Workplace Violence Against Nurses

Effective Leadership and Management in Nursing Ninth Edition

Eleanor J. Sullivan PhD, RN, FAAN

330 Hudson Street, New York, NY 10013

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Library of Congress Cataloging-in-Publication Data

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

1 17

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

About the Author

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

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

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

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

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

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

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

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

—Eleanor J. Sullivan

iii

Thank You

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

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

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

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

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

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

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

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

iv

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

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

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

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

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

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

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

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

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

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

Thank You v

Preface

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

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

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

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

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

Features of the ninth edition include the following:

• Implementation of the Affordable Care Act

• Evolving models of healthcare organizational structures and relationships

• Expanded content on cultural and gender diversity

• Emphasis on quality management

• Addition of emotional leadership concepts

• Use of social media in management

• Harassing, bullying, and lack of civility in healthcare

• Emergency preparedness for terrorism, disasters, and mass shootings

• Prevention of workplace violence

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

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

vi

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

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

• A chapter outline and preview

• A complete audio version of each chapter

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

• Flashcards to self-test knowledge of new vocabulary

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

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

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

• Up-to-date references

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

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

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

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

Preface vii

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

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

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

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

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

• TestGen Test Bank

• Lecture Note PowerPoints

• Instructor’s Resource Manual

viii Preface

Part 1 Understanding Nursing Management and Organizations

1 Introducing Nursing Management 1

2 Designing Organizations 13

3 Delivering Nursing Care 33

4 Leading, Managing, Following 43

5 Initiating and Managing Change 60

6 Managing and Improving Quality 75

7 Understanding Legal and Ethical Issues 94

8 Understanding Power and Politics 110

Part 2 Learning Key Skills in Nursing Management

9 Thinking Critically, Making Decisions, Solving Problems 125

10 Communicating Effectively 145

11 Delegating Successfully 163

12 Building and Managing Teams 178

13 Handling Conflict 198 14 Managing Time 211

Part 3 Managing Resources

15 Budgeting and Managing Fiscal Resources 224

16 Recruiting and Selecting Staff 241

17 Staffing and Scheduling 260

18 Motivating and Developing Staff 271

19 Evaluating Staff Performance 283

20 Feedback and Coaching, Disciplining, and Terminating Staff 296

21 Managing Absenteeism, Reducing Turnover, Retaining Staff 307

22 Dealing with Disruptive Staff Problems 323

23 Preparing for Emergencies 332

24 Preventing Workplace Violence 340

25 Handling Collective Bargaining Issues 349

Part 4 Taking Care of Yourself

26 Managing Stress 356

27 Advancing Your Career 366

Part 5 Looking to the Future

28 Imagining the Future 382

Brief Contents

ix

Acknowledgments

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

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

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

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

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

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

x

Contents

About the Author iii Thank You iv Preface vi

Part 1 Understanding Nursing Management and Organizations

1 Introducing Nursing Management 1

Introduction 2

Changes in Healthcare 2 Paying for Healthcare 2

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

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

Questions to Challenge You 10

References 10

2 Designing Organizations 13 Introduction 14

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

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

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

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

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

Questions to Challenge You 30

References 31

3 Delivering Nursing Care 33 Introduction 34

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

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

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

Questions to Challenge You 41

References 41

4 Leading, Managing, Following 43 Introduction 44

Leaders and Managers 44 Leadership 45

Leadership Theories 45 Traditional Leadership Theories 45 Contemporary Leadership Theories 46

