Week 2 Discussion: Nursing Dream Hospital Paper

Week 2 Discussion: Nursing Dream Hospital Paper

Week 2 Discussion: Nursing Dream Hospital Paper

Dream Business Project /Project Development/Dream Hospital Presentation: Use the knowledge gained from Unit III, Chapter 7 for organizational planning and develop a Hospital of choice. The hospital/business entity/ dream project must have: vision, mission, philosophy, goals, objectives, policies, procedures and rules. Must be creative with this assignment. (30% – Project development). Refer to Chapter 7 for the SWOT Analysis and Strategic Planning Process. This has two requirements: the entire plan in detail in a formal paper; second is the eposter (format).


The American Association of Colleges of Nursing Essentials of Master’s Education in Nursing The AACN Essentials of Master’s Education in Nursing (commonly called the MSN Essentials) were published in March 2011 and identified the following nine outcomes expected of graduates of master’s nursing programs, regardless of focus, major, or intended practice setting (Table 2). Achievement of these outcomes will prepare graduate nurses to lead change to improve quality outcomes, advance a culture of excellence through lifelong learning, build and lead collaborative interprofessional care teams, navigate and integrate care services across the health-care system, design innovative nursing practices, and translate evidence into practice (AACN, 2011). TABLE 2 AMERICAN ASSOCIATION OF COLLEGES OF NURSING ESSENTIALS OF MASTER’S EDUCATION IN NURSING Essential I: Background for practice from sciences and humanities • Recognizes that the master’s-prepared nurse integrates scientific findings from nursing, biopsychosocial fields, genetics, public health, quality improvement, and organizational sciences for the continual improvement of nursing care across diverse settings. Essential II: Organizational and systems leadership • Recognizes that organizational and systems leadership are critical to the promotion of high quality and safe patient care. Leadership skills are needed that emphasize ethical and critical decision making, effective working relationships, and a systems perspective. Essential III: Quality improvement and safety • Recognizes that a master’s-prepared nurse must be articulate in the methods, tools, performance measures, and standards related to quality, as well as prepared to apply quality principles within an organization. Essential IV: Translating and integrating scholarship into practice • Recognizes that the master’s-prepared nurse applies research outcomes within the practice setting, resolves practice problems, works as a change agent, and disseminates results. Essential V: Informatics and health-care technologies • Recognizes that the master’s-prepared nurse uses patient-care technologies to deliver and enhance care and uses communication technologies to integrate and coordinate care. Essential VI: Health policy and advocacy • Recognizes that the master’s-prepared nurse is able to intervene at the system level through the policy development process and to employ advocacy strategies to influence health and health care. Week 2 Discussion: Nursing Dream Hospital Paper

Essential VII: Interprofessional collaboration for improving patient and population health outcomes • Recognizes that the master’s-prepared nurse, as a member and leader of interprofessional teams, communicates, collaborates, and consults with other health professionals to manage and coordinate care. Essential VIII: Clinical prevention and population health for improving health • Recognizes that the master’s-prepared nurse applies and integrates broad, organizational, client-centered, and culturally appropriate concepts in the planning, delivery, management, and evaluation of evidence-based clinical prevention and population care and services to individuals, families, and aggregates/identified populations. Essential IX: Master’s level nursing practice • Recognizes that nursing practice, at the master’s level, is broadly defined as any form of nursing intervention that influences health-care outcomes for individuals, populations, or systems. Master’s-level nursing graduates must have an advanced level of understanding of nursing and relevant sciences as well as the ability to integrate this knowledge into practice. Nursing practice interventions include both direct and indirect care components. The American Organization of Nurse Executives Nurse Executive Competencies In 2004 (updated in 2015), the AONE published a paper describing skills common to nurses in executive practice regardless of their educational level or titles in different organizations. While these Nurse Executive Competencies differ depending on the leader’s specific position in the organization, the AONE suggested that managers at all levels must be competent in the five areas noted in Table 3 (AONE, 2015). These competencies suggest that nursing leadership/management is as much a specialty as any other clinical nursing specialty, and as such, it requires proficiency and competent practice specific to the executive role. TABLE 3 AMERICAN ORGANIZATION OF NURSE EXECUTIVES NURSE EXECUTIVE COMPETENCIES 1. Communication and relationship building • Communication and relationship building includes effective communication, relationship management, influencing behaviors, diversity, community involvement, medical/staff relationships, and academic relationships. 2. Knowledge of the health-care environment • Knowledge of the health-care environment includes clinical practice knowledge, delivery models and work design, health-care economics and policy, governance, evidence-based practice/outcome measurement and research, patient safety, performance improvement/metrics, and risk management. 3. Leadership • Leadership skills include foundational thinking skills, personal journey disciplines, systems thinking, succession planning, and change management. 4. Week 2 Discussion: Nursing Dream Hospital Paper

Professionalism • Professionalism includes personal and professional accountability, career planning, ethics, and advocacy. 5. Business skills • Business skills include financial management, human resource management, strategic management, and information management and technology. The American Nurses Association Standards of Professional Performance In 2015, ANA published six Standards of Practice for Nursing Administration as well as eleven Standards of Professional Performance. These standards describe a competent level of nursing practice and professional performance common to all registered nurses (Table 4). Because the Standards of Practice for nursing administration describe the nursing process and thus cross all aspects of nursing care, only the Standards of Professional Performance have been included in the crosswalk of this book (Table 4). TABLE 4 AMERICAN NURSES ASSOCIATION NURSING ADMINISTRATION STANDARDS OF PROFESSIONAL PERFORMANCE Standard 7. Ethics • The registered nurse practices ethically. Standard 8. Culturally congruent practice • The registered nurse practices in a manner that is congruent with cultural diversity and inclusion principles. Standard 9. Communication • The registered nurse communicates effectively in all areas of practice. Standard 10. Collaboration • The registered nurse collaborates with health-care consumers and other key stakeholders in the conduct of nursing practice. Standard 11. Leadership • The registered nurse leads within the professional practice setting and the profession. Standard 12. Education • The registered nurse seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking. Standard 13. Evidence-based practice and research • The registered nurse integrates evidence and research findings into practice. Standard 14. Quality of practice • The registered nurse contributes to quality nursing practice. Standard 15. Professional practice evaluation • The registered nurse evaluates one’s own and others’ nursing practice. Standard 16. Resource utilization • The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, and fiscally responsible. Standard 17. Environmental health • The registered nurse practices in an environmentally safe and healthy manner. The Quality and Safety Education for Nurses Competencies Using the Institute of Medicine (2003) competencies for nursing, the QSEN Institute (2014; Cronenwett, 2007) defined six prelicensure and graduate quality and safety competencies for nursing (Table 5) and proposed targets for the knowledge, skills, and attitudes to be developed in nursing programs for each of these competencies. Led by a national advisory board and distinguished faculty, QSEN pursues strategies to develop effective teaching approaches to assure that future graduates develop competencies in patientcentered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. TABLE 5 QUALITY AND SAFETY EDUCATION FOR NURSES COMPETENCIES Patient-centered care • Week 2 Discussion: Nursing Dream Hospital Paper

Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs. Teamwork and collaboration • Definition: Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care. Evidence-based practice • Definition: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care. Quality improvement • Definition: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health-care systems. Safety • Definition: Minimizes the risk of harm to patients and providers through both system effectiveness and individual performance. Informatics • Definition: Use information and technology to communicate, manage knowledge, mitigate error, and support decision making. Leadership Roles and Management Functions in Nursing, ninth edition, has ancillary resources designed with both students and instructors in mind, available on web site. Student Resources Available on Glossary—Fully updated for the ninth edition, the glossary contains definitions of all important terms in the text. Journal Articles—25 full articles from Wolters Kluwer journals (one corresponding to each chapter) —are provided for additional learning opportunities. Learning Objectives from the textbook are available in Microsoft Word for your convenience. Nursing Professional Roles and Responsibilities Instructor’s Resources Available on Competency Maps pull together the mapping provided in the crosswalk feature for each chapter, showing how the book content as a whole integrates key competencies for practice. An Image Bank lets you use the photographs and illustrations from this textbook in your PowerPoint slides or as you see fit in your course. An Instructor’s Guide includes information on experiential learning and guidelines on how to use the text for various types of learners and in different settings as well as information on how to use the various types of Learning Exercises included in the text. Learning Management System Course Cartridges PowerPoint presentations provide an easy way for you to integrate the textbook with your students’ classroom experience, either via slide shows or handouts. Audience response questions are integrated into the presentations to promote class participation and allow you to use i-clicker technology. Sample Syllabi provide guidance for structuring your leadership and management course and are provided for two different course lengths: 7 and 14 weeks. Strategies for Effective Teaching offer creative approaches for engaging students. A Test Generator lets you put together exclusive new tests from a bank containing over 750 questions to help you in assessing your students’ understanding of the material. Test questions link to chapter learning objectives. Access to all student resources. Comprehensive, Integrated Digital Learning Solutions We are delighted to introduce an expanded suite of digital solutions to support instructors and students using Leadership Roles and Management Functions in Nursing, ninth edition. Now for the first time, our textbook is embedded into two integrated digital learning solutions—one specific for prelicensure programs and the other for postlicensure—that build on the features of the text with proven instructional design strategies. To learn more about these solutions, visit http://www.nursingeducationsuccess.com/ or contact your local Wolters Kluwer representative. Our prelicensure solution, Lippincott CoursePoint, is a rich learning environment that drives course and curriculum success to prepare students for practice. Lippincott CoursePoint is designed for the way students learn. The solution connects learning to real-life application by integrating content from Leadership Roles and Management Functions in Nursing with video cases, interactive modules, and journal articles. Week 2 Discussion: Nursing Dream Hospital Paper

Ideal for active, case-based learning, this powerful solution helps students develop higher level cognitive skills and asks them to make decisions related to simple-to-complex scenarios. Lippincott CoursePoint for Leadership and Management features the following: Leading content in context: Digital content from Leadership Roles and Management Functions in Nursing is embedded in our Powerful Tools, engaging students and encouraging interaction and learning on a deeper level. The complete interactive eBook features annual content updates with the latest evidence-based practices and provides students with anytime, anywhere access on multiple devices. Full online access to Stedman’s Medical Dictionary for the Health Professions and Nursing ensures students work with the best medical dictionary available. Powerful tools to maximize class performance: Additional course-specific tools provide casebased learning for every student: Video Cases help students anticipate what to expect as a nurse, with detailed scenarios that capture their attention and integrate clinical knowledge with leadership and management concepts that are critical to real-world nursing practice. By watching the videos and completing related activities, students will flex their problem-solving, prioritizing, analyzing, and application skills to aid both in NCLEX preparation and in preparation for practice. Interactive Modules help students quickly identify what they do and do not understand, so they can study smartly. With exceptional instructional design that prompts students to discover, reflect, synthesize, and apply, students actively learn. Remediation links to the digital textbook are integrated throughout. Curated collections of journal articles are provided via Lippincott NursingCenter, Wolters Kluwer’s premier destination for peer-reviewed nursing journals. Through integration of CoursePoint and NursingCenter, students will engage in how nursing research influences practice. Data to measure students’ progress: Student performance data provided in an intuitive display lets instructors quickly assess whether students have viewed interactive modules and video cases outside of class as well as see students’ performance on related NCLEX-style quizzes, ensuring students are coming to the classroom ready and prepared to learn. To learn more about Lippincott CoursePoint, please visit: http://www.nursingeducationsuccess.com/coursepoint Lippincott RN to BSN Online: Leadership and Management is a postlicensure solution for online and hybrid courses, marrying experiential learning with the trusted content in Leadership Roles and Management Functions in Nursing, ninth edition. Built around learning objectives that are aligned to the BSN Essentials and QSEN nursing curriculum standards, every aspect of Lippincott RN to BSN Online is designed to engage, challenge, and cultivate postlicensure students. Self-paced interactive modules employ key instructional design strategies—including storytelling, modeling, and case-based and problem-based scenarios—to actively involve students in learning new material and focus students’ learning outcomes on real-life application. Pre-and post-module assessments activate students’ existing knowledge prior to engaging with the module and then assess their competency after completing the module. Discussion board questions create an ongoing dialogue to foster social learning. Writing and group work assignments hone students’ competence in writing and communication, instilling the skills needed to advance their nursing careers. Collated journal articles acquaint students to the body of nursing research ongoing in recent literature. Case study assignments, including unfolding cases that evolve from cases in the interactive modules, aid students in applying theory to real-life situations. Best Practices in Scholarly Writing Guide covers American Psychological Association formatting and style guidelines. Used alone or in conjunction with other instructor-created resources, Lippincott RN to BSN Online adds interactivity to courses. It also saves instructors time by keeping both textbook and course resources current and accurate through regular updates to the content. To learn more about Lippincott RN to BSN Online, please visit http://www.nursingeducationsuccess.com/nursing-education-solutions/lippincott-rn-bsn-online/ Closing Note It is our hope and expectation that the content, style, and organization of this ninth edition of Leadership Roles and Management Functions in Nursing will be helpful to those students who want to become skillful, thoughtful leaders and managers. Week 2 Discussion: Nursing Dream Hospital Paper

