Leadership & Management in

Hospitals & Healthcare Agencies

Martha Highfield, PhD, RN, AOCN

Associate Professor Nursing
California State University, Northridge, USA
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 Presented at the invitation of the
Guangzhou Municipal Health Bureau
Guangzhou, China

August 2001

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 Driving Forces
• Professional scope & standards of nursing
practice
• Legal requirements
• JCAHO
• Fiscal solvency
• Ideals of compassionate care & valuing the
individual
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 ANA Administration Standards
NURSE EXECUTIVE
1. Leading
2. Collaborating &
integrating nursing in
interdisciplinary
environment
3. Facilitating effective,
efficient, compassionate
care.
4. Evaluating
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MANAGER
1. Report to executive
2. Defined area
3. Allocate resources for
compassionate care
4. Upward & downward
communication
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 Differences: Leader & Manager
• Managers
– Assigned formal position
• Leaders
– Delegated authority
– Informal or formal – Specific functions, duties,
– More roles responsibilities
– Focus on group process – Emphasize control,
– Emphasize decision-making, analysis
& results
relationships
– Manipulate resources
– Direct willing followers
– Direct willing & unwilling
– Goals followers

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 Both Executives & Managers...
1. Promote vertical & horizontal
communication

2. Inspire critical thinking for proper decision-

making

3. Efficient & effective: highest possible

individualized care at the lowest possible cost

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 Standards
• Standards: “Statements that describe a level
of care or nursing performance by which
the quality of nursing practice can be
judged.”
(p. 38-9)

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Standards of Nursing Administration
1. Standards of Care = statement of a competent
level of clinical nursing practice, such as
identifying problems and planning & taking
action to correct them

2. Standards of Performance = statement of

competent role activities, such as collaboration
& quality of care

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 Standards of Care
Standard 1: Assessment
Standard 2: Diagnosis
Standard 3: Identification of Outcomes
Standard 4: Planning
Standard 5: Implementation
Standard 6: Evaluation

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 Standards of Care
1. Assessment: Develops, maintains, & evaluates
patient/client and staff data collection systems and
processes to support the practice of nursing and
delivery of patient care.

2. Diagnosis: Develops, maintains, & evaluates an

environment that supports the professional nurse
in analysis of assessment data and in decisions to
determine relevant diagnoses

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 Standards of Care (cont.)
3. Identification of Outcomes: Develops,
maintains, & evaluates information
processes that promote desired client-
centered outcomes

4. Planning: Develops, maintains, &

evaluates organizational planning systems
to facilitate the delivery of nursing
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 Standards of Care (cont.)
5. Implementation: Develops, maintains, &
evaluates organizational systems that
support implementation of the plan

6. Evaluation: Evaluates the plan and its

progress in relation to the attainment of
outcomes.

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 Standards of Professional Performance

• Standard 1: Quality of care

• Standard 2: Performance appraisal
• Standard 3: Education
• Standard 4: Collegiality
• Standard 5: Collaboration
• Standard 6: Research
• Standard 7: Resource utilization
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 Standards of Performance
1. Quality of Care & Administrative Practice:
Systematically evaluates the quality and
effectiveness of nursing practice & nursing
services administration

2. Performance Appraisal: Evaluates own

performance based on professional practice
standards, relevant statutes & regulations &
organization criteria

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 Standards of Performance (cont.)

3. Education: Acquires & maintains current

knowledge in administrative practice

4. Collegiality: Fosters professional

environment

5. Ethics: Decisions & actions are based on

ethical principles

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 Standards of Performance (cont.)
8. Collaboration: Collaborates with nursing staff at
all levels, interdisciplinary teams, executive
officers, and other stakeholders
9. Research: Supports research & integrates it into
the delivery of nursing care & administration
10. Resource Utilization: Evaluates & administers
the resources of organized nursing services

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Standards
met in
carrying out
Decision-
Making

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 Decision-Making
• Fundamental skill for all aspects
• Traditional decision-making starts with
identifying problem
• Management decision-making starts with
writing objectives--fixed end goals

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 Decision-Making Grid
• List alternatives down the
first column on left
• For each write out
– Financial effect
– Political effect
– Department effect
– Time
• Last column write
decision about each
alternative

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Standards
met in
carrying out
Planning

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 Roles & Functions: Planning
• Mission
• Philosophy
• Goals & objectives
• Strategies to achieve goals & objectives:
programs, policies, procedures
• Time management
• Delegation
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Overcoming Barriers to Planning
• Goals & objectives increase effectiveness
• Plan is a guide & must be flexible
• Include all stakeholders in planning
• Plans should be simple, specific, realistic
• Planned change

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 Planning: Managing Change
• STAGE 1-UNFREEZING

• STAGE 2 - MOVEMENT

• STAGE 3 - REFREEZING

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 Planning:
Emotional Stages of Change

1. Equilibrium 6. Depression
2. Denial 7. Resignation
3. Anger 8. Openness
4. Bargaining 9. Readiness
5. Chaos 10. Reemergence