Followership: An Essential Component of Leadership 49

xi

xii Contents

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

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

Tools for Leading, Managing, and Following 57

Questions to Challenge You 58

References 58

5 Initiating and Managing Change 60

Introduction 61

The Nurse as Change Agent 62

Change Theories 62

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

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

Resistance to Change 68

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

Tools for Initiating and Managing Change 73

Questions to Challenge You 73

References 74

6 Managing and Improving Quality 75

Introduction 76

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

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

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

Tools for Managing and Improving Quality 91

Questions to Challenge You 91

References 92

7 Understanding Legal and Ethical Issues 94

Introduction 95

Law and Ethics 95

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

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

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

Employment Issues 107 What You Know Now 108

Questions to Challenge You 109

References 109

8 Understanding Power and Politics 110

Introduction 111

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

Using Power 114 Image as Power 114 Using Power Appropriately 116

Shared Visioning as a Power Tool 117

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

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

Tools for Using Power and Politics 124

Questions to Challenge You 124

References 124

Part 2 Learning Key Skills in Nursing Management

9 Thinking Critically, Making Decisions, Solving Problems 125

Introduction 126

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

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

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

Stumbling Blocks 141 Personality 141 Rigidity 141 Preconceived Ideas 141

Innovation 142 What You Know Now 142

Tools for Making Decisions and Solving Problems 143

Questions to Challenge You 143

References 143

10 Communicating Effectively 145 Introduction 146

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

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

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

Collaborative Communication 157

Enhancing Your Communication Skills 158 What You Know Now 160

Tools for Communicating Effectively 160

Questions to Challenge You 161

References 161

11 Delegating Successfully 163 Introduction 164

Delegation 164

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

The Five Rights of Delegation 166

Contents xiii

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

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

Tools for Delegating Successfully 176

Questions to Challenge You 176

References 177

12 Building and Managing Teams 178

Introduction 179

Groups and Teams 179 Group Interaction 182 Group Leadership 182

Group and Team Processes: Homans Framework 182

Norms 184 Roles 185

Building Teams 186 Assessment 186 Team-building Activities 187

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

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

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

Tools for Building and Managing Teams 196

Questions to Challenge You 196

References 196

13 Handling Conflict 198 Introduction 199 Conflict 199

Interprofessional Conflict 199 Conflict Process Model 200

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

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

Tools for Handling Conflict 209

Questions to Challenge You 209

Resources 209

References 210

14 Managing Time 211 Introduction 211

Time-wasters 212

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

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

Controlling Time in Meetings 221

Respecting Time 222 What You Know Now 222

Tools for Managing Time 222

Questions to Challenge You 223

References 223

Part 3 Managing Resources

15 Budgeting and Managing Fiscal Resources 224

Introduction 225

The Budgeting Process 225 Timetable for the Budgeting Process 227

xiv Contents

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

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

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

The Capital Budget 234

Monitoring and Controlling Budgetary Performance During the Year 234

Variance Analysis 235 Position Control 237

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

Tools for Budgeting and Managing Resources 240

Questions to Challenge You 240

References 240

16 Recruiting and Selecting Staff 241

Introduction 242

The Recruitment and Selection Process 242

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

Selecting Candidates 247

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

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

Legality in Hiring 255 What You Know Now 258

Tools for Recruiting and Selecting Staff 259

Questions to Challenge You 259

References 259

17 Staffing and Scheduling 260 Introduction 261

Staffing 261 Patient Classification Systems 262 Determining Nursing Care Hours 263

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

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

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

Tools for Handling Staffing and Scheduling 269

Questions to Challenge You 270

References 270

18 Motivating and Developing Staff 271

Introduction 272

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

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

Succession Planning 281 What You Know Now 281

Tools for Motivating and Developing Staff 281

Questions to Challenge You 282

References 282

19 Evaluating Staff Performance 283 Introduction 284

Performance Management 284

Contents xv

The Performance Evaluation Process 284 Management Responsibilities 287 Components of the Annual Performance Evaluation 287 Developing Evaluation Tools 288

Methods for Collecting Performance Data 288 Peer Review 288 Self-evaluation 289 Skill Competency 290 Manager’s Evaluation 291

Facing the Challenges of Performance Review 291 Conducting the Annual Performance Review 292