Bessie L. Marquis, RN, MSN Carol J. Huston, RN, MSN, DPA, FAAN R E FE R E N C E S American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved October 17, 2015, from http://www.aacn.nche.edu/education-resources/baccessentials08.pdf American Association of Colleges of Nursing. (2011). The essentials of master’s education in nursing. Retrieved October 17, 2015, from http://www.aacn.nche.edu/educationresources/MastersEssentials11.pdf American Nurses Association. (2015). Nursing: Scope & standards of practice (3rd ed.). Silver Spring, MD: Author. American Organization of Nurse Executives. (2015). The AONE nurse executive competencies. Retrieved October 17, 2015, from http://www.aone.org/resources/nurse-leadercompetencies.shtml Cronenwett, L., et al. (2007). Quality and safety education for nurses. Nursing Outlook 55(3), 122. Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press. Quality and Safety Education for Nurses Institute. (2014). Competencies. Retrieved October 17, 2015, from http://qsen.org/competencies/ CONTENTS I The Critical Triad: Decision Making, Management, and Leadership 1 Decision Making, Problem Solving, Critical Thinking, and Clinical Reasoning: Requisites for Successful Leadership and Management Decision Making, Problem Solving, Critical Thinking, and Clinical Reasoning Vicarious Learning to Increase Problem-Solving and Decision-Making Skills Theoretical Approaches to Problem Solving and Decision Making Critical Elements in Problem Solving and Decision Making Individual Variations in Decision Making Overcoming Individual Vulnerability in Decision Making Decision Making in Organizations Decision-Making Tools Pitfalls in Using Decision-Making Tools Integrating Leadership Roles and Management Functions in Decision Making Key Concepts Additional Learning Exercises and Applications 2 Classical Views of Leadership and Management Managers Leaders Historical Development of Management Theory Historical Development of Leadership Theory (1900 to Present) Integrating Leadership Roles and Management Functions Key Concepts Additional Learning Exercises and Applications 3 Twenty-First-Century Thinking About Leadership and Management New Thinking About Leadership and Management Transition From Industrial Age Leadership to Relationship Age Leadership Integrating Leadership Roles and Management Functions in the 21st Century Key Concepts Additional Learning Exercises and Applications II Foundation for Effective Leadership and Management Ethics, Law, and Advocacy 4 Ethical Issues Moral Issues Faced by Nurses Ethical Frameworks for Decision Making Principles of Ethical Reasoning American Nurses Association Code of Ethics and Professional Standards Ethical Problem Solving and Decision Making The Moral Decision-Making Model Working Toward Ethical Behavior as the Norm Integrating Leadership Roles and Management Functions in Ethics Key Concepts Additional Learning Exercises and Applications 5 Legal and Legislative Issues Sources of Law Types of Laws and Courts Legal Doctrines and the Practice of Nursing Professional Negligence Avoiding Malpractice Claims Extending the Liability Incident Reports and Adverse Event Forms Intentional Torts Other Legal Responsibilities of the Manager Legal Considerations of Managing a Diverse Workforce Professional Versus Institutional Licensure Integrating Leadership Roles and Management Functions in Legal and Legislative Issues Key Concepts Additional Learning Exercises and Applications 6 Patient, Subordinate, Workplace, and Professional Advocacy Becoming an Advocate Patient Advocacy Patient Rights Subordinate and Workplace Advocacy Whistleblowing as Advocacy Professional Advocacy Integrating Leadership Roles and Management Functions in Advocacy Key Concepts Additional Learning Exercises and Applications III Roles and Functions in Planning 7 Organizational Planning Looking to the Future Proactive Planning Strategic Planning at the Organizational Level Organizational Planning: Week 2 Discussion: Nursing Dream Hospital Paper