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 Planning: Time Management
1. Prioritizes day-to-day planning to meet
short-term & long-term unit goals
2. Schedules time for planning
3. Analyzes others’ use of time
4. Eliminates environmental barriers
5. Handles paperwork promptly & efficiently

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 Time management (cont.)
6. Breaks down large tasks into smaller
achievable ones.
7. Uses technology for documentation &
communication
8. Discriminates between inadequate staffing
& inadequate time

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 Planning: Examples of Specific Strategies
• Use last 30-60 minutes of day to plan next &
clean desk
• Plan what you will do in each 30-60 minute
block
• Number tasks in order of priority
• Start with most difficult priority task & work
for set time
• Plan communication with staff

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 Standards
met in
carrying out
Organizing

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 Roles & Functions:
Organizing Delivery of Nursing Care
• Organizational structure
• Authority & power in organizations
• Nursing systems
• Organizing client care
• Committees
• Nursing informatics

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 Organizing: Management Functions
1. Understand agency’s structure & personal
responsibility & authority within it
2. Informs staff of unit organizational chart
3. Maintains & clarifies unity of command as
possible
4. Follows subordinate complaints upward
5. Establishes proper span of control

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 Organizing: Management Functions

6. Knowledgeable about agency culture

7. Uses informal organization to meet agency
goals
8. Uses committee structure for quality &
quantity of work

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 Organizing: Decision-Making
• Centralized: Few managers at the top

• Decentralized: At the lowest level possible

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 Organizing: Assessing Culture
1. How does the organization view physical
environment?
2. What is the organization’s social environment?
3. How supportive is the organization
4. What is the organizational power structure?
5. How does the organization view safety?
6. What is communication environment?
7. What are organization taboos & heroes?

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 Organizing: Span of Control
• “The appropriate number depends on the
organization, the maturity of the
subordinates, and the type of work to be
done. An inappropriate span of control can
result in inefficiency.”
(p. 161, Marquis & Huston, 2000)

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 Organizing: Committees
• Groups who want to work on a project
• Manager must give parameters--A clear
assignment with deadlines
• Written agendas & chairperson
• Large enough to do task; small enough to
talk
• Discourage “group think”
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 Organizing: Patient Care
C a s e M e th o d O R
T o ta l P a tie n t C a r e S tr u c tu r e

RN M anager
d e le g a t e s t o

C h a rg e N u rs e
fo r e a c h s h ift

RN RN RN

P a tie n ts P a tie n ts P a tie n ts

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 Organizing: Patient Care

F u n c tio n a l N u r s in g O r g a n iz a to n
C h a rg e R N
T y p e title h e r e

M e d ic a tio n R N T re a tm e n t R N N u r s in g A s s is ta n ts C le r ic a l &
T y p e t it le h e r e T y p e t it le h e r e H o u s e k e e p in g

P a tie n ts

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 Organizing: Patient Care
T e a m N u r s in g O r g a n iz a tio n
C h a rg e R N
e a c h s h ift

R N s ta ff R N s ta ff
T y p e title h e r e T y p e title h e r e

RN, LVN, RN, LVN,

N u r s in g A s s is ta n t N u r s in g a s s is ta n t

P a tie n ts P a tie n ts
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 Organizing: Patient Care
• Primary Nursing
– 1 RN plans & manages care for the patient in
collaboration with Associate RNs
– Interfaces with MD, Charge RN, & resources
• Case Management
– All RNs use resources to expedite health; OR
– A special nurses monitors & facilitates use of
resources in the agency for many patients in
collaboration with their nurses

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 Organizing: Informatics
• Data recording & retrieval used to
– Manage care
– Monitor care
• Computer/technology
• RNs must be educated

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Standards
met in
carrying out
Staffing

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 Roles & Functions: Staffing
1. Personnel
2. Fiscal planning/budgeting
3. Staffing & scheduling
4. Staff Development

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 Staffing: Management Functions
1. Ensures adequate, skilled workforce to meet agency
goals
2. Shares recruitment responsibility
3. Interviews with proper techniques
4. Develops selection criteria
5. Places based on agency needs & employee strengths
6. Interprets employee handbook
7. Participates in employee orientation.

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 Staffing: Personnel
• Recruiting: Actively seeking out and hiring those
who can best do job
• Interviewing:
– Based on specific job criteria
– Best predictor of future performance is past
performance
– Give person clear information about job
– Try to contradict your first impressions
– More than 1 interviewer is ideal

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 Staffing: Structured Interview
• Motivation
• Physical
• Education
• Work experience
• Present work
• Previous work
• Personal characteristics & goals
• Anticipated contributions to this agency

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Staffing: Orientation & Socialization
• Orientation --> Competence --> Quality

• Socialization
– Introduce to others & their roles
– Coach as take on role responsibilities
– “Carrot & stick”
– Recognize current skills & knowledge & build
on these

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 Staffing: Scheduling
• Scheduling should
– Meet agency need
– Be fair to all
• Policies should include, for example
– Lateness, absence, illness, emergencies
– Vacations & regular time off; Special requests
– Expectations for working in other areas of the
agency