What You Know Now 294

Tools for Evaluating Staff Performance 294

Questions to Challenge You 295

References 295

20 Feedback and Coaching, Disciplining, and Terminating Staff 296

Introduction 297

Feedback 297

Coaching 297

Feedback versus Coaching 299

Confronting Behavior 299

Discipline 299

Termination 303 What You Know Now 305

Tools for Feedback and Coaching, Disciplining and Terminating Staff 305

Questions to Challenge You 305

References 306

21 Managing Absenteeism, Reducing Turnover, Retaining Staff 307

Introduction 308 Absenteeism 308

A Model of Employee Attendance 308 Managing Employee Absenteeism 311 Absenteeism Policies 312 Selecting Employees and Monitoring Absenteeism 313 Family and Medical Leave 313

Reducing Turnover 314 Cost of Nursing Turnover 314 Causes of Turnover 315 Understanding Voluntary Turnover 315

Retaining Staff 316 Job Satisfaction 316 Improving Salaries 317 Retention Strategies 318 What You Know Now 320

Tools for Reducing Turnover, Retaining Staff 320

Questions to Challenge You 321

References 321

22 Dealing with Disruptive Staff Problems 323

Introduction 323

Harassing Behaviors 324 Bullying 324 Lack of Civility 324 Horizontal Violence 325

How to Handle Problem Behaviors 326 Marginal Employees 327 Disgruntled Employees 327

The Employee with a Substance Abuse Problem 327 State Board of Nursing 329 Strategies for Intervention 329 Reentry 330 The Americans with Disabilities Act and Substance Abuse 330 What You Know Now 330

Tools for Managing Staff Problems 331

Questions to Challenge You 331

References 331

23 Preparing for Emergencies 332 Introduction 332

Types of Emergencies 333 Natural Disasters 333 Man-made Disasters 333 Levels of Disasters 334

Hospital Preparedness for Emergencies 334 All-hazards Approach 334 Emergency Operations Plan 334 Surge Capacity 335 Disaster Triage 336 Continuation of Services 336

Staff Utilization in Emergencies 336 What You Know Now 338

Tools for Preparing for Emergencies and Preventing Violence 338

Questions to Challenge You 338

References 339

xvi Contents

24 Preventing Workplace Violence 340

Introduction 340

Violence in Healthcare 341 Incidence of Workplace Violence 341 Horizontal Violence 341 Consequences of Workplace Violence 342 Factors Contributing to Violence in Healthcare 342

Preventing Violence 343 Zero-tolerance Policies 343 Reporting and Education 343 Environmental Controls 343

Dealing with Violence 344 Verbal Intervention 344 A Violent Incident 344 Other Dangerous Incidents 345 Post-incident Follow-up 345 What You Know Now 347

Tools for Preventing Violence 347

Questions to Challenge You 347

References 347

25 Handling Collective Bargaining Issues 349

Introduction 349

Laws Governing Unions 350

Process of Unionization 350

Handling Grievances 351 Unfair Labor Practices 351 The Grievance Process 352

Collective Bargaining and Nurses 352 Legal Issues of Supervision 353 The Future of Collective Bargaining for Nurses 354 What You Know Now 354

Tools for Handling Collective Bargaining Issues 355

Questions to Challenge You 355

References 355

Part 4 Taking Care of Yourself

26 Managing Stress 356 Introduction 356

The Nature of Stress 357

Causes of Stress 358

Organizational Factors 358

Interpersonal Factors 358

Individual Factors 359

Consequences of Stress 360

Managing Stress 361

Personal Methods 361

Organizational Methods 362

What You Know Now 364

Tools for Managing Stress 364

Questions to Challenge You 364

References 365

27 Advancing Your Career 366 Introduction 366

Envisioning Your Future 367

Acquiring Your First Position 367

Applying for the Position 368

The Interview 368

Accepting the Position 373

Declining the Position 373

Progressing in Your Career 373

Tracking Your Progress 375

Identifying Your Learning Needs 376

Finding and Using Mentors 378

Considering Your Next Position 379

Finding Your Next Position 379

Leaving Your Present Position 379

Adapting to Change 380

What You Know Now 380

Tools for Advancing Your Career 381

Questions to Challenge You 381

Online Resources 381

References 381

Part 5 Looking to the Future

28 Imagining the Future 382 Introduction 382

Ways to Consider the Future 383

Possible Future 383

Plausible Future 383

Probable Future 383

Preferable Future 383

Contents xvii

Societal Predictions About the Future 383

The Future of Healthcare 384 Technological Innovations 384 Healthcare Legislation 385 Demands of Consumerism 385

