WU Lewis Change Theory Discussion

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Research one of the three theories (presented in Chapter 18) for planned change and how that process could be applied to a real nursing change situation.

Be sure to apply concepts from the readings and research. You must cite (with reference) at least one source: your textbook, scholarly resources, or ATI textbook (no blogs, Wiki, or other school of nursing website) in current APA Style.


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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...
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Running head: LEWIN’S CHANGE THEORY

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Lewin’s Change Theory

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LEWIN’S CHANGE THEORY

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Change within a nursing environment can be brought about by increasing technology,
workforce shortages, a growing elderly population, rising healthcare costs, and declining
reimbursement. One of the change theories is Lewin’s change theory, which has three driving
phases: unfreezing, movement, and refreezing. An example of a real-life nursing change situation
is the introduction of robotics in healthcare delivery. This is not a simple implemen...

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