The Planning Hierarchy Vision and Mission Statements Organizational Philosophy Societal Philosophies and Values Related to Health Care Individual Philosophies and Values Goals and Objectives Policies and Procedures Rules Overcoming Barriers to Planning Integrating Leadership Roles and Management Functions in Planning Key Concepts Additional Learning Exercises and Applications 8 Planned Change Lewin’s Change Theory of Unfreezing, Movement, and Refreezing Lewin’s Change Theory of Driving and Restraining Forces A Contemporary Adaptation of Lewin’s Model Classic Change Strategies Resistance: The Expected Response to Change Planned Change as a Collaborative Process The Leader-Manager as a Role Model During Planned Change Organizational Change Associated With Nonlinear Dynamics Organizational Aging: Change as a Means of Renewal Integrating Leadership Roles and Management Functions in Planned Change Key Concepts Additional Learning Exercises and Applications 9 Time Management Three Basic Steps to Time Management Personal Time Management Integrating Leadership Roles and Management Functions in Time Management Key Concepts Additional Learning Exercises and Applications 10 Fiscal Planning Balancing Cost and Quality Responsibility Accounting and Forecasting Basics of Budgets Steps in the Budgetary Process Types of Budgets Budgeting Methods Critical Pathways Health-Care Reimbursement Medicare and Medicaid The Prospective Payment System Managed Care Health-Care Reform and the Patient Protection and Affordable Care Act Integrating Leadership Roles and Management Functions in Fiscal Planning Key Concepts Additional Learning Exercises and Applications 11 Career Planning and Development in Nursing Career Stages Justifications for Career Development Individual Responsibility for Career Development The Organization’s Role in Employee Career Development Career Coaching Management Development Continued Competency as Part of Career Development Professional Specialty Certification Reflective Practice and the Professional Portfolio Career Planning and the New Graduate Nurse Transition-to-Practice Programs/Residencies for New Graduate Nurses Resumé Preparation Integrating Leadership Roles and Management Functions in Career Planning and Development Key Concepts Additional Learning Exercises and Applications IV Roles and Functions in Organizing 12 Organizational Structure Formal and Informal Organizational Structure Organizational Theory and Bureaucracy Components of Organizational Structure Limitations of Organization Charts Types of Organizational Structures Decision Making Within the Organizational Hierarchy Stakeholders Organizational Culture Shared Governance: Organizational Design for the 21st Century? Magnet Designation and Pathway to Excellence Committee Structure in an Organization Responsibilities and Opportunities of Committee Work Organizational Effectiveness Integrating Leadership Roles and Management Functions Associated With Organizational Structure Key Concepts Additional Learning Exercises and Applications 13 Organizational, Political, and Personal Power Understanding Power The Authority–Power Gap Mobilizing the Power of the Nursing Profession An Action Plan for Increasing Professional Power in Nursing Strategies for Building a Personal Power Base The Politics of Power Integrating Leadership Roles and Management Functions When Using Authority and Power in Organizations Key Concepts Additional Learning Exercises and Applications 14 Organizing Patient Care Traditional Modes of Organizing Patient Care Disease Management Selecting the Optimum Mode of Organizing Patient Care New Roles for the Changing Health Care Arena: Nurse Navigators, Clinical Nurse Leaders, and Leaders in Patient-Centered Care Integrating Leadership Roles and Management Functions in Organizing Patient Care Key Concepts Additional Learning Exercises and Applications V Roles and Functions in Staffing 15 Employee Recruitment, Selection, Placement, and Indoctrination Predicting Staffing Needs Is a Nursing Shortage Imminent? Supply and Demand Factors Leading to a Potential Nursing Shortage Recruitment Interviewing as a Selection Tool Tips for the Interviewee Selection Placement Indoctrination Integrating Leadership Roles and Management Functions in Employee Recruitment, Selection, Placement, and Indoctrination Key Concepts Additional Learning Exercises and Applications 16 Socializing and Educating Staff in a Learning Organization Week 2 Discussion: Nursing Dream Hospital Paper

The Learning Organization Staff Development Learning Theories Assessing Staff Development Needs Evaluation of Staff Development Activities Shared Responsibility for Implementing Evidence-Based Practice Socialization and Resocialization Overcoming Motivational Deficiencies Coaching as a Teaching Strategy Meeting the Educational Needs of a Culturally Diverse Staff Integrating Leadership and Management in Team Building Through Socializing and Educating Staff in a Learning Organization Key Concepts Additional Learning Exercises and Applications 17 Staffing Needs and Scheduling Policies Unit Manager’s Responsibilities in Meeting Staffing Needs Centralized and Decentralized Staffing Complying With Staffing Mandates Staffing and Scheduling Options Workload Measurement Tools The Relationship Between Nursing Care Hours, Staffing Mix, and Quality of Care Managing a Diverse Staff Generational Considerations for Staffing The Impact of Nursing Staff Shortages on Staffing Fiscal and Ethical Accountability for Staffing Developing Staffing and Scheduling Policies Integrating Leadership Roles and Management Functions in Staffing and Scheduling Key Concepts Additional Learning Exercises and Applications VI Roles and Functions in Directing 18 Creating a Motivating Climate Intrinsic Versus Extrinsic Motivation Motivational Theory Creating a Motivating Climate Strategies for Creating a Motivating Climate Promotion: A Motivational Tool Promoting Self-Care Integrating Leadership Roles and Management Functions in Creating a Motivating Climate at Work Key Concepts Additional Learning Exercises and Applications 19 Organizational, Interpersonal, and Group Communication The Communication Process Variables Affecting Organizational Communication Organizational Communication Strategies Communication Modes Elements of Nonverbal Communication Verbal Communication Skills Listening Skills Written Communication Within the Organization Technology as a Tool in Contemporary Organizational Communication Communication, Confidentiality, and Health Insurance Portability and Accountability Act Electronic Health Records and Meaningful Use Group Communication Group Dynamics Integrating Leadership and Management in Organizational, Interpersonal, and Group Communication Key Concepts Additional Learning Exercises and Applications 20 Delegation Delegating Effectively Common Delegation Errors Delegation as a Function of Professional Nursing Subordinate Resistance to Delegation Delegating to a Multicultural Work Team Integrating Leadership Roles and Management Functions in Delegation Key Concepts Additional Learning Exercises and Applications 21 Effective Conflict Resolution and Negotiation The History of Conflict Management Intergroup, Intrapersonal, and Interpersonal Conflict The Conflict Process Conflict Management Managing Unit Conflict Bullying, Incivility, Mobbing, and Workplace Violence Negotiation Alternative Dispute Resolution Seeking Consensus Integrating Leadership Skills and Management Functions in Managing Conflict Key Concepts Additional Learning Exercises and Applications 22 Collective Bargaining, Unionization, and Employment Laws Unions and Collective Bargaining Historical Perspective of Unionization in America Union Representation of Nurses American Nurses Association and Collective Bargaining Employee Motivation to Join or Reject Unions Averting the Union Union-Organizing Strategies Steps to Establish a Union The Managers’ Role During Union Organizing The Nurse as Supervisor: Week 2 Discussion: Nursing Dream Hospital Paper