The Future of Nursing 386 Institute of Medicine Recommendations 386 New Careers in Nursing Project 386

What You Know Now 388

Questions to Challenge You 388

References 388

Glossary 390

Credits 398

Index 401

xviii Contents

Chapter 1

Introducing Nursing Management

Learning Outcomes

After completing this chapter, you will be able to:

1. Explain changes to healthcare over the past decade, including those resulting from implementation of the Affordable Care Act; demands to reduce errors and improve patient safety; and evolving medical and communication technology.

2. Describe how nursing management is influenced by changes in society.

3. Identify the changes and challenges that nurses face now and in the future.

Key Terms accountable care organization

(ACO)

Affordable Care Act (ACA)

benchmarking

Centers for Medicare & Medicaid Services (CMS)

electronic health records (EHRs)

evidence-based practice (EBP)

health home

Leapfrog Group

Magnet Recognition Program

Changes in Healthcare Paying for Healthcare

Changes in Society Cultural, Gender, and Generational Differences

Violence, Pandemics, and Disasters

Changes in Nursing’s Future Current Status of Nursing

Institute of Medicine’s Recommendations for Nursing

Adapting to Constant Change

1

2 Chapter 1

medical errors

medical home

Quality and Safety Education for Nurses (QSEN)

quality management

robotics

telehealth

Introduction Today, all nurses are managers. And leaders. And followers. Whether you work in an urgent care center, an ambulatory surgical center, a critical care unit in an acute care hospital, or in hospice care for a home care agency, you interact with staff, including other nurses and unlicensed assistive personnel, who work with you and for you. You must be able to collaborate with others, as a leader, a follower, and a team member. More than ever before, today’s rapidly changing healthcare environment demands highly refined management skills and superb leadership.

Leading at the Bedside: Management Skills You may think you don’t need this text. After all, you’re a staff nurse. You take care of patients in a hospital or clinic. You’re neither a designated manager nor an identified leader.

But you would be wrong. For every plan you make, every time you instruct an

assistant, every interaction with a patient or family member,

you use management skills. Don’t you manage patient safety? Solve problems? Handle conflict? And—my favorite—manage time? These are just a few of the skills you will learn in this text. Good luck!

Changes in Healthcare Healthcare continues to change at a rapid rate. Reimbursement for care, demands for safe care, and evolving technology are affecting every aspect of care. In addition, soci- etal changes, including cultural, gender, and generational differences, as well as an increase in violence, pandemics, and disasters force the healthcare system to adapt quickly. In turn, these changes challenge nursing and nurses to adapt.

Paying for Healthcare In the past, healthcare providers were paid for the amount of care they gave patients. The more care they provided, the more money they received. There was no provi- sion for the effectiveness of that care. Also, if mistakes were made, healthcare orga- nizations were reimbursed for whatever care they provided to ameliorate those mistakes. That system is being replaced by reimbursement for the quality of the care provided and not reimbursing healthcare organizations for the cost of correct- ing mistakes.

AffordAblE CArE ACt Implementation of the Affordable Care Act (ACA) in 2010 radically changed how healthcare is delivered and compensated in the

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United States. Such healthcare reform was desperately needed to fix a system that rewarded more care and discouraged preventive care. In addition, the cost of medical care continued to soar while many Americans lacked access to basic care (Centers for Medicare & Medicaid Services [CMS], 2015). Although the ACA has undergone numerous court challenges that remain unsettled, implementation is proceeding.

The ACA was designed to provide quality, affordable healthcare for all Ameri- cans (Emanuel, 2015). Its emphasis is on preventing disease and coordinating care, and it provides mechanisms for the uninsured to acquire health insurance by enrolling in state or federal exchanges of health insurance companies (Blumenthal & Collins, 2014). Through incentives and penalties, the ACA encourages health- care organizations to establish accountable care organizations (ACO), consisting of hospitals and healthcare providers who agree to provide care to a designated population.

