Eighth
8th Edition
Edition
Leadership Roles and
Management Functions
in Nursing
Theory and Application
Bessie L. Marquis, RN, MSN
Professor Emeritus of Nursing
California State University
Chico, California
Carol J. Huston, RN, MSN, DPA, FAAN
Director, School of Nursing
California State University
Chico, California
Acquisitions Editor: Christopher Richardson
Product Development Editor: Maria McAvey
Production Project Manager: Joan Sinclair
Editorial Assistant: Zachary Shapiro
Senior Designer: Joan Wendt
Manufacturing Coordinator: Karin Duffield
Prepress Vendor: Integra Software Services Pvt. Ltd.
8th edition
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Copyright © 2012 by Wolters Kluwer Health | Lippincott Williams & Wilkins, Copyright ©, 2009, 2006,
2003, and 2000 by Lippincott Williams & Wilkins. Copyright © 1996 by Lippincott-Raven Publishers.
Copyright © 1992 by J. B. Lippincott Company. All rights reserved. This book is protected by copyright. No
part of this book may be reproduced or transmitted in any form or by any means, including as photocopies
or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without
written permission from the copyright owner, except for brief quotations embodied in critical articles and
reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S.
government employees are not covered by the above-mentioned copyright. To request permission, please
contact Lippincott Williams & Wilkins at Two Commerce Square, 2001 Market Street, Philadelphia, PA
19103, via e-mail at permissions@lww.com, or via our Web site at lww.com (products and services).
987654321
Printed in China
1SPVEMZTPVSDFEBOEVQMPBEFECZ
,JDLBTT5PSSFOUT]5IF1JSBUF#BZ]&YUSB5PSSFOU
Not authorised for sale in United States, Canada, Australia, New Zealand, Puerto Rico or the U.S. Virgin Islands.
Library of Congress Cataloging-in-Publication Data
Marquis, Bessie L., author.
Leadership roles and management functions in nursing: theory and application/Bessie L. Marquis, Carol
J. Huston.—8th edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4511-9281-0 — ISBN 1-4511-9281-9
I. Huston, Carol Jorgensen, author. II. Title.
[DNLM: 1. Leadership. 2. Nursing, Supervisory. 3. Nurse Administrators. 4. Nursing—organization
& administration. WY 105]
RT89
362.17′3068—dc23
2013036678
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted
practices. However, the author(s), editors, and publisher are not responsible for errors or omissions or for any
consequences from application of the information in this book and make no warranty, expressed or implied,
with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this
information in a particular situation remains the professional responsibility of the practitioner; the clinical
treatments described and recommended may not be considered absolute and universal recommendations.
The author(s), editors, and publisher have exerted every effort to ensure that drug selection and dosage
set forth in this text are in accordance with the current recommendations and practice at the time of
publication. However, in view of ongoing research, changes in government regulations, and the constant
flow of information relating to drug therapy and drug reactions, the reader is urged to check the package
insert for each drug for any change in indications and dosage and for added warnings and precautions. This is
particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA)
clearance for limited use in restricted research settings. It is the responsibility of the health-care provider to
ascertain the FDA status of each drug or device planned for use in his or her clinical practice.
LWW.com
I dedicate this book to the two most important
partnerships in my life: my husband, Don Marquis,
and my colleague, Carol Huston.
BESSIE L. MARQUIS
I dedicate this book to my mother Marilyn Jorgensen.
You are one of the reasons
I have become the capable woman I am today.
CAROL JORGENSEN HUSTON
Reviewers
Carol Amann, MSN, RN-BC, CDP
Instructor
Gannon University
Erie, Pennsylvania
Joanne Casatelli, DNP
Molloy College
Rockville Centre, New York
Joanne Clements, MS, RN, ACNP
Assistant Professor of Clinical Nursing
University of Rochester
Rochester, New York
Margaret Decker, MS, RN, CNE
Clinical Assistant Professor
Binghamton University
Binghamton, New York
Hobie Feagai, EdD, MSN, FNP-BC, APRN-Rx
Chair
Department of Baccalaureate Nursing Program
Hawaii Pacific University
Kaneohe, Hawaii
Lisa Marie Greenwood, MSN, RN, APRN-BC, CWOCN, CNS
Nursing Instructor
Madison Area Technical College
Reedsburg, Wisconsin
Vonna Henry, BSN, MPH, RN
Assistant Professor
St. Cloud State University
St. Cloud, Minnesota
Debora Kirsch, RN, MS, CNS
Director of Undergraduate Nursing Studies
SUNY Upstate Medical University
Syracuse, New York
v
vi
REVIEWERS
Carole McCue, RN, MS, CNE
Instructor
Cochran School of Nursing
Yonkers, New York
Jennifer Douglas Pearce, MSN, RN, CNE
Professor and Chairperson
University of Cincinnati
Blue Ash, Ohio
Tawna Pounders, RN, MNSc
Coordinator and Medical-Surgical Theory Faculty
Baton Rouge Community College
Baton Rouge, Louisiana
Loretta Quigley, MSN
Academic Dean
St. Joseph’s College of Nursing
Syracuse, New York
Elaine Rose, RN, BN, MHS, DM(c)
Assistant Professor
Mount Royal University
Calgary, Alberta, Canada
Charlotte Sortedahl, DNP, MPH, MS, RN
Assistant Professor
University of Wisconsin
Eau Claire, Wisconsin
Patricia Varga, MSN, RN
Assistant Professor
Alverno College
Milwaukee, Wisconsin
Preface
This book’s philosophy has evolved over the past 30+ years of teaching leadership and
management. We entered academe from the acute care sector of the health-care industry,
where we held nursing management positions. In our first effort as authors, Management
Decision Making for Nurses: 101 Case Studies, published in 1987, we used an experiential
approach and emphasized management functions appropriate for first- and middle-level
managers. The primary audience for this text was undergraduate nursing students.
Our second book, Retention and Productivity Strategies for Nurse Managers, focused
on leadership skills necessary for managers to decrease attrition and increase productivity.
This book was directed at the nurse-manager rather than the student. The experience of
completing research for the second book, coupled with our clinical observations, compelled
us to incorporate more leadership content in our teaching and to write this book.
Leadership Roles and Management Functions in Nursing was also influenced by national
events in business and finance that led many to believe that a lack of leadership in management
was widespread. It became apparent that if managers are to function effectively in the rapidly
changing health-care industry, enhanced leadership and management skills are needed.
What we attempted to do, then, was to combine these two very necessary elements:
leadership and management. We do not see leadership as merely one role of management
nor management as only one role of leadership. We view the two as equally important and
necessarily integrated. We have attempted to show this interdependence by defining the
leadership components and management functions inherent in all phases of the management
process. Undoubtedly, a few readers will find fault with our divisions of management
functions and leadership roles; however, we felt it was necessary to first artificially separate
the two components for the reader, and then to reiterate the roles and functions. We do believe
strongly, however, that adoption of this integrated role is critical for success in management.
The second concept that shaped this book was our commitment to developing criticalthinking skills through the use of experiential learning exercises and the promotion of wholebrain thinking. We propose that integrating leadership and management and using whole-brain
thinking can be accomplished through the use of learning exercises. The majority of academic
instruction continues to be conducted in a teacher-lecturer–student-listener format, which
is one of the least effective teaching strategies. Few individuals learn best using this style.
Instead, most people learn best by methods that utilize concrete, experiential, self-initiated,
and real-world learning experiences.
In nursing, theoretical teaching is almost always accompanied by concurrent clinical
practice that allows concrete and real-world learning experience. However, the exploration of
leadership and management theory may have only limited practicum experience, so learners
often have little first-hand opportunity to observe middle- and top-level managers in nursing
practice. As a result, novice managers frequently have little chance to practice their skills before
assuming their first management position, and their decision making thus reflects trial-anderror methodologies. For us, then, there is little question that vicarious learning, or learning
vii
viii
PREFACE
through mock experience, provides students the opportunity to make significant leadership and
management decisions in a safe environment and to learn from the decisions they make.
Having moved away from the lecturer–listener format in our classes, we lecture for only a small
portion of class time. A Socratic approach, case study debate, and problem solving are emphasized.
Our students, once resistant to the experiential approach, are now our most enthusiastic supporters.
We also find this enthusiasm for experiential learning apparent in the workshops and seminars we
provide for registered nurses. Experiential learning enables management and leadership theory to
be fun and exciting, but most important, it facilitates retention of didactic material. The research
we have completed on this teaching approach supports these findings.
Although many leadership and management texts are available, our book meets the need
for an emphasis on both leadership and management and the use of an experiential approach.
Two hundred and fifty-nine learning exercises, taken from various health-care settings and
a wide variety of learning modes, are included to give readers many opportunities to apply
theory, resulting in internalized learning. In Chapter 1, we provide guidelines for using the
experiential learning exercises. We strongly urge readers to use them to supplement the text.
We also provide guidelines for instructors on thePoint, Wolters Kluwer Health’s
trademarked web-based course and content management system that is available to
instructors who adopt the text. We recommend its use. The Web site includes a test bank, an
image collection, suggestions for using the learning exercises, a glossary, and a large number
of PowerPoint slides with images.
TEXT ORGANIZATION
The first edition of Leadership Roles and Management Functions in Nursing presented the
symbiotic elements of leadership and management, with an emphasis on problem solving and
critical thinking. This eighth edition maintains this precedent with a balanced presentation
of a strong theory component along with a variety of real-world scenarios in the experiential
learning exercises. Nineteen new learning exercises have been added to this edition, further
strengthening the problem-based element of this text. Almost 200 displays, figures, and tables
(46 of which are new) help readers to visualize important concepts.
Responding to reviewer recommendations, we have added and deleted content. In
particular, we have attempted to strengthen the leadership component of the book while
maintaining a balance of management content. We have also added a chapter crosswalk
(pp. 15–22) of content based on the American Association of Colleges of Nursing (AACN)
Essentials of Baccalaureate Education for Professional Nursing Practice (2008); the AACN
Essentials of Master’s Education in Nursing (2011); the American Organization of Nurse
Executive (AONE) Competencies; and the Quality and Safety Education for Nurses (QSEN)
Competencies. This crosswalk shows how content in each chapter draws from or contributes
to content identified as essential for baccalaureate and graduate education, for practice as a
nurse administrator, and for safety and quality in clinical practice.