Eligibility for Protection Under the National Labor Relations Act Employment Legislation State Health Facilities Licensing Boards Integrating Leadership Skills and Management Functions When Working With Collective Bargaining, Unionization, and Employment Laws Key Concepts Additional Learning Exercises and Applications VII Roles and Functions in Controlling 23 Quality Control Defining Quality Health Care Quality Control as a Process The Development of Standards Audits as a Quality Control Tool Standardized Nursing Languages Quality Improvement Models Who Should Be Involved in Quality Control? Quality Measurement as an Organizational Mandate Professional Standards Review Organizations The Joint Commission Centers for Medicare & Medicaid Services National Committee for Quality Assurance National Database of Nursing Quality Indicators Report Cards Medical Errors: An Ongoing Threat to Quality of Care The Leapfrog Group Six Sigma Approach and Lean Manufacturing Reforming the Medical Liability System Integrating Leadership Roles and Management Functions With Quality Control Key Concepts Additional Learning Exercises and Applications 24 Performance Appraisal Using the Performance Appraisal to Motivate Employees Strategies to Ensure Accuracy and Fairness in the Performance Appraisal Performance Appraisal Tools Planning the Performance Appraisal Interview Overcoming Appraisal Interview Difficulties Performance Management Coaching: A Mechanism for Informal Performance Appraisal When Employees Appraise Their Manager’s Performance Using Leadership Skills and Management Functions in Conducting Performance Appraisals Key Concepts Additional Learning Exercises and Applications 25 Problem Employees: Rule Breakers, Marginal Employees, and the Chemically or Psychologically Impaired Constructive Versus Destructive Discipline Self-Discipline and Group Norms Fair and Effective Rules Discipline as a Progressive Process Disciplinary Strategies for the Manager Disciplining the Unionized Employee The Disciplinary Conference The Termination Conference Grievance Procedures Transferring Employees The Marginal Employee The Chemically Impaired Employee Recognizing the Chemically Impaired Employee Integrating Leadership Roles and Management Functions When Dealing With Problem Employees Key Concepts Additional Learning Exercises and Applications Appendix Solutions to Selected Learning Exercises Index 1 Decision Making, Problem Solving, Critical Thinking, and Clinical Reasoning: Requisites for Successful Leadership and Management . . . again and again, the impossible problem is solved when we see that the problem is only a tough decision waiting to be made. —Robert H. Schuller . . . in any moment of decision the best thing you can do is the right thing, the next best thing is the wrong thing, and the worst thing you can do is nothing. —Theodore Roosevelt This chapter addresses: BSN Essential I: Liberal education for baccalaureate generalist nursing practice BSN Essential III: Scholarship for evidence-based practice BSN Essential IV: Information management and application of patient care technology BSN Essential VI: Interprofessional communication and collaboration for improving patient health outcomes MSN Essential I: Background for practice from sciences and humanities MSN Essential IV: Translating and integrating scholarship into practice AONE Nurse Executive Competency I: Communication and relationship building AONE Nurse Executive Competency III: Week 2 Discussion: Nursing Dream Hospital Paper

Leadership ANA Standard of Professional Performance 13: Evidence-based practice and research ANA Standard of Professional Performance 16: Resource utilization QSEN Competency: Informatics QSEN Competency: Evidence-based practice The learner will: differentiate between problem solving, decision making, critical thinking, and clinical reasoning describe how case studies, simulation, and problem-based learning can be used to improve the quality of decision making explore strengths and limitations of using intuition and heuristics as adjuncts to problem solving and decision making identify characteristics of successful decision makers use a PICO (patient or population, intervention, comparison, and outcome) format to search for current best evidence or practices to address a problem identify strategies the new nurse might use to promote evidence-based practice select appropriate models for decision making in specific situations describe the importance of individual variations in the decision making process identify critical elements of decision making identify strategies that help decrease individual subjectivity and increase objectivity in decision making explore his or her personal propensity for risk taking in decision making discuss the effect of organizational power and values on individual decision making differentiate between the economic man and the administrative man in decision making select appropriate management decision-making tools that would be helpful in making specific decisions differentiate between autocratic, democratic, and laissez-faire decision styles and identify situation variables that might suggest using one decision style over another Introduction Decision making is often thought to be synonymous with management and is one of the criteria on which management expertise is judged. Much of any manager’s time is spent critically examining issues, solving problems, and making decisions. The quality of the decisions that leader-managers make is the factor that often weighs most heavily in their success or failure. Decision making, then, is both an innermost leadership activity and the core of management. This chapter explores the primary requisites for successful management and leadership: decision making, problem solving, and critical thinking. Also, because it is the authors’ belief that decision making, problem solving, and critical thinking are learned skills that improve with practice and consistency, an introduction to established tools, techniques, and strategies for effective decision making is included. This chapter also introduces the learning exercise as a new approach for vicariously gaining skill in management and leadership decision making. Finally, evidence-based decision making is introduced as an imperative for both personal and professional problem solving. Decision Making, Problem Solving, Critical Thinking, and Clinical Reasoning Decision making is a complex, cognitive process often defined as choosing a particular course of action. BusinessDictionary.com (2016, para. 1) defines decision making as “the thought process of selecting a logical choice from the available options.” This implies that doubt exists about several courses of action and that a choice is made to eliminate uncertainty. Problem solving is part of decision making and is a systematic process that focuses on analyzing a difficult situation. Problem solving always includes a decision-making step. Many educators use the terms problem solving and decision making synonymously, but there is a small yet important difference between the two. Although decision making is the last step in the problem-solving process, it is possible for decision making to occur without the full analysis required in problem solving. Because problem solving attempts to identify the root problem in situations, much time and energy are spent on identifying the real problem. Decision making, on the other hand, is usually triggered by a problem but is often handled in a way that does not focus on eliminating the underlying problem. For example, if a person decided to handle a conflict when it occurred but did not attempt to identify the real problem causing the conflict, only decision-making skills would be used. The decision maker might later choose to address the real cause of the conflict or might decide to do nothing at all about the problem. The decision has been made not to problem solve. This alternative may be selected because of a lack of energy, time, or resources to solve the real problem. In some situations, this is an appropriate decision. For example, assume that a nursing supervisor has a staff nurse who has been absent a great deal over the last 3 months. Normally, the supervisor would feel compelled to intervene. However, the supervisor has reliable information that the nurse will be resigning soon to return to school in another state. Because the problem will soon no longer exist, the supervisor decides that the time and energy needed to correct the problem are not warranted. Critical thinking, sometimes referred to as reflective thinking, is related to evaluation and has a broader scope than decision making and problem solving. Week 2 Discussion: Nursing Dream Hospital Paper