Also changed is how primary care providers offer care via a health home (previ- ously called a medical home) (U.S. Department of Health and Human Services, 2015a). Instead of serving as gatekeepers to specialty care in order to contain costs, primary care providers facilitate access to specialty care when needed and monitor that care using electronic health records (Russell, 2014). Regular follow-ups by care providers monitor chronic health conditions and reinforce treatment regimens. Patients, too, have access to their medical records and are encouraged to participate in decisions about their care.

Whether the ACA will remain as it is, be changed by legislation, or be repealed entirely remains to be seen. What is apparent, however, is that access, cost, and quality of care will continue to concern providers, insurers, state and federal gov- ernments, and the American people.

COSt Of MEdiCAL ERRORS Another factor affecting the healthcare system is the cost of medical errors (Andel, Davidow, Hollander, & Moreno, 2012). Since the Insti- tute of Medicine (IOM) reported that 98,000 deaths occur each year from preventable medical mistakes (Institute of Medicine, 1999), both healthcare providers and insur- ers have mounted efforts to prevent such errors, including falls, wrong site surgeries, avoidable infections, pressure ulcers, and adverse drug events. In spite of numerous efforts to prevent mistakes, the cost of medical errors has continued to climb. In addi- tion to loss of life or diminished quality of life, actual dollar estimates put such costs at $17.1 billion annually (Den Bos et al., 2011).

To incentivize hospitals to reduce medical mistakes, the Centers for Medicare & Medicaid Services (CMS), the agency that oversees government payments for care, changed its reimbursement policy to no longer cover costs incurred by medical mis- takes. If medical mistakes occur, the hospital must absorb the costs. Thus, pay for per- formance became the norm, and performance is now measured by the quality of care (Milstein, 2009).

dEMANd fOR QuALity In an effort to ameliorate medical mistakes, a number of quality initiatives have emerged. These include quality management, the Leapfrog Group, benchmarking, evidence-based practice, the Magnet Recognition Program, and Quality and Safety Education for Nurses.

Quality Management. Quality management is a preventive approach designed to address problems before they become crises. Although quality management was

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originally designed for manufacturing, the healthcare industry has adopted various quality management strategies from the airline industry and other fields. Good man- agement techniques can often be transferred from one use to another.

Leapfrog Group. The Leapfrog Group is a consortium of public and private pur- chasers that uses its mammoth purchasing power by rewarding healthcare organi- zations that demonstrate quality outcome measures. Today, the Leapfrog Group compares hospitals’ performance on preventing errors, accidents, injuries, and infections. In 2014, the Leapfrog Group assessed 1,501 hospitals (Leapfrog Group, 2015).

Benchmarking. Benchmarking is a comparison of an organization’s data with simi- lar organizations. Outcome indicators are compared across disciplines or organiza- tions. Once the results are known, healthcare organizations can address areas of weakness and enhance areas of strength (Nolte, 2011).

Evidence-based Practice. Evidence-based practice (EBP) has emerged as a strat- egy to improve quality by using the best available knowledge integrated with clini- cal experience and the patient’s values and preferences to provide care (Houser & Oman, 2010).

Similar to the nursing process, the steps in EBP are as follows:

1. Identify the clinical question.

2. Acquire the evidence to answer the question.

3. Evaluate the evidence.

4. Apply the evidence.

5. Assess the outcome.

Research findings with conflicting results puzzle consumers daily, and nurses are no exception, especially when they search for practice evidence. Hader (2010) suggests that evidence falls into several categories:

• Anecdotal—derived from experience

• Testimonial—reported by an expert in the field

• Statistical—built from a scientific approach

• Case study—an in-depth analysis used to translate to other clinical situations

• Nonexperimental design research—gathering factors related to a clinical condition

• Quasi-experimental design research—a study limited to one group of subjects

• Randomized control trial—uses both experimental and control groups to deter- mine the effectiveness of an intervention

While all forms of evidence are useful for clinical decision making, randomized control design and statistical evidence are the most rigorous (Hader, 2010).

