaining Staff 307

22 Dealing with Disruptive Staff Problems 323

23 Preparing for Emergencies 332

24 Preventing Workplace Violence 340

25 Handling Collective Bargaining Issues 349

Part 4 Taking Care of Yourself

26 Managing Stress 356

27 Advancing Your Career 366

Part 5 Looking to the Future

28 Imagining the Future 382

Brief Contents

ix

Acknowledgments

T he success of previous editions of this text has been due to the expertise of many contributors. Nursing administrators, management professors, and faculty in schools of nursing all made significant contributions to earlier editions. I am

enormously grateful to them for sharing their knowledge and experience to help nurses learn leadership and management skills.

I am especially grateful to the contributors to this edition. They revised and updated content in the following chapters: Chapter 2: Michael Bleich, Chapters 10 and 12: Debbie Ford, Chapters 15 and 17: Rachel Pepper, and Chapters 19 and 20: Pamela Triolo. All are excellent writers, and this edition would not exist without their contributions. In addition, Michael Bleich lent his expertise to a review of the eighth edition, and Rachel Pepper reviewed the previous edition and added specific examples to demonstrate content for this edition as well.

At Pearson Education, I am grateful to continue to work with Executive Editor Pamela Fuller, who has supported this text through many editions. For this edition, Program Manager Erin Rafferty facilitated all aspects of the text’s progress, and Devel- opment Editor Pamela Lappies’s expertise and fine attention to detail ensure that the text will continue to be the first choice of faculty and students worldwide.

To everyone who has contributed to this fine text over the years, I thank you.

Eleanor J. Sullivan, PhD, RN, FAAN www.EleanorSullivan.com

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Contents

About the Author iii Thank You iv Preface vi

Part 1 Understanding Nursing Management and Organizations

1 Introducing Nursing Management 1

Introduction 2

Changes in Healthcare 2 Paying for Healthcare 2

Changes in Society 7 Cultural, Gender, and Generational Differences 7 Violence, Pandemics, and Disasters 8

Changes in Nursing’s Future 8 Current Status of Nursing 8 Institute of Medicine’s Recommendations for Nursing 9 Adapting to Constant Change 9 What You Know Now 9

Questions to Challenge You 10

References 10

2 Designing Organizations 13 Introduction 14

Reductive and Adaptive Organizational Theories 15 Reductive Theory 15 Humanistic Theory as a Bridge 17 Adaptive Theories 18

Organizational Structures and Shared Governance 19 Functional Structure 19 Service-line Structure 20 Matrix Structure 21 Parallel Structure 21 Shared Governance 22

Healthcare Settings 22 Primary Care 23 Acute Care Hospitals 23 Home Healthcare 23 Long-term Care 23

Ownership and Complex Healthcare Arrangements 24 Ownership of Healthcare Organizations 24 Healthcare Networks 24 Interorganizational Relationships 26 Diversification 26 Managed Healthcare Organizations 27 Accountable Care Organizations 27

Redesigning Healthcare 28 Organizational Environment and Culture 29 What You Know Now 30

Questions to Challenge You 30

References 31

3 Delivering Nursing Care 33 Introduction 34

Traditional Models of Care 34 Total Patient Care 35 Functional Nursing 35 Team Nursing 35 Primary Nursing 35

Integrated Models of Care 36 Practice Partnerships 36 Case Management 36 Critical Pathways 37

Evolving Models of Care 38 Patient-centered Care 38 Synergy Model of Care 39 Patient-centered Medical Home 39 What You Know Now 41

Questions to Challenge You 41

References 41

4 Leading, Managing, Following 43 Introduction 44

Leaders and Managers 44 Leadership 45

Leadership Theories 45 Traditional Leadership Theories 45 Contemporary Leadership Theories 46

Followership: An Essential Component of Leadership 49

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xii Contents

Traditional Management Functions 50 Planning 50 Organizing 51 Directing 51 Controlling 51

Nurse Managers in Practice 52 Nurse Manager Competencies 52 Staff Nurse 52 First-level Management 54 Charge Nurse 54 Clinical Nurse Leader 56 What You Know Now 57

Tools for Leading, Managing, and Following 57

Questions to Challenge You 58

References 58

5 Initiating and Managing Change 60

Introduction 61

The Nurse as Change Agent 62

Change Theories 62

The Change Process 64 Step 1: Identify the Problem or Opportunity 64 Step 2: Collect Necessary Data and Information 65 Step 3: Select and Analyze Data 65 Step 4: Develop a Plan for Change, Including Time Frame and Resource 65 Step 5: Identify Supporters and Opposers 66 Step 6: Implement Interventions to Achieve Desired Change 66 Step 7: Evaluate Effectiveness of the Change and, if Successful, Stabilize the Change 66