Dictionary.com (2016) defines critical thinking as “the mental process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and evaluating information to reach an answer or conclusion” (para. 1). Critical thinking also involves reflecting on the meaning of statements, examining the offered evidence and reasoning, and forming judgments about facts. Insight, intuition, empathy, and the willingness to take action are components of critical thinking. Whatever definition of critical thinking is used, most agree that it is more complex than problem solving or decision making, involves higher order reasoning and evaluation, and has both cognitive and affective components. The authors believe that insight, intuition, empathy, and the willingness to take action are additional components of critical thinking. These same skills are necessary to some degree in decision making and problem solving. See Display 1.1 for additional characteristics of a critical thinker. DISPLAY 1.1 Open to New Ideas Intuitive Energetic Analytical Persistent Assertive Communicative Characteristics of a Critical Thinker Flexible Empathetic Caring Observant Risk taker Resourceful “Outside-the-box” thinker Creative Insightful Willing to take action Outcome directed Willing to change Knowledgeable Circular thinker Nurses today must have higher order thinking skills to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes. When nurses integrate and apply different types of knowledge to weigh evidence, critically think about arguments, and reflect on the process used to arrive at a diagnosis, this is known as clinical reasoning. Thus, clinical reasoning is a collaborative and reflective process that involves content-specific knowledge, engagement of the patient and family in understanding the clinical problem, and incorporation of critical contextual factors (Furze, Gale, Black, Cochran, & Jensen, 2015). All of these factors lead to deliberative decision making and sound clinical judgment. Thus, clinical reasoning uses both knowledge and experience to make decisions at the point of care. Vicarious Learning to Increase Problem-Solving and DecisionMaking Skills Decision making, one step in the problem-solving process, is an important task that relies heavily on critical thinking and clinical reasoning skills. How do people become successful problem solvers and decision makers? Although successful decision making can be learned through life experience, not everyone learns to solve problems and judge wisely by this trial-and-error method because much is left to chance. Some educators feel that people are not successful in problem solving and decision making because individuals are not taught how to reason insightfully from multiple perspectives. Moreover, information and new learning may not be presented within the context of real-life situations, although this is changing. For example, in teaching clinical reasoning, nurse educators strive to see that the elements of clinical reasoning, such as noticing crucial changes in patient status, analyzing these changes to decide on a course of action, and evaluating responses to modify care, are embedded at every opportunity throughout the nursing curricula (Rischer, 2017). In addition, time is included for meaningful reflection on the decisions that are made and the outcomes that result. Such learning can occur in both real-world settings and through vicarious learning, where students problem solve and make decisions based on simulated situations that are made real to the learner. Case Studies, Simulation, and Problem-Based Learning Case studies, simulation, and problem-based learning (PBL) are some of the strategies that have been developed to vicariously improve problem solving and decision making. Week 2 Discussion: Nursing Dream Hospital Paper

Case studies may be thought of as stories that impart learning. They may be fictional or include real persons and events, be relatively short and self-contained for use in a limited amount of time, or be longer with significant detail and complexity for use over extended periods of time. Case studies, particularly those that unfold or progress over time, are becoming much more common in nursing education because they provide a more interactive learning experience for students than the traditional didactic approach. Similarly, simulation provides learners opportunities for problem solving that have little or no risk to patients or to organizational performance. For example, some organizations are now using computer simulation (known as discrete event simulation) to imitate the operation of a real-life system such as a hospital. The learner’s actions in the simulation provide insight to the quality of the learner’s decision making based on priority setting, timeliness of action, and patient outcomes. In addition, simulation models are increasingly being used by schools of nursing to allow students the opportunity to gain skill mastery before working directly with acutely ill and vulnerable clients. For example, research by Shelestak, Meyers, Jarzembak, and Bradley (2015) found that the majority of students who successfully recognized cues in human patient simulation were able to make correct judgments and decisions in clinical practice (see Examining the Evidence 1.1). In addition, simulation allows students to apply and improve the critically important “nontechnical” skills of communication, teamwork, leadership, and decision making. EXAMINING THE EVIDENCE 1.1 Source: Shelestak, D. S., Meyers, T. W., Jarzembak, J. M., & Bradley, E. (2015). A process to assess clinical decision-making during human patient simulation: A pilot study. Nursing Education Perspectives, 36(3), 185–187. doi:10.5480/13-1107.1 The purpose of this pilot study of senior nursing students was to describe a process to measure clinical decision making and to examine clinical judgment of nursing students using human patient simulation (HPS). A total of 51 students participated in the study. Data were collected over six simulation sessions, with 10 students in each group. Students alternated between active participant and observer roles during the simulation; at any given time, five students had active roles and five students were observers. A descriptive design was used to assess students’ understanding at various critical decision points during an HPS. The HPS consisted of two separate situations where changes in the patient’s condition warranted action by the nurse. The scenario was developed using American Cardiac Life Support (ACLS) guidelines for bradycardia and pulseless ventricular algorithms. At Time 1, 49% correctly identified the situation; at Time 2, 71% correctly recognized the cues. The descriptive results of this pilot study suggest that correctly identifying cues is foundational to clinical decision making. The majority of students who correctly recognized cues also provided correct judgments and decisions. PBL also provides opportunities for individuals to address and learn from authentic problems vicariously. Typically, in PBL, learners meet in small groups to discuss and analyze real-life problems. Thus, they learn by problem solving. The learning itself is collaborative as the teacher guides the students to be self-directed in their learning, and many experts suggest that this type of active learning helps to develop critical thinking skills. The Marquis-Huston Critical Thinking Teaching Model The desired outcome for teaching and learning decision making and critical thinking in management is an interaction between learners and others that results in the ability to critically examine management and leadership issues. This is a learning of appropriate social/professional behaviors rather than a mere acquisition of knowledge. This type of learning occurs best in groups, using a PBL approach.Week 2 Discussion: Nursing Dream Hospital Paper

