“I need help on the night shift!”
After completing this chapter, you should be able to:
• Differentiate between management and leadership.
• Describe theories of management and leadership.
• List characteristics of an effective manager and an influential leader.
• Discuss the elements of transformational leadership.
• Identify distinguishing generational characteristics of today’s workforce.
• Differentiate between leadership and followership.
• Differentiate the concepts of power and authority.
• Apply problem-solving strategies to clinical management situations.
• Identify the characteristics of effective work groups.
• Discuss the change process.
• Discuss the value of using evidence-based management actions.
As you move closer to meeting your goal of becoming a graduate nurse, give consideration to understanding the role of the nurse as a manager and as a leader. You might be thinking:
I do not want to be a manager; I am just a recent graduate!
I want to take care of patients, not be a paper pusher!
Am I ready to be followed by others?
Nursing, in any role, is a people business. Management is the process of effectively working with people. When you accept your first position as a graduate nurse, it is important to realize that you are becoming a part of a work group where members spend at least a third of their day interacting with each other. Therefore, registered nurses must be prepared to use varying levels of management skills, enhanced by interpersonal, followership, and leadership skills, to be effective in their role as a provider of patient care and as member of the care team.
There are multiple levels of management that a registered nurse can practice. The specific level depends on the experience, competency, and defined role of the individual nurse. For example, as a recent graduate, you will have primary management responsibility for the patients for whom you will be providing care. This will include planning and coordinating the care with other nursing personnel, with health care staff, and with the patient and family members. Provision of this level of management is expected from all registered nurses who practice in the acute-care environment.
Management Versus Leadership
What Is the Difference Between Management and Leadership?
Although the terms management and leadership are frequently interchanged, they do not have the same meaning. A leader selects and assumes the role; a manager is assigned or appointed to the role. Leaders are effective at influencing others; managers, as providers of care, supervise a team of people who are working to help patients achieve their defined outcomes. Managers also have responsibility for organizational goals and the performance of organizational tasks such as budget preparation and scheduling. Although it is desirable for managers to be good leaders, there are leaders who are not managers and, more frequently, managers who are not leaders! So, let us discuss the actual differences in more detail.
The Functions of Management
Management is a problem-oriented process with similarities to the nursing process. Management is needed whenever two or more individuals work together toward a common goal. The manager coordinates the activities of the group to maintain balance and direction. There are generally four functions the manager performs: planning (what is to be done), organizing (how it is to be done), directing (who is to do it), and controlling (when and how it is done). All of these activities occur continuously and simultaneously, with the percentage of time spent on each activity varying with the level of the manager, the characteristics of the group being managed, and the nature of the problem and goal.
According to Rothbauer-Wanish (2009), planning is generally considered a basic management function and one on which managers should spend a significant part of their time. The foundation for all planning begins with the development of goals that reflect the mission and vision of the organization and defining strategies that will be implemented to meet and maintain that mission and vision. The next level of planning is used daily as a part of determining the requirements for accomplishing the work to be done and ensuring that what is needed is available. This planning must be congruent with the strategies for meeting the mission and vision of the organization. Along with this approach, a manager must also be able to plan for contingencies, which, if not addressed, will interfere with accomplishing what needs to be done. When managing a patient-care unit, which needs specific resources 24 hours a day, one can be certain that the unexpected will happen. Being prepared for the unexpected is a key function of a nurse manager.
Staff nurses practice the elements of planning as the plans of care for each patient are developed. For this process, the patient’s current status and goals are assessed to determine what needs to occur during the time one is assigned to provide that care. The interventions needed are selected to advance the patient to the point of meeting his or her defined goals. This process of management of patient care uses the same planning skills as those used by someone who has the responsibility of managing staff.
Organizing occurs as the manager aligns the work to be done with the resources available to do that work (Rothbauer-Wanish, 2009). This requires knowledge of all parts of the work, as well as a clear understanding of the competencies required of those who will be performing the assigned work. The manager must consider not only the licensing regulations but also the facility’s policies when organizing the assignment of work. For example, licensing regulations may allow a licensed practical nurse to administer defined intravenous medications, but the facility policy may not allow that level of employee to perform that procedure. Another example would be that the licensing regulations for registered nurses do not specify that a newly licensed nurse cannot be assigned to work in a critical care unit. However, facility policy may state that registered nurses who wish to work in a critical care unit must gain 1 year of other experience before being assigned to critical care service. Knowing this information prevents the manager from making decisions that may be unacceptable.