Change Strategies 67 Power–Coercive Strategies 67 Empirical–Rational Model Strategies 67 Normative–Reeducative Strategies 67

Resistance to Change 68

The Nurse’s Role 69 Initiating Change 69 Implementing Change 71 Unplanned Change 71 Handling Constant Change 72 What You Know Now 73

Tools for Initiating and Managing Change 73

Questions to Challenge You 73

References 74

6 Managing and Improving Quality 75

Introduction 76

Quality Management 76 Total Quality Management 76 Continuous Quality Improvement 77 Components of Quality Management 77 Six Sigma 78 Lean Six Sigma 79 DMAIC Method 79

Improving the Quality of Care 80 National Initiatives 81 Evidence-based Practice 82 Electronic Health Records 82 Dashboards 82 Rounding 82 Reducing Medication Errors 83

Risk Management 83 Nursing’s Role in Risk Management 84 Incident Reports 84 Examples of Risk 85 Root-cause Analysis 87 Peer Review 87 Role of the Nurse Manager 87 Creating a Blame-free Environment 90 What You Know Now 90

Tools for Managing and Improving Quality 91

Questions to Challenge You 91

References 92

7 Understanding Legal and Ethical Issues 94

Introduction 95

Law and Ethics 95

Ethical Decision Making 96 Autonomy 96 Beneficence and Nonmaleficence 97 Distributive Justice 97

The Legal System 97 Sources of Law 97 Types of Law 98 Liability 99

Legal Issues in Nursing 100 Nursing Licensure 100 Patient Care Rights 100 Management Issues 105

Employment Issues 107 What You Know Now 108

Questions to Challenge You 109

References 109

8 Understanding Power and Politics 110

Introduction 111

Power and Leadership 111 Power: How Managers and Leaders Get Things Done 111

Using Power 114 Image as Power 114 Using Power Appropriately 116

Shared Visioning as a Power Tool 117

Power, Politics, and Policy 118 Nursing’s Political History 118 Using Political Skills to Influence Policies 119 Influencing Public Policies 121

How Nurses Can Influence the Future 123 What You Know Now 123

Tools for Using Power and Politics 124

Questions to Challenge You 124

References 124

Part 2 Learning Key Skills in Nursing Management

9 Thinking Critically, Making Decisions, Solving Problems 125

Introduction 126

Critical Thinking 126 Critical Thinking in Nursing 127 Using Critical Thinking 127 Creativity 128

Decision Making 130 Types of Decisions 130 Decision-making Conditions 131 The Decision-making Process 132 Decision-making Techniques 133 Group Decision Making 135

Problem Solving 135 Problem-solving Methods 135 The Problem-solving Process 137 Group Problem Solving 140

Stumbling Blocks 141 Personality 141 Rigidity 141 Preconceived Ideas 141

Innovation 142 What You Know Now 142

Tools for Making Decisions and Solving Problems 143

Questions to Challenge You 143

References 143

10 Communicating Effectively 145 Introduction 146

Communication 146 Transactional Model of Communication 147 Channels of Communication 148 Nonverbal Messages 149 Directions of Communication 150 Effective Listening 150

Effects of Differences in Communication 151 Gender Differences in Communication 151 Generational and Cultural Differences in Communication 152 Differences in Organizational Culture 152

The Role of Communication in Leadership 153 Employees 153 Administrators 154 Coworkers 156 Medical Staff 156 Other Healthcare Personnel 156 Patients and Families 157

Collaborative Communication 157

Enhancing Your Communication Skills 158 What You Know Now 160

Tools for Communicating Effectively 160

Questions to Challenge You 161

References 161

11 Delegating Successfully 163 Introduction 164

Delegation 164

Benefits of Delegation 165 Benefits to the Nurse 166 Benefits to the Delegate 166 Benefits to the Manager 166 Benefits to the Organization 166

The Five Rights of Delegation 166

Contents xiii

The Delegation Process 167 Steps in the Delegation Process 168 Key Behaviors for Successful Delegation 170 Accepting Delegation 171

Ineffective Delegation 172 Organizational Culture 172 Lack of Resources 172 An Insecure Delegator 172 An Unwilling Delegate 174 Underdelegation 174 Reverse Delegation 175 Overdelegation 175 What You Know Now 176