In addition, learners retain didactic material more readily when it is personalized or when they can relate to the material being presented. The use of case studies that learners can identify with assists in retention of didactic materials. Also, although formal instruction in critical thinking is important, using a formal decision-making process improves both the quality and consistency of decision making. Many new leaders and managers struggle to make quality decisions because their opportunity to practice making management and leadership decisions is very limited until they are appointed to a management position. These limitations can be overcome by creating opportunities for vicariously experiencing the problems that individuals would encounter in the real world of leadership and management. The Marquis-Huston model for teaching critical thinking assists in achieving desired learner outcomes (Fig. 1.1). Basically, the model comprises four overlapping spheres, each being an essential component for teaching leadership and management. The first is a didactic theory component, such as the material that is presented in each chapter; second, a formalized approach to problem solving and decision making must be used. Third, there must be some use of the group process, which can be accomplished through large and small groups and classroom discussion. Finally, the material must be made real for the learner so that the learning is internalized. This can be accomplished through writing exercises, personal exploration, and values clarification, along with risk taking, as case studies are examined. This book was developed with the perspective that experiential learning provides mock experiences that have tremendous value in applying leadership and management theory. The text includes numerous opportunities for readers to experience the real world of leadership and management. Some of these learning situations, called learning exercises, include case studies, writing exercises, specific management or leadership problems, staffing and budgeting calculations, group discussion or problemsolving situations, and assessment of personal attitudes and values. Some exercises include opinions, speculation, and value judgments. All of the learning exercises, however, require some degree of critical thinking, problem solving, decision making, or clinical reasoning. Experiential learning provides mock experiences that have tremendous value in applying leadership and management theory. Some of the case studies have been solved (solutions are found at the back of the book) so that readers can observe how a systematic problem-solving or decision-making model can be applied in solving problems common to nurse-managers. The authors feel strongly, however, that the problem solving suggested in the solved cases should not be considered the only plausible solution or “the right solution” to that learning exercise. Most of the learning exercises in the book have multiple solutions that could be implemented successfully to solve the problem. Theoretical Approaches to Problem Solving and Decision Making Most people make decisions too quickly and fail to systematically examine a problem or its alternatives for solution. Instead, most individuals rely on discrete, often unconscious processes known as heuristics, which allows them to solve problems more quickly and to build on experiences they have gained in their lives. Thus, heuristics use trial-and-error methods or a rule-of-thumb approach to problem solving rather than set rules. Although heuristics are often considered “second-best solutions” as a result of relying heavily on intuition and nonscientific strategies, Bodemer, Hanoch, and Katsikopoulos (2015) suggest that heuristics can actually be more accurate, faster, and easier to apply in comparison to more complex strategies. “This holds particularly true for uncertain situations such as emergency medicine where knowledge, time, and resources are limited.Week 2 Discussion: Nursing Dream Hospital Paper

However, arguing for heuristics does not assume an argument against more complex, statistical tools. The quality of any strategy depends on the environment” (p. 203). Typically, formal process and structure can benefit the decision-making process, as they force decision makers to be specific about options and to separate probabilities from values. A structured approach to problem solving and decision making increases clinical reasoning and is the best way to learn how to make quality decisions because it eliminates trial and error and focuses the learning on a proven process. A structured or professional approach involves applying a theoretical model in problem solving and decision making. Many acceptable problem-solving models exist, and most include a decision-making step; only four are reviewed here. A structured approach to problem solving and decision making increases clinical reasoning. Traditional Problem-Solving Process One of the most well-known and widely used problem-solving models is the traditional problem-solving model. The seven steps are shown in Display 1.2. (Decision making occurs at step 5.) DISPLAY 1. 2. 3. 4. 1.2 Traditional Problem-Solving Process Identify the problem. Gather data to analyze the causes and consequences of the problem. Explore alternative solutions. Evaluate the alternatives. 5. Select the appropriate solution. 6. Implement the solution. 7. Evaluate the results. Although the traditional problem-solving process is an effective model, its weakness lies in the amount of time needed for proper implementation. This process, therefore, is less effective when time constraints are a consideration. Another weakness is lack of an initial objective-setting step. Setting a decision goal helps to prevent the decision maker from becoming sidetracked. Managerial Decision-Making Models To address the weaknesses of the traditional problem-solving process, many contemporary models for management decision making have added an objective-setting step. These models are known as managerial decision-making models or rational decision-making models. One such model suggested by Decision-making-confidence.com (2006–2015) includes the six steps shown in Display 1.3. DISPLAY 1. 2. 3. 4. 5. 6. 1.3 Managerial Decision-Making Model Determine the decision and the desired outcome (set objectives). Research and identify options. Compare and contrast these options and their consequences. Make a decision. Implement an action plan. Evaluate results. In the first step, problem solvers must identify the decision to be made, who needs to be involved in the decision process, the timeline for the decision, and the goals or outcomes that should be achieved. Identifying objectives to guide the decision making helps the problem solver determine which criteria should be weighted most heavily in making their decision. Most important decisions require this careful consideration of context. In step 2, problem solvers must attempt to identify as many alternatives as possible. Alternatives are then analyzed in step 3, often using some type of SWOT (strengths, weaknesses, opportunities, and threats) analysis. Decision makers may choose to apply quantitative decision-making tools, such as decisionmaking grids and payoff tables (discussed further later in this chapter), to objectively review the desirability of alternatives. In step 4, alternatives are rank ordered on the basis of the analysis done in step 3 so that problem solvers can make a choice. In step 5, a plan is created to implement desirable alternatives or combinations of alternatives. In the final step, challenges to successful implementation of chosen alternatives are identified and strategies are developed to manage those risks. An evaluation is then conducted of both process and outcome criteria, with outcome criteria typically reflecting the objectives that were set in step 1. The Nursing Process The nursing process, developed by Ida Jean Orlando in the late 1950s, provides another theoretical system for solving problems and making decisions. Originally a four-step model (assess, plan, implement, and evaluate), diagnosis was delineated as a separate step, and most contemporary depictions of this model now include at least five steps (Display 1.4). DISPLAY 1. 2. 3. 4. 5. 1.4 Nursing Process Assess. Diagnose. Plan. Implement.Week 2 Discussion: Nursing Dream Hospital Paper