We have also retained the strengths of earlier editions, reflecting content and application
exercises appropriate to the issues faced by nurse-leader-managers as they practice in an era
increasingly characterized by limited resources and emerging technologies. The eighth edition
also includes contemporary research and theory to ensure accuracy of the didactic material.
Unit I provides a foundation for the decision-making, problem-solving, and criticalthinking skills, as well as management and leadership skills needed to address the
management–leadership problems presented in the text. Unit II covers ethics, legal concepts,
and advocacy, which we see as core components of leadership and management decision
making. The remaining units are organized using the management processes of planning,
organizing, staffing, directing, and controlling.
PREFACE
ix
LEARNING TOOLS
The eighth edition contains many pedagogical features designed to benefit both the student
and the instructor:
Examining the Evidence, appearing in each chapter, depicts new research findings,
evidence-based practice, and best practices in leadership and management.
Learning Exercises interspersed throughout each chapter foster readers’ critical-thinking
skills and promote interactive discussions. Additional learning exercises are also presented
at the end of each chapter for further study and discussion.
Breakout Comments are highlighted throughout each chapter, visually reinforcing key ideas.
Tables, displays, figures, and illustrations are liberally supplied throughout the text to
reinforce learning as well as to help clarify complex information.
Key Concepts summarize important information within every chapter.
NEW AND EXPANDED CONTENT
Additional content that has been added or expanded in this edition includes:
Increased focus on evidence-driven leadership and management decision making
New models for ethical problem solving and an increased emphasis on patient,
professional, and subordinate advocacy
Expanded discussion of full-range leadership theory, transformational leadership, and
leadership competency identification
Emerging leadership theories such as Strengths-Based Leadership and the Positive
Psychology Movement, Level 5 leadership, thought leadership, authentic leadership, and
servant leadership
Introduction to Affordable Care Act in 2010, and the new Patient’s Bill of Rights
Key components of the Patient Protection and Affordable Care Act (PPACA) as well as its
implementation plan between 2010 and 2014
Health-care reform and financing mechanisms, including bundled payments, accountable
care organizations, value-based purchasing, medical homes, and health insurance
marketplaces
The shifting in health-care reimbursement from volume to value
Reflective practice and the professional portfolio
Transition-to-practice programs/residencies for new graduate nurses
Civility, incivility, bullying, mobbing, and workplace violence
Visioning of health care’s future
A broad discussion of social media as a communication tool and cause for work distraction
and the ethical issues encompassed in the topic
Continuing competence, lifelong learning, nurse residencies, reflective practice, and the
professional portfolio
Interprofessional collaboration including the Multidisciplinary Team Leader,
Interprofessional Primary Healthcare Teams, and Interprofessional Primary Health Care
Teams (PHCTs)
The unique needs of a culturally diverse workforce as well as a workforce representing up
to four generations at the same time
Nurse navigators
Patient- and family-centered care
Importance of self-care for nurses
x
PREFACE
The use of ISBAR (Introduction, Situation, Background, Assessment, Recommendation) as
a tool to promote communication between care providers or between care providers and
patients/families
Social media and organizational communication
New mergers of collective bargaining agents to form super unions for nurses
Leapfrog initiatives including electronic health records, computerized provider order
entry, evidence-based hospital staffing, and ICU physician staffing
New Joint Commission core measures and National Patient Safety Goals
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
survey
Patient safety and quality of care
thePoint (http://thepoint.lww.com), a trademark of Wolters Kluwer Health, is a web-based
course and content management system providing every resource that instructors and students
need in one easy-to-use site.
Instructor Resources
Advanced technology and superior content combine at thePoint to allow instructors to design
and deliver online and off-line courses, maintain grades and class rosters, and communicate
with students.
In addition, instructors will find the following content designed specifically for this
edition:
Test bank
Image bank
Instructor’s guide, including guidelines for using the experiential learning exercises in
the text
PowerPoint slides with images
Student Resources
Students can visit thePoint to access supplemental multimedia resources to enhance their
learning experience, download content, upload assignments, and join an online study group.
Students will also find a glossary that defines the italicized terms in the text.
THE CROSSWALK
New to this edition is a chapter crosswalk of content based on the AACN Essentials of
Baccalaureate Education for Professional Nursing Practice (2008); the AACN Essentials of
Master’s Education in Nursing (2011); the AONE Competencies; and the QSEN Competencies.
A crosswalk is a table that shows elements from different databases or criteria that interface.
This edition then attempts to show how content in each chapter draws from or contributes
to content identified as essential for baccalaureate and graduate education, for practice as a
nurse administrator, and for safety and quality in clinical practice.
Without doubt, some readers will disagree with the author’s determinations of which
Essential or Competency has been addressed in each chapter, and certainly, an argument
could be made that most chapters address many, if not all, of the Essentials or Competencies
in some way. The crosswalks in this book then are intended to note the primary content focus
in each chapter although additional Essentials or Competencies may well be a part of the
learning experience with each chapter.
PREFACE
xi
The American Association of Colleges of Nursing Essentials of
Baccalaureate Education for Professional Nursing Practice
The AACN Essentials of Baccalaureate Education for Professional Nursing Practice
(commonly called the BSN Essentials) were released in 2008 and identified the following
nine outcomes expected of graduates of baccalaureate nursing programs (Table 1). Essential
IX describes generalist nursing practice at the completion of baccalaureate nursing education
and includes practice-focused outcomes that integrate the knowledge, skills, and attitudes
delineated in Essentials I to VIII. Achievement of the outcomes identified in the BSN
Essentials will enable graduates to practice within complex health-care systems and to
assume the roles of provider of care; designer/manager/coordinator of care’; and member of
a profession (AACN, 2008) (Table 1).
TABLE 1
American Association of Colleges of Nursing Essentials of Baccalaureate
Education for Professional Nursing Practice
Essential I: Liberal education for baccalaureate generalist nursing practice
s A solid base in liberal education provides the cornerstone for the practice and education of nurses
Essential II: Basic organizational and systems leadership for quality care and patient safety
s Knowledge and skills in leadership, quality improvement, and patient safety are necessary to provide high-quality health care.
Essential III: Scholarship for evidence-based practice
s Professional nursing practice is grounded in the translation of current evidence into one’s practice.
Essential IV: Information management and application of patient-care technology
s Knowledge and skills in information management and patient-care technology are critical in the delivery of quality patient care
Essential V: Health-care policy, finance, and regulatory environments
s Health-care policies, including financial and regulatory, directly and indirectly influence the nature and functioning of the
health-care system and thereby are important considerations in professional nursing practice.
Essential VI: Interprofessional communication and collaboration for improving patient health outcomes
s Communication and collaboration among health-care professionals are critical to delivering high quality and safe patient care.
Essential VII: Clinical prevention and population health
s Health promotion and disease prevention at the individual and population level are necessary to improve population health and
are important components of baccalaureate generalist nursing practice.
Essential VIII: Professionalism and professional values
s Professionalism and the inherent values of altruism, autonomy, human dignity, integrity, and social justice are fundamental to
the discipline of nursing.
Essential IX: Baccalaureate generalist nursing practice
s The baccalaureate graduate nurse is prepared to practice with patients, including individuals, families, groups, communities,
and populations across the lifespan and across the continuum of health-care environments.
s The baccalaureate graduate understands and respects the variations of care, the increased complexity, and the increased use
of health-care resources inherent in caring for patients.
xii
PREFACE
The American Association of Colleges of Nursing Essentials of Master’s
Education in Nursing
The AACN Essentials of Master’s Education in Nursing (commonly called the MSN
Essentials) were published in March 2011 and identified the following nine outcomes
expected of graduates of master’s nursing programs, regardless of focus, major, or intended
practice setting (Table 2). Achievement of these outcomes will prepare graduate nurses to
lead change to improve quality outcomes, advance a culture of excellence through lifelong
learning, build and lead collaborative interprofessional care teams, navigate and integrate
care services across the health-care system, design innovative nursing practices, and translate
evidence into practice (AACN, 2011).
TABLE 2
American Association of Colleges of Nursing Essentials of Master’s
Education in Nursing
Essential I: Background for practice from sciences and humanities
s Recognizes that the master’s-prepared nurse integrates scientific findings from nursing, biopsychosocial fields, genetics, public
health, quality improvement, and organizational sciences for the continual improvement of nursing care across diverse settings.
Essential II: Organizational and systems leadership
s Recognizes that organizational and systems leadership are critical to the promotion of high quality and safe patient care.
Leadership skills are needed that emphasize ethical and critical decision making, effective working relationships, and a
systems perspective.
Essential III: Quality improvement and safety
s Recognizes that a master’s-prepared nurse must be articulate in the methods, tools, performance measures, and standards
related to quality, as well as prepared to apply quality principles within an organization.
Essential IV: Translating and integrating scholarship into practice
s Recognizes that the master’s-prepared nurse applies research outcomes within the practice setting, resolves practice
problems, works as a change agent, and disseminates results.
Essential V: Informatics and health-care technologies
s Recognizes that the master’s-prepared nurse uses patient-care technologies to deliver and enhance care and uses
communication technologies to integrate and coordinate care
Essential VI: Health policy and advocacy
s Recognizes that the master’s-prepared nurse is able to intervene at the system level through the policy development
process and to employ advocacy strategies to influence health and health care.
Essential VII: Interprofessional collaboration for improving patient and population health outcomes
s Recognizes that the master’s-prepared nurse, as a member and leader of interprofessional teams, communicates,
collaborates, and consults with other health professionals to manage and coordinate care.
Essential VIII: Clinical prevention and population health for improving health
s Recognizes that the master’s-prepared nurse applies and integrates broad, organizational, client-centered, and culturally
appropriate concepts in the planning, delivery, management, and evaluation of evidence-based clinical prevention and
population care and services to individuals, families, and aggregates/identified populations.