Tools for Delegating Successfully 176

Questions to Challenge You 176

References 177

12 Building and Managing Teams 178

Introduction 179

Groups and Teams 179 Group Interaction 182 Group Leadership 182

Group and Team Processes: Homans Framework 182

Norms 184 Roles 185

Building Teams 186 Assessment 186 Team-building Activities 187

Managing Teams 187 Task 187 Group Size and Composition 188 Productivity and Cohesiveness 188 Development and Growth 190 Shared Governance 190

The Nurse Manager as Team Leader 190 Communication 190 Evaluating Team Performance 191

Leading Committees and Task Forces 192 Guidelines for Conducting Meetings 192 Managing Task Forces 193 Patient Care Conferences 195 What You Know Now 196

Tools for Building and Managing Teams 196

Questions to Challenge You 196

References 196

13 Handling Conflict 198 Introduction 199 Conflict 199

Interprofessional Conflict 199 Conflict Process Model 200

Antecedent Conditions 200 Perceived and Felt Conflict 202 Conflict Behaviors 203 Conflict Resolved or Suppressed 203 Outcomes 203

Managing Conflict 204 Conflict Responses 206 Alternative Dispute Strategies 208 What You Know Now 209

Tools for Handling Conflict 209

Questions to Challenge You 209

Resources 209

References 210

14 Managing Time 211 Introduction 211

Time-wasters 212

Setting Goals 214 Determining Priorities 215 Daily Planning and Scheduling 216 Grouping Activities and Minimizing Routine Work 216 Personal Organization and Self-discipline 217

Controlling Interruptions 217 Phone Calls, Voice Mail, Email, and Text Messages 218 In-person Interruptions 220 Paperwork 220

Controlling Time in Meetings 221

Respecting Time 222 What You Know Now 222

Tools for Managing Time 222

Questions to Challenge You 223

References 223

Part 3 Managing Resources

15 Budgeting and Managing Fiscal Resources 224

Introduction 225

The Budgeting Process 225 Timetable for the Budgeting Process 227

xiv Contents

Approaches to Budgeting 227 Incremental Budget 228 Zero-based Budget 228 Fixed or Variable Budgets 229

The Operating Budget 229 The Revenue Budget 229 The Expense Budget 230

Determining the Salary and Nonsalary Budget 230 The Salary Budget 230 The Supply and Nonsalary Expense Budget 233

The Capital Budget 234

Monitoring and Controlling Budgetary Performance During the Year 234

Variance Analysis 235 Position Control 237

Staff Impact on Budget 237 Improving Performance 237 What You Know Now 239

Tools for Budgeting and Managing Resources 240

Questions to Challenge You 240

References 240

16 Recruiting and Selecting Staff 241

Introduction 242

The Recruitment and Selection Process 242

Recruiting Applicants 243 Where to Look 244 How to Look 245 When to Look 245 How to Promote the Organization 245 Cross-training as a Recruitment Strategy 246

Selecting Candidates 247

Interviewing Candidates 248 Principles for Effective Interviewing 248 Involving Staff in the Interview Process 252 Interview Reliability and Validity 253

Making a Hire Decision 253 Education, Experience, and Licensure 253 Integrating the Information 254 Making an Offer 255

Legality in Hiring 255 What You Know Now 258

Tools for Recruiting and Selecting Staff 259

Questions to Challenge You 259

References 259

17 Staffing and Scheduling 260 Introduction 261

Staffing 261 Patient Classification Systems 262 Determining Nursing Care Hours 263

Planning FTE Workforce 263 Determining Staffing Mix 264 Determining Distribution of Staff 264

Scheduling 266 Self-staffing and Scheduling 266 Shared Schedule 267 Open Shift Management 267 Weekend Staffing Plan 267 Automated Scheduling 268

Supplementing Staff 268 Internal Pools 268 External Pools 269 What You Know Now 269

Tools for Handling Staffing and Scheduling 269

Questions to Challenge You 270

References 270

18 Motivating and Developing Staff 271

Introduction 272

A Model of Job Performance 272 Employee Motivation 273 Motivational Theories 273

Staff Development 275 Orientation 276 On-the-job Instruction 276 Preceptors 277 Mentoring 278 Coaching 278 Nurse Residency Programs 279 Career Advancement 279 Leadership Development 280

Succession Planning 281 What You Know Now 281

Tools for Motivating and Developing Staff 281

…