Read Chapter 5
1. Describe the organizational characteristics of the facility in which you currently have a clinical assignment. Include the following:
a. Type of organization
b. Overall climate of the facility
c. How the organization is structured
d. Formal and informal goals and processes of the organization
2. Why is the work climate of an organization important to nurse leaders and managers?
3. What are the ways in which a nurse can enhance his or her expertise?
4. Explain “shared governance,” and describe how it can affect the power structure of a health-care organization.
5. Why is it important for staff nurses to understand the culture and real goals of the organization in which they work?
1. Describe your ideal organization. Explain each feature and why you think it is important.
2. Interview one of the staff nurses on your unit. Find out what practices within the organization help to empower the nurses. Compare this list of practices with those discussed in the textbook.
3. Recall the last time you walked into a hospital, clinic, or physician’s office for the first time. What was your first impression? Did you feel comfortable and welcome? Why or why not? If you could change the first impression this facility makes, what would you do?
4-What changes could be made at a very low cost? What changes would be expensive?Finally, discuss why it is important for a health-care facility to make a good first impression
APA style and Plagiarism FREE
• Sally A. Weiss and Ruth M. Tappen
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. Essentials of
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and Management
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Essentials of
Nursing Leadership
and Management
SIXTH EDITION
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Essentials of
Nursing Leadership
and Management
SIXTH EDITION
Sally A. Weiss, MSN, EdD, RN, CNE, ANEF
Professor of Nursing
Nova Southeastern University Nursing Department
Fort Lauderdale, Florida
Ruth M. Tappen, EdD, RN, FAAN
Christine E. Lynn Eminent Scholar and Professor
Florida Atlantic University College of Nursing
Boca Raton, Florida
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F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2015 by F. A. Davis Company
Copyright © 2015, 2010, 2007, 2004, 2001, 1998 by F. A. Davis Company. All rights reserved. This book
is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in
any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written
permission from the publisher.
Printed in the United States of America
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
Acquisitions Editor, Nursing: Megan Klim
Developmental Editor: Laurie Sparks
Director of Content Development: Darlene D. Pedersen
Content Project Manager: Echo Gerhart
Electronic Project Editor: Katherine Crowley
Design and Illustration Manager: Carolyn O’Brien
As new scientific information becomes available through basic and clinical research, recommended treat-
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v
Dedication
To my granddaughter Sydni and my grandson Logan,
who remind me how important it is to nurture our young nurses
and help them learn and grow.
—SALLY A. WEISS
To students, colleagues, family, and friends,
who have taught me so much about leadership.
—RUTH M. TAPPEN
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vii
Preface
We are delighted to bring our readers this Sixth Edition of Essentials of Nursing Leadership and
Management. This new edition has been updated to reflect the dynamic health care environment,
safety initiatives, and changes in nursing practice. As in our previous editions, the content, examples,
and diagrams were designed with the goal of assisting the new graduate to make the transition to
professional nursing practice.
The Sixth Edition of Essentials of Nursing Leadership and Management focuses on the necessary
knowledge and skills needed by the staff nurse as an integral member of the interprofessional health-
care team and manager of patient care. Issues related to setting priorities, delegation, quality improve-
ment, legal parameters of nursing practice, and ethical issues are updated for this edition.
This edition focuses on the current quality and safety issues and initiatives impacting the current
health-care environment. We continue to bring you comprehensive, practical information on develop-
ing a nursing career. Updated information on leading, managing, followership, and workplace issues
continue to be included.
Essentials of Nursing Leadership and Management provides a strong foundation for the beginning
nurse leader. We would like to thank the people at F. A. Davis for their assistance and our contribu-
tors, reviewers, and students for their guidance and support.
—SALLY A. WEISS
—RUTH M. TAPPEN
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ix
Contributor
PATRICIA BRADLEY, MED, PHD, RN
Coordinator, Internationally Educated Nurses Program
Faculty, Nursing Department
York University
Toronto, Ontario, Canada
Reviewers
WENDY GREENSPAN, MSN, RN, CCRN, CNE
Assistant Professor
Rockland Community College
Suffem, New York
PAULA HOPPER, MSN, RN, CNE
Professor of Nursing
Jackson Community College
Jackson, Mississippi
CLAIRE MEGGS, MSN, RN
Associate Professor
Lincoln Memorial University
Harrogate, Tennessee
LUISE SPEAKMAN, PHD, RN
Adjunct Faculty, Nursing
Cape Cod Community College
West Barnstable, Massachusetts
JENNIFER SUGG, RN, BSN, MSN, CCRN
Nursing Instructor
Wayne Community College
Goldsboro, North Carolina
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xi
Table of Contents
unit 1 Professional Considerations 1
chapter 1 Leadership and Followership 3
chapter 2 Manager 17
chapter 3 Nursing Practice and the Law 27
chapter 4 Questions of Values and Ethics 49
unit 2 Working Within an Organization 69
chapter 5 Organizations, Power, and Empowerment 71
chapter 6 Communicating With Others and Working
With the Interprofessional Team 87
chapter 7 Delegation and Prioritization of Client Care 103
chapter 8 Dealing With Problems and Conflict 121
chapter 9 People and the Process of Change 133
unit 3 Career Considerations 145
chapter 10 Issues of Quality and Safety 147
chapter 11 Promoting a Healthy Work Environment 173
unit 4 Professional Issues 203
chapter 12 Your Nursing Career 205
chapter 13 Evolution of Nursing as a Profession 225
chapter 14 Looking to the Future 235
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xii ■ Table of Contents
Appendices
appendix 1 Codes of Ethics for Nurses 247
American Nurses Association Code of Ethics for Nurses
Canadian Nurse Association Code of Ethics for Registered Nurses
The International Council of Nurses Code of Ethics for Nurses
appendix 2 Standards Published by the American Nurses
Association 249
appendix 3 Guidelines for the Registered Nurse in Giving,
Accepting, or Rejecting a Work Assignment 251
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unit 1
Professional Considerations
chapter 1 Leadership and Followership
chapter 2 Manager
chapter 3 Nursing Practice and the Law
chapter 4 Questions of Values and Ethics
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3
chapter 1
Leadership and Followership
OBJECTIVES
After reading this chapter, the student should be able to:
■ Define the terms leadership and followership.