The next phase of management is providing direction or supervision. The manager retains accountability for ensuring the work is completed in a timely and competent manner. Additionally, staff members need to complete assigned work according to standards, policies, and procedures with the understanding that the manager will provide sufficient observation and assessment of care being delivered to ensure that the care provided is safe and complete. When patient care falls below minimum standards, the manager has two actions to take. The first is to make certain the care and safety of the patient are addressed by ensuring the proper care is provided, and the second is to address the performance of the staff who did not provide the care as assigned. Managers need to be able to make decisions regarding the level of supervision needed by each staff member. Managers must also be able to motivate staff toward reaching their full competence to perform the assigned work with minimal observation and direction.
Staff nurses who are managing the care of patients need to have a clear understanding of the relevant policies and procedures related to the care provided and must be confident that he or she is competent to provide that care. The staff nurse must be cognizant of the expected outcomes of the care to be provided and how to determine if progress toward those outcomes is occurring. Actions to take when outcomes are not being met must be understood by the staff nurse who is managing the care.
Controlling is the last aspect of the planning function of the nurse manager. Most of the controls in health care facilities exist because health care is a highly regulated system, and much of what must be done is dictated by governments, insurers, evaluating agencies, health policy, and institutional policy. The effective manager needs to be cognizant of the regulations that affect his or her area of practice and must be able to clearly communicate the essence of these regulations to the staff. Staff members need to have a thorough understanding of regulations and implications of noncompliance with these regulations. An example of external controls imposed because of regulations is the elimination of the use of certain dangerous abbreviations when a physician writes a medication order (see Chapter 11 for a list of abbreviations). This regulation is a part of The Joint Commission (TJC) Standards, as well as Standards from the Centers for Medicare & Medicaid Services (CMS). Although the initial focus of this regulation is on the physician, registered nurses may not implement an order that includes these eliminated abbreviations.
Control by the manager may also be demonstrated through data collected when reviewing quality of care to determine the level of compliance with standards and other quality monitors. These data give the manager the ability to validate observations, because these observations can represent the outcomes of care that has been provided. For instance, if the rate of hospital-acquired infections continues to be above the expected level, the manager has the information needed to implement and mandate interventions to reduce the number of infections.
What Are the Characteristics and Theories of Management?
Active interest in management as a separate entity was first noted as part of the industrial revolution. The traditional theory developed at that time was based on the premise that there was a need to have the highest productivity level possible from each worker (Wertheim, n.d.). This theory is the basis for the hierarchy that has dominated much of management theory for almost two centuries. This type of management is also known as the bureaucratic theory of management, defined as “dividing organizations into hierarchies, establishing strong lines of authority and control. He [Weber, the author of this theory] suggested organizations develop comprehensive and detailed standard operating procedures for all routinized tasks” (McNamara, n.d.). The manager who functions under the traditional theory follows rules closely and understands the concept of the division of labor and the chain-of-command structure. Historically, this kind of functioning was thought to be efficient and clear and was considered necessary to attain the most work from each employee. Throughout nursing history, this has been the theory on which the work of nurse managers was based. Since the mid-1990s, movement from this traditional theory has occurred, and more appropriate theories have been put into practice in multiple health care settings across the country.
Following the development of traditional theory of management was behavioral theory (also called human-interaction theory). This evolved as it became more evident that the humanistic side of management needed to be addressed (Hellriegel et al., 1999). Employees seeking recourse from some of the rules of hierarchy looked for assistance outside of their place of work, for instance, in the growing labor unions. Employers recognized the need to consider the human side of productivity so as to maintain a stable, satisfied work force.