Essential IX: Advanced generalist nursing practice
s Recognizes that nursing practice, at the master’s level, is broadly defined as any form of nursing intervention that
influences health-care outcomes for individuals, populations, or systems. Master’s-level nursing graduates must have an
advanced level of understanding of nursing and relevant sciences as well as the ability to integrate this knowledge into
practice. Nursing practice interventions include both direct and indirect care components.
PREFACE
xiii
The Quality and Safety Education for Nurses Competencies
Using the Institute of Medicine (2003) competencies for nursing, the QSEN Institute defined
six pre-licensure and graduate quality and safety competencies for nursing (Table 3) and
proposed targets for the knowledge, skills, and attitudes to be developed in nursing programs
for each of these competencies. Led by a national advisory board and distinguished faculty,
QSEN pursues strategies to develop effective teaching approaches to assure that future
graduates develop competencies in patient-centered care, teamwork and collaboration,
evidence-based practice, quality improvement, safety, and informatics.
TABLE 3
Quality and Safety Education for Nurses Competencies
Patient-centered care
s Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and
coordinated care based on respect for patient’s preferences, values, and needs.
Teamwork and collaboration
s Definition: Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect,
and shared decision making to achieve quality patient care.
Evidence-based practice
s Definition: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of
optimal health care.
Quality improvement
s Definition: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes
to continuously improve the quality and safety of health-care systems.
Safety
s Definition: Minimizes the risk of harm to patients and providers through both system effectiveness and individual
performance.
Informatics
s Definition: Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.
The American Organization of Nurse Executives - Nurse Executive
Competencies
In 2004, the AONE published a paper describing skills common to nurses in executive
practice regardless of their educational level or titles in different organizations. While these
Nurse Executive Competencies differed depending on the leader’s specific position in the
organization, the AONE suggested that managers at all levels must be competent in the five
areas noted in Table 4 (AONE, 2011). These competencies suggest that nursing leadership/
management is as much a specialty as any other clinical nursing specialty and as such, it
requires proficiency and competent practice specific to the executive role (AONE).
xiv
PREFACE
TABLE 4
American Organization of Nurse Executive Competencies
I. Communication and relationship building
s Communication and relationship building includes effective communication; relationship management; influence of
behaviors; ability to work with diversity; shared decision making; community involvement; medical staff relationships; and
academic relationships.
II. A knowledge of the health-care environment
s Knowledge of the health-care environment includes clinical practice knowledge; patient-care delivery models and work
design knowledge; health-care economics knowledge; health-care policy knowledge; understanding of governance;
understanding of evidence-based practice; outcome measurement; knowledge of, and dedication to patient safety;
understanding of utilization/case management; knowledge of quality improvement and metrics; and knowledge of risk
management.
III. Leadership
s Leadership skills include foundational thinking skills; personal journey disciplines; the ability to use systems thinking;
succession planning; and change management.
IV. Professionalism
s Professionalism includes personal and professional accountability; career planning; ethics; evidence-based clinical and
management practice; advocacy for the clinical enterprise and for nursing practice; and active membership in professional
organizations.
V. Business skills
s Business skills include understanding of health-care financing; human resource management and development; strategic
management; marketing; and information management and technology.
REFERENCES
American Association of Colleges of Nursing (AACN).
(2008, October 20). The essentials of baccalaureate
education for professional nursing practice.
Retrieved June 20, 2013, from http://www.aacn.nche
.edu/education-resources/baccessentials08.pdf
American Association of Colleges of Nursing (AACN).
(2011, March 21) The essentials of master’s
education in nursing. Retrieved June 20, 2013, from
http://www.aacn.nche.edu/education-resources/
MastersEssentials11.pdf
American Organization of Nurse Executives (2011). The
AONE nurse executive competencies. Retrieved
June 20, 2013, from http://www.aone.org/resources/
leadership%20tools/nursecomp.shtml
Institute of Medicine. (2003). Health professions education:
A bridge to quality. Washington, DC: National
Academies Press.
Quality and Safety Education for Nurses Institute (2013).
Competencies. Retrieved June 20, 2013, from http://
qsen.org/competencies/
Contents
UNIT
I
The Critical Triad: Decision Making, Management, and Leadership 1
1 Decision Making, Problem Solving, Critical Thinking, and Clinical Reasoning:
Requisites for Successful Leadership and Management 2
Decision Making, Problem Solving, Critical Thinking, and Clinical Reasoning 3
Vicarious Learning to Increase Problem-Solving and Decision-Making Skills 4
Theoretical Approaches to Problem Solving and Decision Making 7
Critical Elements in Problem Solving and Decision Making 11
Individual Variations in Decision Making 15
Overcoming Individual Vulnerability in Decision Making 18
Decision Making in Organizations 19
Decision-Making Tools 20
Pitfalls in Using Decision-Making Tools 24
Summary 24
Key Concepts 25
Additional Learning Exercises and Applications 25
2 Classical Views of Leadership and Management 32
Managers 33
Leaders 34
Historical Development of Management Theory 35
Historical Development of Leadership Theory (1900 to Present) 39
Interactional Leadership Theories (1970 to Present) 42
Integrating Leadership and Management 47
Key Concepts 48
Additional Learning Exercises 49
3 Twenty-First-Century Thinking about Leadership and Management 53
New Thinking about Leadership and Management 54
Transition from Industrial Age Leadership to Relationship Age Leadership 63
Leadership and Management for Nursing’s Future 65
Key Concepts 66
Additional Learning Exercises and Applications 66
xv
xvi
CONTENTS
UNIT
II
Foundation for Effective Leadership and Management Ethics, Law,
and Advocacy 69
4 Ethical Issues 70
Types of Ethical Issues 72
Ethical Frameworks for Decision Making 74
Principles of Ethical Reasoning 75
American Nurses Association Code of Ethics and Professional Standards 79
Ethical Problem Solving and Decision Making 80
The Moral Decision-Making Model 84
Working toward Ethical Behavior as the Norm 86
Ethical Dimensions in Leadership and Management 88
Integrating Leadership Roles and Management Functions in Ethics 89
Key Concepts 90
Additional Learning Exercises and Applications 90
5 Legal and Legislative Issues 94
Sources of Law 95
Types of Laws and Courts 96
Legal Doctrines and the Practice of Nursing 97
Professional Negligence 98
Avoiding Malpractice Claims 101
Extending the Liability 102
Incident Reports 104
Intentional Torts 104
Other Legal Responsibilities of the Manager 105
Legal Considerations of Managing a Diverse Workforce 111
Professional Versus Institutional Licensure 112
Integrating Leadership Roles and Management Functions
in Legal and Legislative Issues 113
Key Concepts 114
Additional Learning Exercises and Applications 114
6 Patient, Subordinate, and Professional Advocacy 117
Becoming an Advocate 118
Patient Advocacy 120
Patient Rights 121
Subordinate and Workplace Advocacy 124
Whistleblowing as Advocacy 125
Professional Advocacy 127
Integrating Leadership Roles and Management Functions in Advocacy 131
Key Concepts 132
Additional Learning Exercises and Applications 133
CONTENTS
UNIT
III
Roles and Functions in Planning 137
7 Strategic and Operational Planning 138
Looking to the Future 140
Proactive Planning 142
Strategic Planning 144
Organizational Planning: The Planning Hierarchy 146
Vision and Mission Statements 147
The Organization’s Philosophy Statement 148
Societal Philosophies and Values 151
Individual Philosophies and Values 151
Goals and Objectives 153
Policies and Procedures 155
Rules 157
Overcoming Barriers to Planning 157
Integrating Leadership Roles and Management Functions
in Planning 158
Key Concepts 158
Additional Learning Exercises and Applications 159
8 Planned Change 162
The Development of Change Theory: Kurt Lewin 164
Lewin’s Driving and Restraining Forces 166
A Contemporary Adaptation of Lewin’s Model 167
Classic Change Strategies 167
Resistance: The Expected Response to Change 169
Planned Change as a Collaborative Process 171
The Leader-Manager as a Role Model during Planned Change 171
Organizational Change Associated with Nonlinear Dynamics 172
Organizational Aging: Change as a Means of Renewal 174
Integrating Leadership Roles and Management Functions
in Planned Change 175
Key Concepts 176
Additional Learning Exercises and Applications 177
9 Time Management 181
Three Basic Steps to Time Management 183
Personal Time Management 191
Integrating Leadership Roles and Management Functions
in Time Management 195
Key Concepts 195
Additional Learning Exercises and Applications 196
xvii
xviii
CONTENTS
10 Fiscal Planning 204
Balancing Cost and Quality 207
Responsibility Accounting and Forecasting 208
Basics of Budgets 208
Steps in the Budgetary Process 208
Types of Budgets 212
Budgeting Methods 216
Critical Pathways 218
Health-Care Reimbursement 218
Medicare and Medicaid 219
The Prospective Payment System 220
The Managed Care Movement 221
Proponents and Critics of Managed Care Speak Up 223
The Future of Managed Care 224
Health-Care Reform and the Patient Protection and
Affordable Care Act 226
Integrating Leadership Roles and Management
Functions in Fiscal Planning 228
Key Concepts 228
Additional Learning Exercises and Applications 229
11 Career Development: From New Graduate to Retirement 235
Career Stages 237
Justifications for Career Development 238
Individual Responsibility for Career Development 238
The Organization’s Responsibility for Career Development 239
Career Coaching 240
Management Development 243
Competency Assessment as Part of Career Development 245
Professional Specialty Certification 246
Reflective Practice and the Professional Portfolio 248
Career Planning and the New Graduate Nurse 249
Transition-to-Practice Programs/Residencies for New Graduate Nurses 249
Resume Preparation 251
Integrating Leadership Roles and Management Functions in Career
Development 253
Key Concepts 253
Additional Learning Exercises and Applications 254
CONTENTS
