Chapter 9 The Nurse as Leader and Manager

Challenges and Opportunities
• Limited access to healthcare services for many
• Limited resources for providing care
• Need to provide care for uninsured and underinsured
• Need to recruit and retain high-quality nurses
• Develop innovative approaches to nursing caredelivery and redefine the roles of professional nurses

Nursing Leadership

• Advocate for improvements in
– Client care quality
– Working environment
– Social well-being

Leadership occurs when influencing others to act
– Managers are assigned their roles
– Leaders attain their roles

Leadership characteristics
– Integrity
– Courage
– Positive attitude
– Initiative
– Energy
– Optimism
– Perseverance
– Balance
– Ability to handle stress
– Self-awareness
– Vision

American Nurses Association charges nurses with
leadership expectations
– Participate in professional organizations
– Communicate effectively
– Seek ways to advance nursing autonomy and accountability
– Participate in effort to influence healthcare policy
– Oversee nursing care by others while retaining accountability for quality of care
– Abide by vision, goals, and plan to implement and measure progress of clients
– Mentor colleagues
– Develop communication and conflict resolution skills

• Authoritarian leadership
– Makes the decisions for the group
– Directive, autocratic, or bureaucratic
– Negative connotations
-makes minimal openess and trust
-procedures well defined, predictbale, security
-supreses creativity
-can be effective when project must be completed quickly and efficiently

• Democratic leadership
– Participative leadership
Acts as a catalyst or facilitator
Seeks participation or consultation of subordinates
Actively guides the group toward achieving the group goals
Provides constructive criticism, offers information, makes
suggestions, asks questions

• Laissez-faire leadership
– Nondirectional leadership
– Minimal participation
– Group’s members act independently of each other
-inactive, inpassive, permissive

• Situational leadership
– Levels of direction and support vary depending on the maturity of the group
– Value placed on accomplishment of tasks and on interpersonal relationships
– Leadership style changes based on task, urgency, and individual needs

leader assumes one of four styles
-*directive*: clear direction and instruction to immature employees
– *coaching*: 2 way communicative, helps mature employee build confidence
– *supporting*: support mature emplyee use talents
– *delegating*: hands off, employees given responsibilities for carrying out plans

• Transactional leadership
– Traditional manager focused on the day-to-day tasks of
achieving organizational goals
– Relationship is based on exchange for some resource
valued by the follower

• Transformational leadership
– Emphasizes the importance of interpersonal relationships
– Leader serves as a role model who encourages and empowers team members to achieve team and personal goals
– Vital in creation of healthcare system that embodies community well-being, basic care for all, costeffectiveness, and holistic nursing care

4 factors of tranformational leader
-charisma: highly rescpected, inspires others
– inspirational motivation: shares visions with staff to go appeal to emotions and ideals
– intellectual stimulation: encourgae staff to question status quo
– contingent reward- recognizes mutual goals and rewards achievemnts

• Caring leadership
– An extension of transformational leadership
– Good management is a matter of love
– Proper management involves caring for people, not manipulation

• Quantum leadership
Humanistic interaction involving leader and followers
– Additional focus on problem to be solved or goal to be achieved
– Interaction and outcomes are affected by the leader, the followers, and the task to be accomplished
– Leader is creative, flexible, and encouraging
– Each team member adds value

Effective leadership
– a learned process requiring
an understanding of the needs and goals that motivate, knowledge to apply skills, and interpersonal skills to influence others
• Success is more than goal attained, also opportunity for growth

Nursing Management

Nurses as managers responsible for
– Planning
– Organizing
– Directing/delegating
– Controlling resources used in delivery of client care

• Resources used in delivery of client care
– Equipment and materials
– Technology
– Finances
– Environment
– Personnel

Management Roles

• Authority
– Official power given by organization to direct work of
– Conveyed through leadership action

• Accountability
– Ability and willingness to assume responsibility and consequences

• Planning
– First and most basic management function
– Four stages
Establishing goals and objectives
Evaluating current situation and predicting future trends and
Formulating a planning statement
Converting plan into an action statement

• Organizing
– Process of coordinating work to be done

• Leading
– Power is essential component of leading
– Power is the ability and authority to influence others
– Based on honor, respect, loyalty, and commitment