This was followed by the introduction of systems theory, which considers inputs, transformation of the material, outputs, and feedback (Hellriegel et al., 1999). Systems theory is implemented when consideration is given to the impact of decisions made by one manager on other managers or on parts of the system as a whole. This is important in health care, because it helped management move from making decisions in the traditional manner, in which departments functioned as though they were independent, to recognizing the interdependence of departments on each other. Recognizing that patients cannot be treated as though they are a number of separate and distinct parts has promoted the understanding and importance of systems theory. Whereas behavioral theory as it relates to management considers the attitudes and needs of the employee, systems theory examines the possible outcomes of all individuals affected by a decision.
The last theory of management to be considered is the contingency theory, which is also referred to as the motivational theory (Hellriegel et al., 1999). This theory focuses on the manager being able to blend the elements of the earlier theories, using those elements to determine what motivates people to make choices and leading to the most effective methods to complete the work that needs to be done. All of these theories are directed toward ways to ensure that employees are as productive and timely as possible when working to meet the organizational goals or targets.
What Is Meant by Management Style?
You will experience a variety of management styles in your nursing practice. These styles follow a continuum from autocratic to laissez-faire (Fig. 10.1).
The autocratic manager uses an authoritarian approach to direct the activities of others. This individual makes most of the decisions alone without input from other staff members. Under this style of management, the emphasis is on the tasks to be done, with less focus on the individual staff members who perform the tasks. The autocratic manager may be most effective in crisis situations when structure and control are critical to success, such as during a cardiac arrest or code situation. In general, however, the autocratic manager will have a difficult time in motivating staff to become part of a satisfactory work environment, because there is minimal recognition of the contributions of staff to the work that needs to be done and minimal focus on the necessary relationships that make up the successful health care team. Many individuals, particularly those from generations after the Baby Boomers, will not stay in a position in which autocracy is the major style of management.
On the other end of the continuum is the laissez-faire manager, who maintains a permissive climate with little direction or control exerted. This manager allows staff members to make and implement decisions independently and relinquishes most of his or her power and responsibility to them. Although this style of management may be effective in highly motivated groups, it may not be effective in a bureaucratic health care setting that requires many different individuals and groups to interact.
In the middle of the continuum is the democratic manager. This manager is people-oriented and emphasizes effective group functioning. The goals of the group are identified, and the manager is perceived as a group member who is also its organizer who keeps the group moving in the defined direction. The environment is open, and communication flows both ways. The democratic manager encourages participation in decision making; he or she recognizes, however, that there are situations in which such participation may not be appropriate, and the manager is willing to assume responsibility for a decision when necessary. The democratic style is the blend of autocracy and laissez-faire with assurances that the extreme ends of the continuum are rarely, if ever, necessary.
One example of a democratic manager following either the behavioral or contingency theory would be a manager who creates a Nurse Practice Committee on his or her unit. This committee would have some defined authority and responsibility to address specific items in the practice environment, such as schedules and practices on the unit. This type of committee supports the idea that staff and management are interdependent in governing the successful practice environment (Tonges et al., 2004).
To be a successful manager in today’s hierarchical organizations, the nurse manager will need to adopt a democratic style of management, one that is flexible enough to adapt to the changing roles of nursing staff. The nurse manager should be willing and able to share power with the same people whom he or she will supervise. The successful manager will also need to acquire an element of laissez-faire style for those components of governance that will be under the auspices of the staff. It will be important for staff nurses to develop a balanced combination of autocracy and laissez-faire as they implement shared governance (stakeholder participation in decision making) that will include quality of care and peer review (Institute of Medicine, 2004).
As is evident, the continuum of management styles ranges from what might be considered total control to complete freedom for subordinates. In choosing a management style, the manager must decide on levels of control and freedom and then determine which trade-offs are acceptable in each situation. Behaviors vary from telling others what to do, to relinquishing to another group within the organization the authority for portions of the work to be done. As a new staff nurse, your initial involvement in management occurs when you manage the care of a group of patients. The next involvement may be as a part of the shared governance model that may be developing in your facility. As you gain experience and knowledge, it is important for you to develop an understanding of which style you should use, depending on what you hope to be able to achieve.
Leadership, in contrast, is a way of behaving; it is the ability to cause others to respond, not because they have to but because they want to. Leadership is needed as much as management for effective group functioning, but each role has its place. The manager determines the agenda, sets time limits, and facilitates group functioning. The leader “models change, establishes trust, sets the pace, creates the vision, [provides] focus, and builds commitment” (Manion, 1996, p.148).