UNIT
IV
Roles and Functions in Organizing 259
12 Organizational Structure 260
Formal and Informal Organizational Structure 261
Organizational Theory and Bureaucracy 263
Components of Organizational Structure 264
Limitations of Organization Charts 269
Types of Organizational Structures 270
Decision Making within the Organizational Hierarchy 272
Stakeholders 273
Organizational Culture 274
Shared Governance: Organizational Design for the 21st Century? 277
Magnet Designation and Pathway to Excellence 278
Committee Structure in an Organization 280
Responsibilities and Opportunities of Committee Work 280
Organizational Effectiveness 281
Integrating Leadership Roles and Management Functions Associated with
Organizational Structure 282
Key Concepts 283
Additional Learning Exercises and Applications 284
13 Organizational, Political, and Personal Power 287
Understanding Power 289
The Authority–Power Gap 292
Mobilizing the Power of Nursing 296
Strategies for Building a Personal Power Base 299
The Politics of Power 302
Integrating Leadership Roles and Management Functions When Using
Authority and Power in Organizations 305
Key Concepts 306
Additional Learning Exercises and Applications 307
14 Organizing Patient Care 311
Traditional Modes of Organizing Patient Care 313
Disease Management 323
Selecting the Optimum Mode of Organizing Patient Care 324
Integrating Leadership Roles and Management Functions in Organizing Patient
Care 329
Key Concepts 329
Additional Learning Exercises and Applications 330
xix
xx
CONTENTS
UNIT
V
Roles and Functions in Staffing 333
15 Employee Recruitment, Selection, Placement, and Indoctrination 334
Predicting Staffing Needs 336
Is There a Current Nursing Shortage? 336
Recruitment 338
Interviewing as a Selection Tool 339
Tips for the Interviewee 348
Selection 349
Placement 353
Indoctrination 354
Integrating Leadership Roles and Management Functions in Employee
Recruitment, Selection, Placement, and Indoctrination 358
Key Concepts 358
Additional Learning Exercises and Applications 359
16 Socializing and Educating Staff for Team Building in a
Learning Organization 363
The Learning Organization 365
Staff Development 366
Learning Theories 367
Assessing Staff Development Needs 371
Evaluation of Staff Development Activities 372
Shared Responsibility for Implementing Evidence-Based Practice 373
Socialization and Resocialization 373
Overcoming Motivational Deficiencies 380
Coaching as a Teaching Strategy 381
Meeting the Educational Needs of a Culturally Diverse Staff 382
Integrating Leadership and Management in Team Building through Socializing
and Educating Staff for Team Building in a Learning Organization 383
Key Concepts 384
Additional Learning Exercises and Applications 384
17 Staffing Needs and Scheduling Policies 388
Unit Manager’s Responsibilities in Meeting Staffing Needs 390
Centralized and Decentralized Staffing 390
Complying with Staffing Mandates 391
Staffing and Scheduling Options 393
Workload Measurement Tools 397
The Relationship between Nursing Care Hours, Staffing Mix,
and Quality of Care 401
Managing a Diverse Staff 402
CONTENTS
xxi
Generational Considerations for Staffing 403
The Impact of Nursing Staff Shortages upon Staffing 404
Fiscal and Ethical Accountability for Staffing 405
Developing Staffing and Scheduling Policies 406
Integrating Leadership Roles and Management Functions
in Staffing and Scheduling 407
Key Concepts 408
Additional Learning Exercises and Applications 408
UNIT
VI
Roles and Functions in Directing 413
18 Creating a Motivating Climate 414
Intrinsic Versus Extrinsic Motivation 416
Motivational Theory 417
Creating a Motivating Climate 422
Strategies for Creating a Motivating Climate 424
Promotion: A Motivational Tool 426
Promoting Self-Care 428
Integrating Leadership Roles and Management Functions in Creating
a Motivating Climate at Work 429
Key Concepts 430
Additional Learning Exercises and Applications 431
19 Organizational, Interpersonal, and Group Communication 436
The Communication Process 438
Variables Affecting Organizational Communication 440
Organizational Communication Strategies 441
Communication Modes 443
Elements of Nonverbal Communication 444
Verbal Communication Skills 446
Listening Skills 449
Written Communication within the Organization 450
The Impact of Technology on Contemporary Organizational Communication 452
Communication, Confidentiality, and Health Insurance Portability and
Accountability Act 454
Group Dynamics 457
Integrating Leadership and Management in Organizational, Interpersonal, and
Group Communication 459
Key Concepts 460
Additional Learning Exercises and Applications 461
xxii
CONTENTS
20 Delegation 466
Delegating Effectively 468
Common Delegation Errors 471
Delegation as a Function of Professional Nursing 473
Delegating to a Transcultural Work Team 479
Integrating Leadership Roles and Management Functions
in Delegation 480
Key Concepts 481
Additional Learning Exercises and Applications 482
21 Effective Conflict Resolution and Negotiation 487
The History of Conflict Management 489
Categories of Conflict: Intergroup, Intrapersonal,
and Interpersonal 490
The Conflict Process 493
Conflict Management 495
Managing Unit Conflict 498
Negotiation 500
Alternative Dispute Resolution 505
Seeking Consensus 506
Integrating Leadership Skills and Management Functions
in Managing Conflict 506
Key Concepts 507
Additional Learning Exercises and Applications 507
22 Collective Bargaining, Unionization, and Employment Laws 514
Unions and Collective Bargaining 516
Historical Perspective of Unionization in America 517
Union Representation of Nurses 518
American Nurses Association and Collective Bargaining 519
Employee Motivation to Join or Reject Unions 520
Averting the Union 522
The Nurse as Supervisor: Eligibility for Protection Under the National
Labor Relations Act 523
Union-Organizing Strategies 524
Managers’ Role During Union-Organizing 525
Steps to Establish a Union 526
Effective Labor–Management Relations 526
Employment Legislation 528
State Health Facilities Licensing Boards 535
Integrating Leadership Skills and Management Functions When Working with
Collective Bargaining, Unionization and Employment Laws 536
Key Concepts 536
Additional Learning Exercises and Applications 537
CONTENTS
xxiii
UNIT VII
Roles and Functions in Controlling 541
23 Quality Control 542
Defining Quality Health Care 545
Quality Control as a Process 546
The Development of Standards 548
Audits as a Quality Control Tool 551
Standardized Nursing Languages 553
Quality Improvement Models 554
Who Should Be Involved in Quality Control? 556
Quality Measurement as an Organizational Mandate 556
Centers for Medicare and Medicaid Services 559
Medical Errors: An Ongoing Threat to Quality of Care 562
Integrating Leadership Roles and Management Functions with Quality
Control 565
Key Concepts 566
Additional Learning Exercises and Applications 568
24 Performance Appraisal 573
Using the Performance Appraisal to Motivate Employees 575
Strategies to Ensure Accuracy and Fairness in the Performance Appraisal 576
Performance Appraisal Tools 579
Planning the Appraisal Interview 587
Overcoming Appraisal Interview Difficulties 587
Performance Management 590
Coaching: A Mechanism for Informal Performance Appraisal 590
Becoming an Effective Coach 591
Using Leadership Skills and Management Functions in Conducting Performance
Appraisals 591
Key Concepts 591
Additional Learning Exercises and Applications 592
25 Problem Employees: Rule Breakers, Marginal Employees, and the Chemically
or Psychologically Impaired 596
Constructive Versus Destructive Discipline 599
Self-Discipline and Group Norms 600
Fair and Effective Rules 600
Discipline as a Progressive Process 601
Disciplinary Strategies for the Nurse-Manager 604
Transferring the Problem Employee 609
Grievance Procedures 610
Disciplining the Unionized Employee 611
xxiv
CONTENTS
The Marginal Employee 612
The Chemically Impaired Employee 614
Recognizing the Chemically Impaired Employee 615
Integrating Leadership Roles and Management Functions through Dealing with
Problem Employees 622
Key Concepts 623
Additional Learning Exercises and Applications 623
Appendix 627
Solutions to Selected Learning Exercises 627
Index 637
UNIT I
The Critical Triad:
Decision Making, Management,
and Leadership
1
Decision Making, Problem Solving, Critical
Thinking, and Clinical Reasoning: Requisites
for Successful Leadership and Management
… again and again, the impossible problem is solved when we see that the problem is only a tough
decision waiting to be made.
—Robert H. Schuller
… in any moment of decision the best thing you can do is the right thing, the next best thing is the
wrong thing, and the worst thing you can do is nothing.
—Theodore Roosevelt
CROSSWALK THIS CHAPTER ADDRESSES:
BSN Essential I: Liberal education for baccalaureate generalist nursing practice
BSN Essential III: Scholarship for evidence-based practice
BSN Essential IV: Information management and application of patient care technology
BSN Essential VI: Interprofessional communication and collaboration for improving patient health
outcomes
MSN Essential I: Background for practice from sciences and humanities
QSEN Competency: Informatics
MSN Essential IV: Translating and integrating scholarship into practice
AONE Nurse Executive Competency I: Communication and relationship building
AONE Nurse Executive Competency III: Leadership
QSEN Competency: Evidence-based practice
LEARNING OBJECTIVES The learner will:
●
●
●
●
●
●
●
●
●
●
2
differentiate between problem solving, decision making, critical thinking, and clinical
reasoning
describe how case studies, simulation, and problem-based learning can be used to improve
the quality of decision making
explore strengths and limitations of using intuition and heuristics as adjuncts to problem
solving and decision making
identify characteristics of successful decision makers
select appropriate models for decision making in specific situations
describe the importance of the individual in the decision-making process
identify critical elements of decision making
explore his or her personal propensity for risk taking in decision making
discuss the effect of organizational power on decision making
differentiate between the economic man and the administrative man in decision making
Chapter 1
●
●
Decision Making, Problem Solving and Critical Thinking
3
select appropriate management decision-making tools that would be helpful in making
specific decisions
differentiate between autocratic, democratic, and laissez-faire decision styles and identify
situation variables that might suggest using one decision style over another
Decision making is often thought to be synonymous with management and is one of the criteria
on which management expertise is judged. Much of any manager’s time is spent critically
examining issues, solving problems, and making decisions. The quality of the decisions that
leader-managers make is the factor that often weighs most heavily in their success or failure.