• Delegating
– Determine what is required, then identify help
– Development of the potential of nursing and support personnel
– Delegated individuals must be supervised and evaluated
– Provide ongoing feedback about performanc
– Getting work done through others
– Major tool in making most efficient use of time

– Five “rights” of delegation
Right task
Rights circumstances
Right person
Right direction and communication
Right supervision and evaluation

– Effective delegation requires nurses to be aware of
Needs and goals of the client and family
Nursing activities that can help the client meet the goals
Skills and knowledge of various nursing and support personnel

• Controlling
– Method to ensure that behaviors and performances are
consistent with expectations developed in planning
– Should be done with employees, not to employees
– Shared governance and team building help make
control easier

• Three levels of management
– First level
– Middle level
– Upper level
• Dependent on the type of organization

Management competencies described by American Organization of Nurse Executives
– Communication and relationship building
– Knowledge of healthcare environment
– Leadership skills
– Professionalism
– Business skills

• Magnet recognition
Program of American Nurses Credentialing Center
– Recognizes healthcare organizations for quality patient
care, nursing excellence, and innovations
– Identifies characteristics of hospitals that are successful
in recruiting and retaining nurses

• Pathway to Excellence Program
– Program of *American Nurses Credentialing Center*, launched in 2009
– Recognizes healthcare organizations and long-termcare
facilities for having positive practice environments
– Standards unique to long-term-care environment have been developed

Nursing Delivery Models

• Total patient care
– Case method
– Earliest model of nursing care
– Private-duty nurses
– Client-centered
– Client has consistent contact with one nurse during shift

• Functional method
– Evolved from concepts of scientific management
– Focuses on jobs to be completed
– Task-oriented approach
– Disadvantage is fragmentation of care
-ex. nurse and nursing assistant

• Team nursing
– Individualized nursing care given to clients by a nursing team led by a professional nurse
– Members include RNs, LPNs, nursing assistants
– Responsible for coordinated nursing during a shift
– Emphasizes humanistic values and individualized client care at a personal level
– Nurse leader motivates employees

• Primary nursing
– A system in which one nurse is responsible for total care of a number of clients 24 hours a day, seven days a week
– Provides comprehensive, individualized, and consistent
– Associates provide care, but the primary nurse plans and coordinates care

• Interdisciplinary team model
– Team consists of all disciplines required to provide quality care to client
– Each team member brings expertise to help client achieve quality outcome
– All members focus on client’s needs and collaborate to meet those needs

Case Management
pg 176
• Pioneered at the New England Medical Center
• Used in
– Insurance-based programs
– Employer-based health programs
– Workers’ compensation
– Maternal-child health
– Mental health
– Hospital-based practice

Case Management Defined as
– A collaborative process of assessment, planning,
facilitation, care coordination, evaluation, and advocacy to meet individual’s and family’s comprehensive health needs to promote quality, cost-effective outcome
– assist clients through complex
healthcare system

Differentiated Practice
• Differentiates nurses by level of education, expected clinical skills or competencies, job descriptions, pay scales, and participation in
decision making
• Can improve client care and contribute to client safety
• Allows for the effective and efficient use of resources

Shared Governance
• Nurses participate in decision making at all levels of the organization
• Employees will be more committed to an organization’s goals if they have input
• Promotes involvement, investment, participation,
sharing of power, interdependence, cooperation, horizontal relationships, autonomy, and

• Mentor
– Wise and trusted adviser who guides others on particular journey
– Provides support, challenge, and vision
-• Process can promote professional growth of both mentor and mentee

• Three phases
– Invitational
– Questioning
– Transitional

• Preceptor
– An experienced nurse who orients a nurse who is new
to the nursing unit and organization
– Assigned to assist in improving clinical nursing skill and
judgment necessary for effective practice in her or his environment
– Assists new nurses in learning routines, policies, and procedures of the unit

• Professional network consists of people that nurses may call on for assistance, support of ideas, and guidance
• Networking builds linkages with people
• Long-term process for building relationships
• Requires time, commitment, and follow-through

• Opportunities include
– Active membership in professional organizations
– Continuing education and university classes
– Socializing with professional colleagues
– Keeping in touch with former professors and nursing

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