Magnet Recognition Program. More than 25 years ago, the Magnet Recognition Pro- gram was designed to recognize excellence in nursing. The purpose was to improve patient care by focusing on nurses’ qualifications, work life, and participation within the organization. The program designated 14 factors that indicated a culture of

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excellence, resulting in an environment for quality patient care. Institutions that met the stringent guidelines for nurses were credentialed by the American Nurses Creden- tialing Center (ANCC) as Magnet-certified hospitals.

In 2007, the Magnet program was redesigned to provide a framework for the future of nursing practice and education (American Nurses Credentialing Center, 2008). To focus on outcome measures, the 14 factors from the original program were reconfigured into five components:

• Transformational leadership

• Structural components

• Exemplary professional practice

• New knowledge, innovations, and improvement

• Empirical outcomes

Magnet hospitals are those organizations that are recognized for “quality patient care, nursing excellence and innovations in professional nursing practice.” (American Nurses Credentialing Center, 2016). To qualify for recognition as a Magnet hospital, the organization must demonstrate that they are achieving the following:

• Promoting quality in a setting that supports professional practice

• Identifying excellence in the delivery of nursing services to patients/residents

• Disseminating “best practices” in nursing services (ANCC, 2015)

In 2013, the US News Best Hospitals in America Honor Roll included 15 medical centers of the 18 recognized as holding Magnet certification (ANCC, 2015).

Quality and Safety Education for Nurses. Based on recommendations of the Institute of Medicine (IOM, 2003), a national advisory board of experts developed quality and safety competencies, designating targets of knowledge, skills, and attitudes (KSAs) for nursing education known as Quality and Safety Education for Nurses (QSEN; Cronenwett et al., 2007).

The six prelicensure KSAs are as follows:

• Patient-centered care

• Teamwork and collaboration

• Evidence-based practice

• Quality improvement

• Safety

• Informatics (Quality and Safety Education for Nurses Institute, 2015)

These competencies are being used as guides for nursing education, to assist nurses transitioning to practice, and for nurses continued lifelong learning (Amer, 2013).

EvOLviNG tECHNOLOGy Rapid changes in technology seem, at times, to over- whelm us. Hospital information systems (HIS); electronic health records (EHRs); com- puterized physician/provider point-of-care data entry (CPOE); barcode medication administration; dashboards to manage, report, and compare data across platforms; telehealth provided from a distance; and robotics—to name a few of the many

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evolving technologies—both fascinate and frighten us simultaneously. At the same time, communication technology—from smartphones to social media—continues to march into the future. It is no wonder that people who work in healthcare complain that they can’t keep up! The rapidity of technological change promises to continue unabated (Huston, 2013).

Electronic Health Records. Electronic health records (EHRs) reduce redundancies, improve efficiency, decrease medical errors, and lower healthcare costs. Continuity of care, discharge planning and follow-up, ambulatory care collaboration, and patient safety are just a few of the additional advantages of EHRs. Furthermore, fully inte- grated systems allow for collective data analysis across clinical conditions and between and among healthcare organizations, and they support evidence-based decision making. Federal incentives (e.g., reimbursement and grants) encourage the expanded use of EHRs, which is expected to continue (Amer, 2013).

Telehealth. telehealth has evolved as technologies to assess, intervene, and moni- tor patients remotely continue to improve. The technology to diagnose and treat patients from a distance, along with patient-accessible EHRs and mobile devices such as smartphones, enables providers to interact with patients regardless of their location.

Nurses, for example, can watch banks of video screens miles away from the hospi- tal monitoring ICU patients’ vital signs. Electronic equipment, such as a stethoscope, can be accessed by a healthcare provider in a distant location. Such systems are espe- cially useful in providing expert consultation for specialty care (Zapatochny-Rufo, 2010). This technology, too, is expected to grow (Amer, 2013).

Robotics. Another technological advance is robotics. In the hospital, supplies can be ordered electronically. Next, laser-guided robots fill orders in the pharmacy or central supply and deliver them to nursing units via dedicated elevators—and do so more efficiently, accurately, and in less time than individuals can. Robot functionality will continue to expand, limited only by resources and ingenuity.