Decision making, then, is both an innermost leadership activity and the core of management.
This chapter explores the primary requisites for successful management and leadership:
decision making, problem solving, and critical thinking. Also, because it is the authors’ belief
that decision making, problem solving, and critical thinking are learned skills that improve
with practice and consistency, an introduction to established tools, techniques, and strategies
for effective decision making is included. This chapter also introduces the learning exercise as
a new approach for vicariously gaining skill in management and leadership decision making.
Finally, evidence-based decision making is introduced as an imperative for both personal and
professional problem solving.
DECISION MAKING, PROBLEM SOLVING, CRITICAL THINKING,
AND CLINICAL REASONING
Decision making is a complex, cognitive process often defined as choosing a particular course
of action. BusinessDictionary.com (2013, para 1) defines decision making as “the thought
process of selecting a logical choice from the available options.” This implies that doubt
exists about several courses of action and that a choice is made to eliminate uncertainty.
Problem solving is part of decision making and is a systematic process that focuses on
analyzing a difficult situation. Problem solving always includes a decision-making step.
Many educators use the terms problem solving and decision making synonymously, but there
is a small yet important difference between the two. Although decision making is the last
step in the problem-solving process, it is possible for decision making to occur without the
full analysis required in problem solving. Because problem solving attempts to identify the
root problem in situations, much time and energy are spent on identifying the real problem.
Decision making, on the other hand, is usually triggered by a problem but is often handled
in a manner that does not focus on eliminating the underlying problem. For example, if a
person decided to handle a conflict when it occurred but did not attempt to identify the real
problem causing the conflict, only decision-making skills would be used. The decision maker
might later choose to address the real cause of the conflict or might decide to do nothing at
all about the problem. The decision has been made not to problem solve. This alternative may
be selected because of a lack of energy, time, or resources to solve the real problem. In some
situations, this is an appropriate decision. For example, assume that a nursing supervisor has a
staff nurse who has been absent a great deal over the last 3 months. Normally, the supervisor
would feel compelled to intervene. However, the supervisor has reliable information that the
nurse will be resigning soon to return to school in another state. Because the problem will
soon no longer exist, the supervisor decides that the time and energy needed to correct the
problem are not warranted.
Critical thinking, sometimes referred to as reflective thinking, is related to evaluation and
has a broader scope than decision making and problem solving. Dictionary.com (2013) defines
critical thinking as “the mental process of actively and skillfully conceptualizing, applying,
analyzing, synthesizing, and evaluating information to reach an answer or conclusion”
4
UNIT I
THE CRITICAL TRIAD: DECISION MAKING, MANAGEMENT, AND LEADERSHIP
(para 1). Critical thinking also involves reflecting upon the meaning of statements, examining
the offered evidence and reasoning, and forming judgments about facts.
Whatever definition of critical thinking is used, most agree that it is more complex than
problem solving or decision making, involves higher-order reasoning and evaluation, and has
both cognitive and affective components. The authors believe that insight, intuition, empathy,
and the willingness to take action are additional components of critical thinking. These same
skills are necessary to some degree in decision making and problem solving. See Display 1.1
for additional characteristics of a critical thinker.
DISPLAY 1.1
Characteristics of a Critical Thinker
Open to new ideas
Intuitive
Energetic
Analytical
Persistent
Assertive
Communicator
Flexible
Empathetic
Caring
Observant
Risk taker
Resourceful
“Outside-the-box” thinker
Creative
Insightful
Willing to take action
Outcome directed
Willing to change
Knowledgeable
Circular thinking
Insight, intuition, empathy, and the willingness to take action are components of critical thinking.
Nurses today must have higher-order thinking skills to identify patient problems and to direct
clinical judgments and actions that result in positive patient outcomes. When nurses integrate
and apply different types of knowledge to weigh evidence, critically think about arguments
and reflect upon the process used to arrive at a diagnosis; this is known as clinical reasoning
(Linn, Khaw, Kildea, & Tonkin, 2012). Thus, clinical reasoning uses both knowledge and
experience to make decisions at the point of care.
VICARIOUS LEARNING TO INCREASE PROBLEM-SOLVING AND
DECISION-MAKING SKILLS
Decision making, one step in the problem-solving process, is an important task that relies
heavily on critical thinking and clinical reasoning skills. How do people become successful
problem solvers and decision makers? Although successful decision making can be learned
through life experience, not everyone learns to solve problems and judge wisely by this trialand-error method because much is left to chance. Some educators feel that people are not
successful in problem solving and decision making because individuals are not taught how to
reason insightfully from multiple perspectives.
Moreover, information and new learning may not be presented within the context of reallife situations, although this is changing. For example, in teaching clinical reasoning, nurse
educators strive to see that the elements of clinical reasoning, such as noticing crucial changes
in patient status, analyzing these changes to decide on a course of action, and evaluating
responses to modify care, are embedded at every opportunity throughout the nursing curricula
(Russell, Geist, & Maffett, 2013). In addition, time is included for meaningful reflection on
the decisions that are made and the outcomes that result. Such learning can occur in both
real-world settings and through vicarious learning, where students problem solve and make
decisions based on simulated situations that are made real to the learner.
Case Studies, Simulation, and Problem-Based Learning
Case studies, simulation, and problem-based learning (PBL) are some of the strategies that
have been developed to vicariously improve problem solving and decision making. Case
Chapter 1
Decision Making, Problem Solving and Critical Thinking
5
studies may be thought of as stories that impart learning. They may be fictional or include
real persons and events, be relatively short and self-contained for use in a limited amount of
time, or be longer with significant detail and complexity for use over extended periods of
time. Case studies, particularly those that unfold or progress over time, are becoming much
more common in nursing education since they provide a more interactive, learning experience
for students than the traditional didactic approach.
Similarly, simulation provides learners opportunities for problem solving that have little
or no risk to patients or to organizational performance. For example, some organizations
are now using computer simulation (known as discrete event simulation) to imitate the
operation of a real-life system such as a hospital. Based on chosen alternatives, the simulation
can determine the relative performance of patient throughputs, the timeliness of care, and
the appropriateness of resource utilization, thus integrating management priorities and
operational decision making (Hamrock, Paige, Parks, Scheulen, & Levin, 2013).
In addition, simulation models are increasingly being used by schools of nursing to allow
students the opportunity to gain skill mastery before working directly with acutely ill and
vulnerable clients. In addition, simulation allows students to apply and improve the critically
important “nontechnical” skills of communication, teamwork, leadership, and decision
making (Lewis, Strachan, & Smith, 2012). (See Examining the Evidence 1.1.)
Examining the Evidence 1.1
Source: Lewis, R., Strachan, A., & Smith, M. (2012). Is high fidelity simulation the most effective method for the
development of non-technical skills in nursing? A review of the current evidence. Open Nursing Journal, 6, 82–89.
This literature review suggested that simulation was positively associated with significantly
improved interpersonal communication skills at patient handover as well as improved team performance in the management of crisis situations. It also appeared to enable the development of
transferable, transformational leadership skills, improved students’ critical thinking and clinical
reasoning in complex care situations, and aided in the development of students’ self-efficacy
and confidence in their own clinical abilities. The authors concluded that simulation provides a
learning environment in which both technical and nontechnical skills can be improved without
fear of compromising patient safety.
PBL also provides opportunities for individuals to address and learn from authentic
problems vicariously. Typically, in PBL, learners meet in small groups to discuss and analyze
real-life problems. Thus, they learn by problem solving. The learning itself is collaborative as
the teacher guides the students to be self-directed in their learning, and many experts suggest
that this type of active learning helps to develop critical thinking skills.
The Marquis-Huston Critical Thinking Teaching Model
The desired outcome for teaching and learning decision making and critical thinking in
management is an interaction between learners and others that results in the ability to
critically examine management and leadership issues. This is a learning of appropriate social/
professional behaviors rather than a mere acquisition of knowledge. This type of learning
occurs best in groups, using a PBL approach.
In addition, learners retain didactic material more readily when it is personalized or when
they can relate to the material being presented. The use of case studies that learners can
identify with assists in retention of didactic materials.
Also, while formal instruction in critical thinking is important, using a formal decisionmaking process improves both the quality and consistency of decision making. Many new
leaders and managers struggle to make quality decisions because their opportunity to practice
6
UNIT I
THE CRITICAL TRIAD: DECISION MAKING, MANAGEMENT, AND LEADERSHIP
making management and leadership decisions is very limited until they are appointed to
a management position. These limitations can be overcome by creating opportunities for
vicariously experiencing the problems that individuals would encounter in the real world of
leadership and management.
The Marquis-Huston model for teaching critical thinking assists in achieving desired
learner outcomes (Fig. 1.1). Basically, the model comprises four overlapping spheres,
each being an essential component for teaching leadership and management. The first is a
didactic theory component, such as the material that is presented in each chapter; second,
a formalized approach to problem solving and decision making must be used. Third, there
must be some use of the group process, which can be accomplished through large and small
groups and classroom discussion. Finally, the material must be made real for the learner so
that the learning is internalized. This can be accomplished through writing exercises, personal
exploration, and values clarification, along with risk taking, as case studies are examined.
Experiential learning provides mock experiences that have tremendous value in applying
leadership and management theory.
This book was developed with the perspective that experiential learning provides mock
experiences that have tremendous value in applying leadership and management theory. The
text includes numerous opportunities for readers to experience the real world of leadership
and management. Some of these learning situations, called learning exercises, include
case studies, writing exercises, specific management or leadership problems, staffing and
budgeting calculations, group discussion or problem-solving situations, and assessment
of personal attitudes and values. Some exercises include opinions, speculation, and value
judgments. All of the learning exercises, however, require some degree of critical thinking,
problem solving, decision making, or clinical reasoning.
Didactic
theory
Problem
solving
Personalized
learning
Group
process
&)'52% s The Marquis-Huston critical thinking teaching model.