What Are the Characteristics and Theories of Leadership?
The many attempts to define what makes a good leader have resulted in a variety of studies and proposals. Researchers have tried to identify the characteristics or traits necessary to be a good leader. Several of these studies have defined the concept of a born leader, implying that the desired traits are inherited. This is often referred to as the “Great Man” theory, because it was first identified when leadership was generally thought to be a male quality, particularly as it related to military leadership (Van Wagner, 2007). With later research, it became clear that desired leadership traits could be learned through education and experience. It also became clear that the most effective leadership style for one situation was not necessarily the most effective for another and that the effectiveness of the leader is influenced by the situation itself. As leadership theories continue to develop, emphasis is more on what the leader does rather than on the traits the leader possesses.
Several other theories of leadership are worth discussing. The first is contingency leadership, which says that leadership should be flexible enough to address varying situations. Although this may sound complicated, it can be compared with your approach to patient care. As a nurse, you individualize a patient care plan based on the needs of the individual. Then the plan is implemented using available resources. The effective leader, using contingency leadership, brings the same flexible approach to each individual situation where leadership is required.
Situational leadership theory resulted from the study of the contingency theory. Under situational leadership theory, the leader attempts to function more closely in the situation being addressed. Blanchard and Hersey (1964) define the situational leader as one who analyzes the needs of the current situation and then selects the most appropriate leadership style to address that particular situation. The selected style depends on the competencies of each employee who will be helping address the current situation. The authors state that a good situational leader may use different styles of leadership for different employees, all of whom are involved in addressing the same situation. This is not unlike what you, as a team leader, will be doing when assigning work to members of your work team. The assignments will need to be individualized based on the competencies of each member of the team to help ensure the patient-care goals can be met.
Interactional leadership is the next theory to consider. With this theory, the focus is on the development of trust in the relationship (Marquis & Huston, 2003). Interactional leadership includes concepts of behavioral theories, which begin to address the theory that leaders are made and not born, because the needed behaviors can be taught and learned. Individuals who function based on the theory of interactional leadership use democratic concepts of management and view the tasks to be accomplished from the standpoint of a team member.
Leadership theory can also be described as transactional, noting that the transactional leader is one who has a greater focus on vision, defined as the ability to envision some future state and describe it to others so they can begin to share that vision. The transactional leader holds power and control over followers by providing incentives when the followers respond in a positive way to the leader’s vision and the actions needed to reach that vision. The basis for the relationship between leader and follower is that punishment and reward motivate people. Transactional leaders seek equilibrium so the vision can be reached and he or she only intervenes when it appears that goals will not be attained (Sullivan & Decker, 2012).
This leadership theory does not sound like one that many would be encouraged to embrace or follow, as the rewards are ultimately one-sided. However, the transactional approach to leadership still exists in most organizations, generally at the management level as incentives are provided to gain a defined level of productivity. One may believe that this approach is closer to management than leadership, which may explain why it might not be effective at other levels in the organization.
Transformational leadership occurs when the leader has a strong, clear vision that has developed through listening, observing, analyzing, and finally by truly buying into the vision to change dramatically the way things are currently done (Bass, 1990). This theory was introduced as early as the 1970s and is still in its infancy of use by particular industries such as health care. However, this theory of leadership is a “major component of the Magnet model developed by the American Nurses Credentialing Center” (Sherman, 2012, p.62).
According to Sherman (2012), there are four key elements that characterize the transformational leadership style. The first element is idealized influence, meaning that the transformational leader is a “role model for outstanding practices which in turn inspires followers to practice at this same level.” Inspirational motivation, the second element, is demonstrated by the leader being able to “communicate a vision” in a manner that others understand. Intellectual stimulation and individual consideration are the last two elements and address the fact that the leader values staff input and creativity while continuing to coach and mentor staff, recognizing there are both group and individual needs and issues to consider (Sherman, 2012, p.64).
Characteristics of transformational leaders, according to Tichy and Devanna (1986), are that these leaders are courageous change agents who believe people will do what is right when provided direction, information, and support. They are also value-driven visionaries, lifelong learners, and individuals who can successfully handle the complexities of leadership. To accomplish their goals, they effectively change the traditional way of leading, which is often from the office, to leading from the place where the action is occurring.