Evaluate. As a decision-making model, the greatest strength of the nursing process may be its multiple venues for feedback. The arrows in Figure 1.2 show constant input into the process. When the decision point has been identified, initial decision making occurs and continues throughout the process via a feedback mechanism. Although the process was designed for nursing practice with regard to patient care and nursing accountability, it can easily be adapted as a theoretical model for solving leadership and management problems. Table 1.1 shows how closely the nursing process parallels the decision-making process. The weakness of the nursing process, like the traditional problem-solving model, is in not requiring clearly stated objectives. Goals should be clearly stated in the planning phase of the process, but this step is frequently omitted or obscured. However, because nurses are familiar with this process and its proven effectiveness, it continues to be recommended as an adapted theoretical process for leadership and managerial decision making. Integrated Ethical Problem-Solving Model A more contemporary model for effective thinking and problem solving was developed by Park (2012) upon review of 20 existing models for ethical decision making (Display 1.5). Although developed primarily for use in solving ethical problems, the model also works well as a general problem-solving model. Similar to the three models already discussed, this model provides a structured approach to problem solving that includes an assessment of the problem, problem identification, the analysis and selection of the best alternative, and a means for evaluation. The model does go one step further, however, in requiring the learner to specifically identify strategies that reduce the likelihood of a problem recurring. DISPLAY 1. 2. 3. 4. 5. 6. 1.5 Integrated Ethical Problem-Solving Model State the problem. Collect additional information and analyze the problem. Develop alternatives and analyze and compare them. Select the best alternative and justify your decision. Develop strategies to successfully implement a chosen alternative and take action. Evaluate the outcomes and prevent a similar occurrence. Many other excellent problem analysis and decision models exist. The model selected should be one with which the decision maker is familiar and one appropriate for the problem to be solved. Using models or processes consistently will increase the likelihood that critical analysis will occur. Moreover, the quality of management/leadership problem solving and decision making will improve tremendously via a scientific approach. LEARNING EXERCISE 1.1 Applying Scientific Models to Decision Making You are a registered nurse. Since your graduation 3 years ago, you have worked as a full-time industrial health nurse for a large manufacturing plant. Although you love your family (spouse and one preschool-aged child), you love your job as well because career is very important to you. Recently, you and your spouse decided to have another baby. At that time, you and your spouse reached a joint decision that if you had another baby, you would reduce your work time and spend more time at home with the children. Last week, however, the Director of Human Resources told you that the full-time Director of Health Care Services for the plant is leaving and that the organization wants to appoint you to the position. You were initially thrilled and excited; however, you found out several days later that you and your spouse are expecting a baby. Last night, you spoke with your spouse about your career future. Your spouse is an attorney whose practice has suddenly gained momentum. Although the two of you have shared child rearing equally until this point, your spouse is not sure how much longer this can be done if the law practice continues to expand. If you take the position, which you would like to do, it would mean full-time work and more management responsibilities. You want the decision you and your spouse reach to be well-thought-out, as it has far-reaching consequences and concerns many people. ASSI GNM ENT: Determine what you should do. After you have made your decision, get together in a group (four to six people) and share your decisions. Were they the same? How did you approach the problem solving differently from others in your group? Was a rational systematic problemsolving process used, or was the chosen solution based more on intuition? How many alternatives were generated? Did some of the group members identify alternatives that you had not considered? Was a goal or objective identified? How did your personal values influence your decision? Intuitive Decision-Making Models There are theorists who suggest that intuition should always be used as an adjunct to empirical or rational decision-making models. Experienced (expert) nurses often report that gut-level feelings (intuition) encourage them to take appropriate strategic action that impacts patient outcomes (Payne, 2015), although intuition generally serves as an adjunct to decision making founded on a nurse’s scientific knowledge base. Pearson (2013) agrees, suggesting that intuition can and should be used in conjunction with evidencebased practice and that it deserves to be acknowledged as a factor in achieving good outcomes within clinical practice. Pearson goes on to say that intuition is, in reality, often a rapid, automatic process of recognizing familiar problems instantly and using experience to identify solutions. Thus, intuition may be perceived as a cognitive skill rather than a perception or knowing without knowing how. This recognition of familiar problems and the use of intuition to identify solutions is a focus of contemporary research on intuitive decision-making research. Klein (2008) developed the recognitionprimed decision (RPD) model for intuitive decision making in the mid-1980s to explain how people can make effective decisions under time pressure and uncertainty. Considered a part of naturalistic decision making, the RPD model attempts to understand how humans make relatively quick decisions in complex, real-world settings such as firefighting and critical care nursing without having to compare options. Klein’s (2008) work suggests that instead of using classical rational or systematic decision-making processes, many individuals act on their first impulse if the “imagined future” looks acceptable. If this turns out not to be the case, another idea or concept is allowed to emerge from their subconscious and is examined for probable successful implementation. Thus, the RPD model blends intuition and analysis, but pattern recognition and experience guide decision makers when time is limited or systematic rational decision making is not possible. Reiter-Palmon, Kennel, Allen, Jones, and Skinner (2015) explored naturalistic decision making in health care by studying how after-action reviews (postfall huddles) Week 2 Discussion: Nursing Dream Hospital Paper

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