Chapter 1
Decision Making, Problem Solving and Critical Thinking
7
Some of the case studies have been solved (solutions are found at the back of the book)
so that readers can observe how a systematic problem-solving or decision-making model
can be applied in solving problems common to nurse-managers. The authors feel strongly,
however, that the problem solving suggested in the solved cases should not be considered the
only plausible solution or “the right solution” to that learning exercise. Most of the learning
exercises in the book have multiple solutions that could be implemented successfully to solve
the problem.
THEORETICAL APPROACHES TO PROBLEM SOLVING
AND DECISION MAKING
Most people make decisions too quickly and fail to systematically examine a problem or
its alternatives for solution. Instead, most individuals rely on discrete, often unconscious
processes known as heuristics, which allows them to solve problems more quickly and to
build upon experiences they have gained in their lives. Thus, heuristics use trial-and-error
methods or a rule-of-thumb approach to problem solving, rather than set rules.
For example, a study by Muoni (2012) found that nurse midwives often use heuristics
(which are defined as shortcut mental strategies that help simplify information), coupled with
intuition, to make clinical decisions. While Muoni notes that the use of such heuristics does
allow midwives to make decisions more quickly, she questions the reliability of heuristics
and suggests that clinical decisions should always be evidence based and follow a systematic
continuum that clearly portrays the process used to make the decision.
Formal process and structure can benefit the decision-making process, as they force decision
makers to be specific about options and to separate probabilities from values. A structured
approach to problem solving and decision making increases clinical reasoning and is the best
way to learn how to make quality decisions because it eliminates trial and error and focuses
the learning on a proven process. A structured or professional approach involves applying a
theoretical model in problem solving and decision making. Many acceptable problem solving
models exist, and most include a decision-making step; only four are reviewed here.
A structured approach to problem solving and decision making increases clinical reasoning.
Traditional Problem-Solving Process
One of the most well-known and widely used problem-solving models is the traditional
problem-solving model. The seven steps follow in Display 1.2. (Decision-making occurs at
step 5.)
DISPLAY 1.2
1.
2.
3.
4.
5.
6.
7.
Traditional Problem Solving Process
Identify the problem.
Gather data to analyze the causes and consequences of the problem.
Explore alternative solutions.
Evaluate the alternatives.
Select the appropriate solution.
Implement the solution.
Evaluate the results.
Although the traditional problem-solving process is an effective model, its weakness lies
in the amount of time needed for proper implementation. This process, therefore, is less
effective when time constraints are a consideration. Another weakness is lack of an initial
8
UNIT I
THE CRITICAL TRIAD: DECISION MAKING, MANAGEMENT, AND LEADERSHIP
objective-setting step. Setting a decision goal helps to prevent the decision maker from
becoming sidetracked.
Managerial Decision-Making Models
To address the weaknesses of the traditional problem-solving process, many contemporary
models for management decision making have added an objective-setting step. These models
are known as managerial decision-making models or rational decision-making models. One
such model suggested by Decision-making-confidence.com (2006–2013) includes the six
steps shown in Display 1.3.
DISPLAY 1.3
1.
2.
3.
4.
5.
6.
Managerial Decision Making Model
Determine the decision and the desired outcome (set objectives).
Research and identify options.
Compare and contrast these options and their consequences.
Make a decision.
Implement an action plan.
Evaluate results.
In the first step, problem solvers must identify the decision to be made, who needs to be
involved in the decision process, the timeline for the decision, and the goals or outcomes that
should be achieved. Identifying objectives to guide the decision making helps the problem
solver determine which criteria should be weighted most heavily in making their decision.
Most important decisions require this careful consideration of context.
In step 2, problem solvers must attempt to identify as many alternatives as possible.
Alternatives are then analyzed in step 3, often using some type of SWOT (strengths,
weaknesses, opportunities, and threats) analysis. Decision makers may choose to apply
quantitative decision-making tools, such as decision-making grids and payoff tables
(discussed further later in this chapter), to objectively review the desirability of alternatives.
In step 4, alternatives are rank ordered on the basis of the analysis done in step 3 so
that problem solvers can make a choice. In step 5, a plan is created to implement desirable
alternatives or combinations of alternatives. In the final step, challenges to successful
implementation of chosen alternatives are identified and strategies are developed to manage
those risks. An evaluation is then conducted of both process and outcome criteria, with
outcome criteria typically reflecting the objectives that were set in step 1.
The Nursing Process
The nursing process, developed by Ida Jean Orlando in the late 1950s, provides another
theoretical system for solving problems and making decisions. Originally a four-step model
(assess, plan, implement, and evaluate) diagnosis was delineated as a separate step, and most
contemporary depictions of this model now include at least five steps. (See Display 1.4.)
DISPLAY 1.4
1.
2.
3.
4.
5.
Nursing Process
Assess
Diagnose
Plan
Implement
Evaluate
As a decision-making model, the greatest strength of the nursing process may be its
multiple venues for feedback. The arrows in Figure 1.2 show constant input into the process.
Chapter 1
Decision Making, Problem Solving and Critical Thinking
Assess
9
Diagnose
Evaluate
Plan
Implement
&)'52% s Feedback mechanism of the nursing process.
When the decision point has been identified, initial decision making occurs and continues
throughout the process via a feedback mechanism.
Although the process was designed for nursing practice with regard to patient care and
nursing accountability, it can easily be adapted as a theoretical model for solving leadership
and management problems. Table 1.1 shows how closely the nursing process parallels the
decision-making process.
The weakness of the nursing process, like the traditional problem-solving model, is in not
requiring clearly stated objectives. Goals should be clearly stated in the planning phase of the
process, but this step is frequently omitted or obscured. However, because nurses are familiar
with this process and its proven effectiveness, it continues to be recommended as an adapted
theoretical process for leadership and managerial decision making.
Integrated Ethical Problem-Solving Model
A more contemporary model for effective thinking and problem solving was developed by
Park (2012) upon review of 20 existing models for ethical decision making (Display 1.5).
While developed primarily for use in solving ethical problems, the model also works well
as a general problem-solving model. Similar to the three models already discussed, this
model provides a structured approach to problem solving that includes an assessment of
TABLE 1.1
Comparing the Decision-Making Process with the Nursing Process
Decision-Making Process
Identify the decision
Collect data
Identify criteria for decision
Identify alternatives
Choose alternative
Implement alternative
Evaluate steps in decision
Simplified Nursing Process
Assess
Plan
Implement
Evaluate
10
UNIT I
THE CRITICAL TRIAD: DECISION MAKING, MANAGEMENT, AND LEADERSHIP
the problem, problem identification, the analysis and selection of the best alternative, and a
means for evaluation. The model does go one step further, however, in requiring the learner
to specifically identify strategies that reduce the likelihood of a problem recurring.
DISPLAY 1.5
1.
2.
3.
4.
5.
6.
Integrated Ethical Problem Solving Model
State the problem.
Collect additional information and analyze the problem.
Develop alternatives and analyze and compare them.
Select the best alternative and justify your decision.
Develop strategies to successfully implement a chosen alternative and take action.
Evaluate the outcomes and prevent a similar occurrence.
Many other excellent problem analysis and decision models exist. The model selected
should be one with which the decision maker is familiar and one appropriate for the problem
to be solved. Using models or processes consistently will increase the likelihood that critical
analysis will occur. Moreover, the quality of management/leadership problem solving and
decision making will improve tremendously via a scientific approach.
LEARNING EXERCISE 1.1
Applying Scientific Models to Decision Making
You are a registered nurse who graduated 3 years ago. During the last 3 years, your
responsibilities in your first position have increased. Although you enjoy your family (spouse
and one preschool-aged child), you realize that you love your job and that your career is very
important to you. Recently, you and your spouse decided to have another baby. At that time, you
and your spouse reached a joint decision that if you had another baby, you wanted to reduce
your work time and spend more time at home with the children. Last week, your supervisor told
you that the charge nurse is leaving. You were thrilled and excited when she said that she wants
to appoint you to the position. Yesterday, you found out that you and your spouse are expecting
a baby.
Last night, you spoke with your spouse about your career future. Your spouse is an attorney
whose practice has suddenly gained momentum. Although the two of you have shared child
rearing equally until this point, your spouse is not sure how much longer this can be done if the
law practice continues to expand. If you take the position, which you would like to do, it would
mean full-time work. You want the decision that you and your spouse reach to be well thought
out, as it has far-reaching consequences and concerns many people.
Assignment: Determine what you should do. After you have made your decision, get together
in a group (four to six people) and share your decisions. Were they the same? How did you
approach the problem solving differently from others in your group? Was a rational systematic
problem-solving process used, or was the chosen solution based more on intuition? How many
alternatives were generated? Did some of the group members identify alternatives that you had
not considered? Was a goal(s) or objective identified? How did your personal values influence
your decision?
Intuitive Decision-Making Models
There are theorists who suggest that intuition should always be used as an adjunct to
empirical or rational decision-making models. Experienced nurses often report that gut-level
feelings encourage them to take appropriate strategic action that impacts patient outcomes,
Chapter 1
Decision Making, Problem Solving and Critical Thinking
11
although intuition should generally serve as an adjunct to decision making founded on nurse’s
scientific knowledge base.
Pearson (2013) agrees, suggesting that intuition can and should be used in conjunction
with evidence-based practice and that it deserves to be acknowledged as a factor in achieving
good outcomes within clinical practice. Pearson goes on to say that intuition is, in reality,
often a rapid, automatic process of recognizing familiar problems instantly and using
experience to identify solutions. Thus, intuition may be perceived as a cognitive skill rather
than a perception or knowing without knowing how.
This recognition of familiar problems and the use of intuition to identify solutions is a focus
of contemporary research on intuitive decision-making research. Klein and his colleagues
(Klein, 2008) developed the recognition-primed decision (RPD) model for intuitive decision
making in the mid-1980s to explain how people can make effective decisions under time
pressure and uncertainty. Considered a part of naturalistic decision making, the RPD model
attempts to understand how humans make relatively quick decisions in complex, real-world
settings such as firefighting and critical care nursing without having to compare options.