Transformational leadership will be implemented when it is clear to the strong, visionary leaders that the current situation(s) cannot be “fixed” using the traditional methods that have worked in the past. In the early 1990s, Leland Kaiser, a renowned health care futurist, discussed transformational leadership, identifying the transformational leader as the primary architect of life in the 21st century. Many of the predictions made by Kaiser are now being recognized as part of transformational leadership. An example of this is what has occurred at Virginia Mason Medical Center, as the leadership of that organization took on the task of transforming health care at that facility (Kenney, 2011). The entire leadership team has worked together to ensure that this transformation occurred as envisioned.
If transactional leadership involves the use of leadership power over rewards and punishments, transformational leadership can be characterized as a process whereby leader and followers work together in a way that changes or transforms the organization, the employees/followers, and the leader. It recognizes that real leadership involves transformation and learning on the part of follower and leader. As such, it is more like a partnership, even though there are power imbalances involved.
Whereas transactional leadership involves telling, commanding, or ordering (and using contingent rewards), transformational leadership is based on inspiring, getting followers to buy in voluntarily, and creating common vision. Transformational leadership is what most of us refer to when we talk about great leaders in our lives and in society.
The nurse shortage is a good example of a problem in which the solution will most likely be found by transformational leaders. It is evident that the old ways of fixing the nurse shortage have not been effective. Managers, lawmakers, and organizations have tried increasing wages, paying bonuses, recruiting foreign nurses, mandating staff-to-patient ratios, adding nurse-extenders, and implementing flexible shifts. None of these methods has had any long-lasting effects, because they do not address the conflicts that have occurred as newer generations of nurses have reached the level where they want control of their practice as granted by education and licensure. A transformational leader understands the basis for these conflicts and develops a vision, which will address the needs of the people involved in the conflict.
One might anticipate that the Chief Executive Officer and the Chief Nursing Officer of a hospital would both be transformational leaders. These leaders have a responsibility to see the bigger picture and to be able to describe that vision or picture to others. Porter-O’Grady (2003a) describes this type of leader as one who can “stand on the balcony” (p.175). From this position, the leader can monitor the ebb and flow of the organization and determine in which direction the organization is moving. To be effective, the transformational leader must have a vision that can be put into words for others to understand. Check out the relevant websites and online resources at the end of the chapter for additional information on transformational leadership.
Although most leaders tend to lean toward one of the theories discussed here, fluctuations from one to another can occur, depending on the particular situation. In the health care setting, good leaders carefully balance job-centered and employee-centered behaviors to meet both staff and patient needs effectively (Critical Thinking Box 10.1).
An effective leader works toward established goals and has a sense of purpose and direction. She or he must also be aware of how her or his behavior impacts the workplace. Emotions, moods, and patterns of behavior displayed by the leader will create a lasting impression on the behavior of the team involved. It is critical for the leader to be aware of this impact if she or he is going to be effective in managing and leading a team (Porter-O’Grady, 2003b). Rather than push staff members in many directions, the effective leader uses personal attributes to organize the activities and pull the staff toward a common direction.
The most current theory addressing the changing environment in which we work is the complexity theory of leadership. The complexity theory addresses the “unpredictable, disorderly, nonlinear, and uncontrollable ways that living systems behave” (Burns, 2001, p.474). This theory indicates that we need to look at systems, such as those in health care organizations, as patterns of relationships and the interactions that occur among those in the system.
Complexity theory is complex! However, the basis of the thinking can most easily be understood by comparing traditional ways of analyzing an organization to the ways in which this analysis would be accomplished using the complexity theory. The traditional method used to understand an organization is to “break a system into smaller bits and when we believe we understand the bits we put them all back together again and draw some conclusions about the whole” (IOM, 2004). Complexity theory examines the whole rather than the sum of its parts, because breaking a system apart removes all the impact of the human relationships that affect the whole.
Smyth (2015) asked, “Why do we struggle to achieve our goals in clinical outcomes, safety and financial performance in [health care facilities] when these facilities are chockfull of brilliant, well-intentioned people?” It is because those people bring factors such as varying levels of competence and performance and differing emotional states—all of which can have an unpredictable impact on the outcome. In general, most health care organizations work solely through hierarchies, which does not allow for the openness needed to achieve the best solutions to problems being addressed.