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 Staffing: Scheduling & Budgeting

NCH/PPD = Nursing hours in 24 hour period

Patient census

• Acuity of patients calculated to adjust RNs

• Cost controlled

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 Staffing: Staff Development
• Interface with educators
• Own role in orientation & motivation
• Preceptor program
– Identification of clinical & teaching expertise
– Education of preceptor
– Adjustment in assignments of preceptor & new
staff
– Competence checklists
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Standards
met in
carrying out
Directing

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 Roles & Functions: Directing
1. Use authority to provide reward system
2. Use positive feedback as reward
3. Unit goals that integrate agency & employee needs
4. Environment that
– Reduces job dissatisfiers
– Focuses on employee motivators
5. Maintain tension for productivity along with job
satisfaction

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 Roles & Functions: Directing (cont.)

6. Clear communication of expectations

7. Communicates sincere respect, concern, trust, &
sense of belonging to subordinates
8. Assigns work appropriate to employee
competence
9. Identifies what motivates subordinates, and
develops motivational strategies to meet these.

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 Directing: Communications
1. Understand & use agency formal communication
network
2. Uses appropriate communication mode for
distribution of information
3. Prepares appropriate written communication
4. Consults/coordinates with others who have
overlapping functions
5. Differentiates between information &
communication and recognizes need for both.

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 Directing: Communications
6. Protects subordinate confidentiality
7. Prepares self & staff for use of technology
8. Uses group dynamics knowledge to achieve
agency goals

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Directing: Delegation
1. Creates & follows specific job descriptions that
conform to national/professional standard of care
2. Understands legal liabilities of management
3. Delegates based on abilities/limits of staff
4. Delegates authority appropriately to achieve goals
5. Maintains periodic review of delegated task
6. Recognition & rewards for task completion

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 Directing: Managing Conflict
1. Anticipates & minimizes sources of conflict on
unit
2. Uses authority when quick, unpopular decision
must be made
3. Facilitates conflict resolution between employees
4. Accepts mutual responsibilities for reaching goals
5. Effectively negotiates for needed resources
6. Compromises unit needs only on the noncritical
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 Directing: Labor Issues
1. Uses union contract appropriately
2. Administers policies fairly
3. Works cooperatively with administration &
personnel when dealing with unions
4. Understands laws relating to manager’s work
5. Safe work environment
6. Alert for discrimination
7. Ensures licensing requirements met
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Standards
met in
carrying out
Control

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 Leadership & Management
• Leader focus more on
– Agency system for quality control
– Maximizing employee potential

• Manager focus more on control

– Unit criteria for quality control
– Controlling employee behavior to meet
standards
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 Roles & Functions: Controlling
1. In collaboration with others, “establishes clear-cut
measurable standards of care & determines the
most appropriate method for measure [whether]
those standards have been met.
2. Selects & uses process, outcome & structure audits
as quality control
3. Gathers data from appropriate sources
4. Determines discrepancies between performance &
standards & determine why

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 Roles & Functions: Controlling
5. Uses quality findings for performance review,
rewards, & development of employees
6. Educates self about state & accrediting regulations
that define quality
7. Participates in “benchmarking” efforts and “best
practices” initiatives.

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 Controlling: Quality
STEPS
1. Identify standards & expected outcomes
2. What information would objectively measure these
standards/outcomes?
3. Determine how & where to collect the information
4. Gather information
5. Compare information to standards/outcomes
6. Make a judgment about quality
7. Share information & take corrective action prn

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 Controlling: Quality
Audits
1. Structure

2. Process

3. Outcomes

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 Controlling: Quality
• Total Quality Improvement (TQI or QI or
QAI or CQI) is a different philosophy
• “Identifying doing the right things, the right
way, the first time, and problem-prevention
planning--NOT inspection and problem-
solving--lead to quality outcomes”
(p. 402, Marquis & Huston, 2000)

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 Controlling: Performance Appraisal
1. Uses formal, established system of appraisal
2. Gathers fair & objective data
3. Uses to determine staff education & training needs
4. Based on written standards that have been communicated
5. Documents process
6. Follows up on deficiencies
7. Conducts appraisal in way that promotes positive outcome
8. Provides continuous feedback to employees.

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 Example
• Part of an oncology nurse performance evaluation
tool for Professional Performance Standard 3:
Education The oncology nurse acquires and maintains
current knowledge in oncology nursing practice.

• Rating scale used:

– 1. Performance below standards
– 2. Performance meets standard
– 3. Performance exceeds standard

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 Professional Performance Standard 3:
Education: The oncology nurse acquires and
maintains current knowledge in oncology
nursing practice.
Criteria: Rating
1 2 3
1. Participates in ongoing
educational activities (including
inservices, continuing education,
formal education, and
experientatil learning) to expand
oncology knowledge of
professional issues
2. Seeks experiences to develop
& maintain clinical skills
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 Promoting Professionalism
• Professional standards
• Professional relationships & commitment
• Patient advocate
• Staff education & career planning

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