Klein’s work suggests that instead of using classical rational or systematic decisionmaking processes, many individuals act on their first impulse if the “imagined future” looks
acceptable. If this turns out not to be the case, another idea or concept is allowed to emerge
from their subconscious and is examined for probable successful implementation. Thus,
the RPD model blends intuition and analysis, but pattern recognition and experience guide
decision makers when time is limited or systematic rational decision making is not possible.
CRITICAL ELEMENTS IN PROBLEM SOLVING AND DECISION MAKING
Because decisions may have far-reaching consequences, some problem solving and decision
making must be of high quality. Using a scientific approach alone for problem solving and
decision making does not, however, ensure a quality decision. Special attention must be paid
to other critical elements. The elements in Display 1.6, considered crucial in problem solving,
must occur if a high-quality decision is to be made.
DISPLAY 1.6
1.
2.
3.
4.
5.
6.
Critical Elements in Decision Making
Define objectives clearly.
Gather data carefully.
Take the time necessary.
Generate many alternatives.
Think logically.
Choose and act decisively.
Define Objectives Clearly
Decision makers often forge ahead in their problem-solving process without first determining
their goals or objectives. However, it is especially important to determine goals and
objectives when problems are complex. Even when decisions must be made quickly, there
is time to pause and reflect on the purpose of the decision. A decision that is made without a
clear objective in mind or a decision that is inconsistent with one’s philosophy is likely to be
a poor-quality decision. Sometimes the problem has been identified but the wrong objectives
are set.
If a decision lacks a clear objective or if an objective is not consistent with the individual’s or
organization’s stated philosophy, a poor-quality decision is likely.
12
UNIT I
THE CRITICAL TRIAD: DECISION MAKING, MANAGEMENT, AND LEADERSHIP
For example, it would be important for the decision maker in Learning Exercise 1.1 to
determine whether their most important objective is career advancement, having more time
with family, or meeting the needs of their spouse. None of these goals is more “right” than the
others, but not having clarity about which objective(s) is paramount makes decision making
very difficult.
Gather Data Carefully
Because decisions are based on knowledge and information available to the problem solver
at the time the decision must be made, one must learn how to process and obtain accurate
information. The acquisition of information begins with identifying the problem or the
occasion for the decision and continues throughout the problem-solving process. Often the
information is unsolicited, but most information is sought actively. Acquiring information
always involves people, and no tool or mechanism is infallible to human error. Questions that
should be asked in data gathering are shown in Display 1.7.
DISPLAY 1.7
1.
2.
3.
4.
5.
6.
7.
8.
9.
Questions to Examine in Data Gathering
What is the setting?
What is the problem?
Where is it a problem?
When is it a problem?
Who is affected by the problem?
What is happening?
Why is it happening? What are the causes of the problem? Can the causes be prioritized?
What are the basic underlying issues? What are the areas of conflict?
What are the consequences of the problem? Which is the most serious?
In addition, human values tremendously influence our perceptions. Therefore, as problem
solvers gather information, they must be vigilant that their own preferences and those of
others are not mistaken for facts.
Facts can be misleading if they are presented in a seductive manner, if they are taken out of
context, or if they are past oriented.
How many parents have been misled by the factual statement, “Johnny hit me”? In this
case, the information seeker needs to do more fact finding. What was the accuser doing
before Johnny hit him? What was he hit with? Where was he hit? When was he hit? Like the
parent, the manager who becomes expert at acquiring adequate, appropriate, and accurate
information will have a head start in becoming an expert decision maker and problem solver.
LEARNING EXERCISE 1.2
Gathering Necessary Information
Identify a poor decision that you recently made because of faulty data gathering. Have you
ever made a poor decision because necessary information was intentionally or unintentionally
withheld from you?
Take the Time Necessary
Moxley, Anders Ericsson, Charness, and Krampe (2012) suggest that most current problemsolving and decision-making theories argue that human decision making is largely based on
Chapter 1
Decision Making, Problem Solving and Critical Thinking
13
the quick, automatic, and intuitive processes that are a part of heuristics, and that these are
only occasionally supplemented by slow controlled deliberation. Moxley et al. (2012) argue
that slow deliberation results in improved decision making for both experts and those less
skilled, regardless of whether the problem is easy or difficult.
Use an Evidence-Based Approach
To gain knowledge and insight into managerial and leadership decision making, individuals
must reach outside their current sphere of knowledge in solving the problems presented in
this text. Some data-gathering sources include textbooks, periodicals, experts in the field,
colleagues, and current research. Indeed, most experts agree that the best practices in nursing
care and decision making are also evidence-based practices (Prevost, 2014).
While there is no one universally accepted definition for an evidence-based approach,
most definitions suggest the term evidence based can be used synonymously with research
based or science based. Others suggest that evidence based means that the approach has
been reviewed by experts in the field using accepted standards of empirical research and that
reliable evidence exists that the approach or practice works to achieve the desired outcomes.
Typically, a PICO (patient or population, intervention, comparison, and outcome) format is
used in evidence-based practice to guide the search for the current best evidence to address
a problem.
Given that human lives are often at risk, nurses, then, should feel compelled to use
an evidence-based approach in gathering data to make decisions regarding their nursing
practice. Yet, Prevost (2014) suggests that many practicing nurses feel they do not have
the time, access, or expertise needed to search and analyze the research literature to answer
clinical questions. In addition, most staff nurses practicing in clinical settings have less than
a baccalaureate degree and therefore may not have been exposed to a formal research course.
Findings from research studies may also be technical, difficult to understand, and even more
difficult to translate into practice. Strategies the new nurse might use to promote evidencebased practice are shown in Display 1.8.
DISPLAY 1.8
1.
2.
3.
4.
5.
6.
7.
8.
9.
Strategies for the New Nurse to Promote Evidence-Based Best Practice
Keep abreast of the evidence—subscribe to professional journals and read widely.
Use and encourage use of multiple sources of evidence.
Use evidence not only to support clinical interventions but also to support teaching strategies.
Find established sources of evidence in your specialty—do not reinvent the wheel.
Implement and evaluate nationally sanctioned clinical practice guidelines.
Question and challenge nursing traditions and promote a spirit of risk taking.
Dispel myths and traditions not supported by evidence.
Collaborate with other nurses locally and globally.
Interact with other disciplines to bring nursing evidence to the table.
Source: Reprinted from Prevost, S. (2014). Evidence-based practice. In C. Huston (Ed.), Professional issues in nursing
(3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Evidence-based decision making and evidence-based practice should be viewed as imperatives
for all nurses today as well as for the profession in general.
It is important to recognize that the implementation of evidence-based best practices is not
just an individual, staff nurse–level pursuit (Prevost, 2014). Too few nurses understand what
best practices and evidence-based practice are all about, and many organizational cultures do
not support nurses who seek out and use research to change long-standing practices rooted
in tradition rather than in science. Administrative support is needed to access the resources,
14
UNIT I
THE CRITICAL TRIAD: DECISION MAKING, MANAGEMENT, AND LEADERSHIP
provide the support personnel, and sanction the necessary changes in policies, procedures,
and practices for evidence-based data gathering to be a part of every nurse’s practice
(Prevost, 2014). This approach to care is even being recognized as a standard expectation
of accrediting bodies, such as the Joint Commission as well as an expectation for magnet
hospital designation.
Generate Many Alternatives
The definition of decision making implies that there are at least two choices in every decision.
Unfortunately, many problem solvers limit their choices to two when many more options
usually are available. Remember that one alternative in each decision should be the choice not
to do anything. When examining decisions to be made by using a formal process, it is often
found that the status quo is the right alternative.
The greater the number of alternatives that can be generated, the greater the chance that the
final decision will be sound.
Several techniques can help to generate more alternatives. Involving others in the process
confirms the adage that two heads are better than one. Because everyone thinks uniquely,
increasing the number of people working on a problem increases the number of alternatives
that can be generated.
Brainstorming is another frequently used technique. The goal in brainstorming is to
think of all possible alternatives, even those that may seem “off target.” By not limiting the
possible alternatives to only apparently appropriate ones, people can break through habitual
or repressive thinking patterns and allow new ideas to surface. Although most often used by
groups, people who make decisions alone also may use brainstorming.
LEARNING EXERCISE 1.3
Possible Alternatives in Problem Solving
In the personal-choice scenario presented in Learning Exercise 1.1, some of the following
alternatives could have been generated:
●
●
●
●
●
●
●
●
●
●
Do not take the new position.
Hire a full-time housekeeper, and take the position.
Ask your spouse to quit working.
Have an abortion.
Ask one of the parents to help.
Take the position, and do not hire child care.
Take the position, and hire child care.
Have your spouse reduce the law practice and continue helping with child care.
Ask the supervisor if you can work 4 days a week and still have the position.
Take the position and wait and see what happens after the baby is born.
Assignment: How many of these alternatives did you or your group generate? What alternatives
did you identify that are not included in this list?
Think Logically
During the problem-solving process, one must draw inferences from information. An
inference is part of deductive reasoning. People must carefully think through the information
and the alternatives. Faulty logic at this point may lead to poor-quality decisions. Primarily,
people think illogically in three ways.
Chapter 1
Decision Making, Problem Solving and Critical Thinking
15
1. Overgeneralizing: This type of “crooked” thinking occurs when one believes that
because A has a particular characteristic, every other A also has the same characteristic.
This kind of thinking is exemplified when stereotypical statements are used to justify
arguments and decisions.
2. Affirming the consequences: In this type of illogical thinking, one decides that if B is
good and he or she is doing A, then A must not be good. For example, if a new method
is heralded as the best way to perform a nursing procedure and the nurses on your unit
are not using that technique, it is illogical to assume that the technique currently used
in your unit is wrong or bad.
3. Arguing from analogy: This thinking applies a component that is present in two separate
concepts and then states that because A is present in B, then A and B are alike in all respects.
An example of this would be to argue that because intuition plays a part in clinical and
managerial nursing, then any characteristic present in a good clinical nurse also should
be present in a good nurse-manager. However, this is not necessarily true; a good nursemanager does not necessarily possess all the same skills as a good nurse-clinician.
Various tools have been designed to assist managers with the important task of analysis.