Following complexity theory, one understands that organizations are “organic, living systems” (Anderson et al., 2005) in which people act quickly and use knowledge sharing and patterns of relationships rather than the rules of a hierarchy. When leading according to the principles of complexity, change is understood as successful when accomplished by individuals as they adapt to variations in the environment and not as the linear managers dictate. “However, we are still mired in the hierarchical structures we have lived with for more than fifty years—going up and down the chain of command to make decisions…” (Smyth, 2015).
As we complete the discussion on the theories and characteristics of leaders and managers, it becomes evident that there are more differences between these two groups than those briefly identified in the opening paragraph of this discussion. According to Manion (1998), the major differences are
• Leaders focus on effectiveness, and Managers focus on efficiency.
• Leaders ask what and why, and Managers ask how.
• Leaders initiate innovation, and Managers maintain the status quo.
• Leaders look to the horizon, and Managers look to the bottom line (pp.3–7).
Management Requires “Followership”
Individuals can manage things, processes, and people. When thinking of nurse managers, it is generally assumed they are managing people, who are managing the care of patients. When being managed, one is in the role of a follower—an essential role in the safe and effective delivery of patient care. The role of the follower is not always considered when discussing management functioning, but it is obvious that those who are expected to follow the direction of the manager are essential to the success of the manager.
Followership is “the ability to take direction well, to get in line behind a program, to be a part of a team and to deliver what is expected of you” (McCallum, 2013). There cannot be a truly effective leader without competent followers since if the followers fail in the work they are doing, the manager will not be able to successfully complete the assigned work.
From the above information, it appears there are significant differences between leadership and followership. While this is true, the interconnections between these two functions make the differences almost irrelevant. “You can’t have one without the other!” truly applies. They need each other to exist and to have a purpose.
While many believe followers are subservient to leaders, leaders are beholden to followers for both leaders and followers to be successful. Followers must have the ability to think critically and actively participate in the successful completion of the leadership directions/goals (Miller, 2007).
When assessing the success of a team or group of staff, it is important to remember that, at times, individuals assume either leadership or followership roles or assume both leadership and followership roles during the completion of required tasks. A successful leader understands the role of followers and recognizes that followers should receive credit for the success of the team/group just as the leader receives this credit (Miller, 2007).
The Twenty-First Century: A Different Age for Management and for Leadership
The face of leadership is changing, and this is very evident in nursing and health care. Changes in health care are altering some of the foundations of nursing practice. Shorter hospital stays and emerging therapeutics require less, but perhaps more intense, clinical time and challenge the need for certain nursing interventions that have become routine over time. Nurses are becoming increasingly frustrated with the reality that the nursing care they were taught to provide—and they feel they need to provide—is not possible given the decreased time spent with their patients (Porter-O’Grady, 2003c). This dissatisfaction may be compounded by the conflict between established nurses and upcoming generations of nurses. In general, younger generations of nurses have accepted the newer foundations of practice, whereas these changes are often resisted by tenured staff. Thus the task of learning how to bridge the gaps in a multigenerational staff must be added to the nurse manager’s other responsibilities.
The generations that have retired or will soon retire in the nursing profession include those born during the 1920s, 1930s, and early 1940s, sometimes referred to as the Silent Generation or the Veteran Generation. The generations currently active in the nursing profession include the Baby Boomer Generation, born more or less between 1945 and 1960; Generation X, born between 1960 and 1980; and the Millennial Generation, born between 1980 and 2000 (Carlson, 2014).
The leadership of health care in the 21st century has been and will continue to be significantly affected by the diverse generations in today’s workplace. These generational groups have major differences in communication styles, in what motivates them, in what turns them off, and in their workplace ideals (Boychuk-Duchscher & Cowin, 2004; Martin, 2004). Great diversity also exists in the beliefs, attitudes, and life experiences of these various generations (Scott, 2007). As such, generational diversity has been recognized as one of the major factors precipitating conflict in the workplace. Box 10.1 lists time frames of each generation as well as the percentage of each generation in the workforce.