Communication Technology. Communication technologies are evolving just as rap- idly as clinical and data technology, changing forever the ways people keep informed and interact (Sullivan, 2013). Information (accurate or inaccurate) is disseminated with lightning speed, while smartphones capture real-time events and broadcast images instantaneously.

Social media have revolutionized communication beyond the realm of possibili- ties of just a few years ago. Social media connect diverse populations and encourage collaboration by way of the exchange of images, ideas, and opinions in online forums, blogs, wikis, podcasts, RSS feeds, Instagram, Pinterest, YouTube, Twitter, Facebook, and LinkedIn, among others (Sullivan, 2013).

Like other enterprises, most healthcare organizations maintain a website as well as a presence on social media sites such as Facebook, Twitter, and blogs. Units within the organization may maintain Facebook pages as well, with staff designated to post on those sites. These opportunities for information sharing and relationship building also come with risks. Patient confidentiality, the organization’s reputa- tion, and recruiting efforts can be enhanced or put in jeopardy by posts to the site (Sullivan, 2013).

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Changes in Society Societal change is occurring as rapidly as healthcare is changing. Changes include dif- ferences in the composition of today’s population, including the nursing population, as well as demands on the healthcare system resulting from increasing violence, threats of pandemics, and challenges of potential disasters.

Cultural, Gender, and Generational Differences The population mix in the United States, the number of men entering nursing, and the average age of practicing nurses all affect nursing. All require nursing to adjust and adapt.

CuLtuRAL diffERENCES According to the U.S. Census Bureau (2013), the minority population in the United States is projected to rise to 56% of the total by 2060, compared with 38% in 2014 (U.S. Census, 2015). This includes Hispanic, Asian, and African American populations, but the fastest growing minority group in the United States are people who identify themselves as two or more races (U.S. Cen- sus, 2015). In addition, the recognition that lesbian, gay, bisexual, and transgender (LGBT) populations are part of communities across the United States challenges healthcare providers to offer appropriate care and services (Budden, Zhong, Moulton, & Cimiotti, 2013).

The nursing profession, however, does not reflect the cultural diversity seen in the general population. A 2013 survey of registered nurses found that only 17% are minor- ities (Budden et al., 2013). Efforts to increase diversity in nursing are recommended (IOM, 2010).

GENdER diffERENCES The gender mix found in nursing also differs from the gen- eral population, with men greatly outnumbered by women. While only 7% of the nursing population is male, only 5% in the profession were male in 2000 (Budden et al., 2013). Cultural and gender diversity challenge nurses to consider such differences when working with staff, colleagues, and administrators as well as mediating conflicts between individuals.

GENERAtiONAL diffERENCES Generational differences in the nursing popula- tion challenge interactions and relationships between workers and patients alike. Three generational cohorts (baby boomers, generation X, and generation Y) are cur- rently working together (Keepnews, Brewer, Kovner, & Shin, 2010) and a fourth (gen- eration Z) will soon join them (Levit, 2015).

Each generational group has different expectations in the workplace. Baby boomers value professional and personal growth and expect that their work will make a difference. Generation X members strive to balance work with family life and believe that they are not rewarded given their responsibilities. Generation Y (also called millennials) are technically savvy and expect immediate access to infor- mation electronically. Generation Z, born in the mid-1990s to early 2000s, will soon graduate and join their older coworkers. Generation Z members are curious, pas- sionate, and diverse, and willing to pursue nontraditional options in their futures (Levit, 2015).

The challenge for nurses in dealing with different generations is similar to that of dealing with cultural and gender differences: to avoid stereotyping within the

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generations, to value the unique contributions of each generation, to encourage mutual respect for differences, and to leverage these differences to enhance team work (Murray, 2013).

Violence, Pandemics, and Disasters Sadly, violence invades today’s workplaces, and healthcare is no exception. Verbal threats, physical attacks, and violent assaults can and do occur in healthcare set- tings (Papa & Venella, 2013). As those who work closely with patients, nurses are vulnerable to attack from patients, family members, coworkers, or others. To reduce the incidence and impact of workplace violence, the organization must establish clear guidelines to prevent it, and staff must be adequately trained to respond to incidents of violence.