Several of these tools are discussed in this chapter. In analyzing possible solutions, individuals
may want to look at the following questions:
1. What factors can you influence? How can you make the positive factors more important
and minimize the negative factors?
2. What are the financial implications in each alternative? The political implications?
Who else will be affected by the decision and what support is available?
3. What are the weighting factors?
4. What is the best solution?
5. What are the means of evaluation?
6. What are the consequences of each alternative?
Choose and Act Decisively
It is not enough to gather adequate information, think logically, select from among many
alternatives, and be aware of the influence of one’s values. In the final analysis, one must act.
Many individuals delay acting because they do not want to face the consequences of their
choices (e.g., if managers granted all employees’ requests for days off, they would have to
accept the consequences of dealing with short staffing).
Many individuals choose to delay acting because they lack the courage to face the
consequences of their choices.
It may help the reluctant decision maker to remember that even though decisions often have
long-term consequences and far-reaching effects, they are not usually cast in stone. Often,
judgments found to be ineffective or inappropriate can be changed. By later evaluating
decisions, managers can learn more about their abilities and where the problem solving was
faulty. However, decisions must continue to be made, although some are of poor quality,
because through continued decision making, people develop improved decision-making skills.
INDIVIDUAL VARIATIONS IN DECISION MAKING
If each person receives the same information and uses the same scientific approach to solve
problems, an assumption could be made that identical decisions would result. However, in
practice, this is not true. Because decision making involves perceiving and evaluating, and
people perceive by sensation and intuition and evaluate their perception by thinking and
16
UNIT I
THE CRITICAL TRIAD: DECISION MAKING, MANAGEMENT, AND LEADERSHIP
feeling, it is inevitable that individuality plays a part in decision making. Because everyone
has different values and life experiences, and each person perceives and thinks differently,
different decisions may be made given the same set of circumstances. No discussion of
decision making would, therefore, be complete without a careful examination of the role of
the individual in decision making.
Gender
New research suggests that gender may play a role in how individuals make decisions,
although some debate continues as to whether these differences are more gender role based
than gender based. Research does suggest, however, that men and women do have different
structures and wiring in the brain and that men and women may use their brains differently
(Edmonds, 1998–2013). For example, Harvard researchers have found that parts of the frontal
lobe, responsible for problem solving and decision making, and the limbic cortex, responsible
for regulating emotions, are larger in women (Hoag as cited by Edmonds). Men also have
approximately 6.5 times more gray matter in the brain than women, but women have about
10 times more white matter than men (Carey as cited by Edmonds). Researchers believe that
men may think more with their gray matter, while women think more with the white matter.
This use of white matter may allow a woman’s brain to work faster than a man’s (Hotz as
cited by Edmonds).
Values
Individual decisions are based on each person’s value system. No matter how objective
the criteria, value judgments will always play a part in a person’s decision making, either
consciously or subconsciously. The alternatives generated and the final choices are limited by
each person’s value system. For some, certain choices are not possible because of a person’s
beliefs. Because values also influence perceptions, they invariably influence information
gathering, information processing, and final outcome. Values also determine which problems
in one’s personal or professional life will be addressed or ignored.
No matter how objective the criteria, value judgments will always play a part in a person’s
decision making, either consciously or subconsciously.
Life Experience
Each person brings to the decision-making task past experiences that include education
and decision-making experience. The more mature the person and the broader his or her
background, the more alternatives he or she can identify. Each time a new behavior or
decision is observed, that possibility is added to the person’s repertoire of choices.
In addition, people vary in their desire for autonomy, so some nurses may want more
autonomy than others. It is likely that people seeking autonomy may have much more
experience at making decisions than those who fear autonomy. Likewise, having made good
or poor decisions in the past will influence a person’s decision making.
Individual Preference
With all the alternatives a person considers in decision making, one alternative may be
preferred over another. The decision maker, for example, may see certain choices as involving
greater personal risk than others and therefore may choose the safer alternative. Physical,
economic, and emotional risks and time and energy expenditures are types of personal
risk and costs involved in decision making. For example, people with limited finances or a
reduced energy level may decide to select an alternative solution to a problem that would not
have been their first choice had they been able to overcome limited resources.
Chapter 1
Decision Making, Problem Solving and Critical Thinking
17
Brain Hemisphere Dominance and Thinking Styles
Our way of evaluating information and alternatives on which we base our final decision
constitutes a thinking skill. Individuals think differently. Some think systematically—and
are often called analytical thinkers—whereas others think intuitively. It is believed that most
people have either right- or left-brain hemisphere dominance. Analytical, linear, left-brain
thinkers process information differently from creative, intuitive, right-brain thinkers. Leftbrain thinkers are typically better at processing language, logic, numbers, and sequential
ordering while right-brain thinkers excel at nonverbal ideation and holistic synthesizing
(Rigby, Gruver, & Allen, 2009). The end result is that individuals with left-brain dominance do
well in mathematics, reading, planning, and organizing while right-brain dominant individuals
are better at handling images, music, colors, and patterns (Rigby et al., 2009). Although the
authors encourage whole-brain thinking, and studies have shown that people can strengthen
the use of the less dominant side of the brain, most people continue to have a dominant side.
Some researchers, including Nobel Prize winner Roger Sperry, suggest that there
are actually four different thinking styles based on brain dominance. Ned Herrmann, a
researcher in critical thinking and whole-brain methods, also suggested that there are four
brain hemispheres and that decision making varies with brain dominance (12 Manage: The
Executive Fast Track, 2013). For example, Herrmann suggested that individuals with upperleft-brain dominance truly are analytical thinkers who like working with factual data and
numbers. These individuals deal with problems in a logical and rational way. Individuals
with lower-left-brain dominance are highly organized and detail oriented. They prefer a stable
work environment and value safety and security over risk taking.
Individuals with upper-right-brain dominance are big picture thinkers who look for hidden
possibilities and are futuristic in their thinking. They also frequently rely on intuition to solve
problems and are willing to take risks to seek new solutions to problems. Individuals with
lower-right-brain dominance experience facts and problem solve in a more emotional way
than the other three types. They are sympathetic, kinesthetic, and empathetic and focus more
on interpersonal aspects of decision making (12 Manage: The Executive Fast Track, 2013).
In the past, some organizations more openly valued their logical, analytical thinkers but
more recently have recognized that intuitive thinking is also a valuable managerial resource.
Indeed, organizations need all types of thinkers, and in fact, smart leaders will see that teams
are composed of individuals with different types of brain dominance. Rigby et al. (2009,
p. 79) agree, suggesting that when resources are constrained, “the key to growth is pairing
an analytic left-brained thinker with an imaginative right-brain partner.” The right-brained
thinker will be creative in producing innovation, and the left-brained thinker will give the
idea structure so that it can become a reality.
There is no evidence that any one thinking style or that having either right- or left-brain
dominance is better.
LEARNING EXERCISE 1.4
Thinking Styles
In small groups, examine how each individual in the group thinks. Did you have a majority of
individuals with right- or left-brain dominance? Did group members self-identify with one or
more of the four thinking styles noted by Herrmann (12 Manage: The Executive Fast Track,
2013)? Did gender seem to influence thinking style or brain hemisphere dominance? What
types of thinkers were represented in group members’ families? Did most group members view
variances in a positive way?
18
UNIT I
THE CRITICAL TRIAD: DECISION MAKING, MANAGEMENT, AND LEADERSHIP
OVERCOMING INDIVIDUAL VULNERABILITY IN DECISION MAKING
How do people overcome subjectivity in making decisions? This can never be completely
overcome, nor should it. After all, life would be boring if everyone thought alike. However,
managers and leaders must become aware of their own vulnerability and recognize how it
influences and limits the quality of their decision making. Using the following suggestions
will help decrease individual subjectivity and increase objectivity in decision making.
Values
Being confused and unclear about one’s values may affect decision-making ability. Overcoming
a lack of self-awareness through values clarification decreases confusion. People who
understand their personal beliefs and feelings will have a conscious awareness of the values on
which their decisions are based. This awareness is an essential component of decision making
and critical thinking. Therefore, to be successful problem solvers, managers must periodically
examine their values. Values clarification exercises are included in Chapter 7.
Life Experience
It is difficult to overcome inexperience when making decisions. However, a person can do
some things to decrease this area of vulnerability. First, use available resources, including
current research and literature, to gain a fuller understanding of the issues involved. Second,
involve other people, such as experienced colleagues, mentors, trusted friends, and experts,
to act as sounding boards and advisors. Third, analyze decisions later to assess their success.
By evaluating decisions, people learn from mistakes and are able to overcome inexperience.
In addition, novice nurse-leaders of the future may increasingly choose to improve the
quality of their decision making by the use of commercially purchased expert networks—
communities of top thinkers, managers, and scientists—to help them make decisions. Such
network panels are typically made up of researchers, health-care professionals, attorneys, and
industry executives.
Individual Preference
Overcoming this area of vulnerability involves self-awareness, honesty, and risk taking.
The need for self-awareness was discussed previously, but it is not enough to be self-aware;
people also must be honest with themselves about their choices and their preferences for
those choices. In addition, the successful decision maker must take some risks. Nearly
every decision has some element of risk, and most decisions involve consequences and
accountability.
Those who can do the right but unpopular thing and who dare to stand alone will emerge as
leaders.
Individual Ways of Thinking
People making decisions alone are frequently handicapped because they are not able to
understand problems fully or make decisions from both analytical and intuitive perspectives.
However, most organizations include both types of thinkers. Using group process, talking
management problems over with others, and developing whole-brain thinking also are
methods for ensuring that both intuitive and analytical approaches will be used in solving
problems and making decisions. Use of heterogeneous rather than homogeneous groups will
usually result in better-quality decision making. Indeed, learning to think “outside the box”
is often accomplished by including a diverse group of thinkers when solving problems and
making decisions.
Chapter 1
Decision Making, Problem Solving and Critical Thinking
19
Although not all experts agree, many consider the following to be qualities of a successful
decision maker:
Courage: Courage is particularly important and involves the willingness to tak...
Purchase answer to see full
attachment