A pandemic is a disease outbreak that spreads rapidly, usually because the infecting virus is new, and humans have little or no immunity to it. The H1N1 virus of 2009 is an example (U.S. Department of Health and Human Services, 2015b). Pan- demics are public health emergencies that require healthcare organizations to have in place the necessary protocols to respond rapidly in the event of a pandemic (Fineberg, 2014).

Both natural and human-caused disasters have increased in recent years and require healthcare organizations to prepare for the influx of mass casualties that may occur. Natural disasters, such as earthquakes, floods, and tornadoes, may damage not only communities but hospitals as well (e.g., the 2012 tornado in Joplin, Missouri). Human-caused disasters may occur accidentally (e.g., industrial accidents, bridge collapses, power outages), but intentional harm from acts of terrorism are unfortu- nately common today. All hospitals and other healthcare organizations must have emergency plans in place and have staff adequately trained to respond to these all-too- common events.

Changes in Nursing’s Future As healthcare organizations are restructuring to implement the ACA, scrambling to improve outcomes to meet safety and quality benchmarks, and struggling to adapt to constantly evolving technology, nurses ask, “What does this mean for our future?”

Current Status of Nursing Slightly more than 3 million nurses are currently licensed as registered nurses in the United States, with 2.6 million practicing in the profession (U.S. Bureau of Labor Sta- tistics, 2014). To meet both anticipated increases in population and an aging populace (U.S. Census Bureau, 2015), more than 500,000 additional nurses will be needed by 2022 (U S. Bureau of Labor Statistics, 2014). Unfortunately, as the population ages, nurses, too, are growing older (Budden et al., 2013). The average age of nurses practic- ing today is 50 years or older, up from 45 a few years ago (Health Resources and Ser- vices Administration [HRSA], 2013).

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Institute of Medicine’s Recommendations for Nursing The IOM’s report on the future of nursing makes sweeping recommendations for the profession, including that “nurses should be full partners, with physicians and other healthcare professionals, in redesigning healthcare in the United States” (IOM, 2010, p. 3). Also, the IOM posits that today’s healthcare environment necessitates better- educated nurses and recommends that 80% of nurses be prepared at the baccalaureate or higher level by 2020.

In addition, the report recommends that barriers limiting the scope of practice for advanced practice nurses be eliminated, and that racial, ethnic, and gender diversity among the nursing workforce should be increased to better care for a diverse patient population. While nurses are consistently ranked as the most trusted profession in the United States (Gallup, 2014), few nurses hold positions of leadership in healthcare, and the IOM recommends an increase in their numbers. Progress on meeting the recommen- dations of the IOM report is substantial and ongoing (Hassmiller & Reinhard, 2015).

Adapting to Constant Change What does the future hold for nursing? Change is the one constant! The challenge for nurses is how to manage in this continually fluctuating system.

Nurses are charged with monitoring and improving the safety and quality of care, managing with limited resources, participating in organizational decision making, working with teams of professionals and nonprofessionals from various generations and cultures, adapting to technological advances, and preparing for constant environ- mental changes. This is no small task. It requires that nurses be committed, involved, enthusiastic, flexible, and innovative; above all else, it requires that they have good mental and physical health. The nurse of today must be a coach, a teacher, and a facili- tator. Most of all, the nurse must be able to live with ambiguity and be flexible enough to adapt to the changes it brings.

That is a tall order, but nurses are up to the challenge. This text is designed to pre- pare you to meet that challenge.

What You Know Now • The Affordable Care Act, which may be changed

or repealed, altered how healthcare is provided and compensated.

• Reducing medical errors is a priority, and organi- zations are scrambling to achieve outcomes better than benchmarks.

• The Magnet Recognition Program certifies hospi- tals that meet rigorous standards and provide excellent nursing.

• Electronic health records, robotics, and telehealth are just a few of the many technologies continu- ing to evolve.