■ Discuss the importance of effective leadership and
followership for the new nurse.
■ Discuss the qualities and behaviors that contribute to
effective leadership.
■ Discuss the qualities and behaviors that contribute to
effective followership.
OUTLINE
Leadership
Are You Ready to Be a Leader?
Leadership Defined
What Makes a Person a Leader?
Leadership Theories
Trait Theories
Behavioral Theories
Task Versus Relationship
Motivation Theories
Emotional Intelligence
Situational Theories
Transformational Leadership
Moral Leadership
Caring Leadership
Qualities of an Effective Leader
Behaviors of an Effective Leader
Followership
Followership Defined
Becoming a Better Follower
Managing Up
Conclusion
Nurses study leadership to learn how to work well
with other people. We work with an extraordinary
variety of people: technicians, aides, unit managers,
housekeepers, patients, patients’ families, physi-
cians, respiratory therapists, physical therapists,
social workers, psychologists, and more. In this
chapter, the most prominent leadership theories are
introduced. Then, the characteristics and behaviors
that can make you, a new nurse, an effective leader
and follower are discussed.
Leadership
Are You Ready to Be a Leader?
You may be thinking, “I’m just beginning my career
in nursing. How can I be expected to be a leader
now?” This is an important question. You will need
time to refine your clinical skills and learn how to
function in a new environment. But you can begin
to assume some leadership functions right away
within your new nursing roles. In fact, leadership
should be seen as a dimension of nursing practice
(Scott & Miles, 2013). Consider the following
example:
Billie Thomas was a new staff nurse at Green Valley
Nursing Care Center. After orientation, she was
assigned to a rehabilitation unit with high ad-
mission and discharge rates. Billie noticed that
admissions and discharges were assigned rather hap-
hazardly. Anyone who was “free” at the moment was
directed to handle them. Sometimes, unlicensed as-
sistant personnel were directed to admit or discharge
residents. Billie believed that this was inappropriate
because they are not prepared to do assessments and
they had no preparation for discharge planning.
Billie had an idea how discharge planning could
be improved but was not sure that she should bring
it up because she was so new. “Maybe they’ve already
thought of this,” she said to a former classmate. They
began to talk about what they had learned in their
leadership course before graduation. “I just keep
hearing our instructor saying, ‘There’s only one
manager, but anyone can be a leader.’ ”
“If you want to be a leader, you have to act on
your idea. Why don’t you talk with your nurse
manager?” her friend asked.
“Maybe I will,” Billie replied.
Billie decided to speak with her nurse manager,
an experienced rehabilitation nurse who seemed not
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4 unit 1 ■ Professional Considerations
only approachable but also open to new ideas. “I
have been so busy getting our new electronic health
record system on line before the surveyors come that
I wasn’t paying attention to that,” the nurse manager
told her. “I’m glad you brought it to my attention.”
Billie’s nurse manager raised the issue at the next
executive meeting, giving credit to Billie for having
brought it to her attention. The other nurse manag-
ers had the same response. “We were so focused on
the new electronic health record system that we
overlooked that. We need to take care of this situa-
tion as soon as possible. Billie Thomas has leadership
potential.”
Leadership Defined
Successful nurse leaders are those who engage
others to work together effectively in pursuit of a
shared goal. Examples of shared goals in nursing
would be providing excellent care, reducing infec-
tion rates, designing cost-saving procedures, or
challenging the ethics of a new policy.
Leadership is a much broader concept than is
management. Although managers need to be
leaders, management itself is focused specifically on
achievement of organizational goals. Leadership,
on the other hand:
. . . occurs whenever one person attempts to influence
the behavior of an individual or group—up, down,
or sideways in the organization—regardless of the
reason. It may be for personal goals or for the goals
of others, and these goals may or may not be congru-
ent with organizational goals. Leadership is influ-
ence (Hersey & Campbell, 2004, p. 12).
In order to lead, one must develop three important
competencies: (1) diagnose: ability to understand
the situation you want to influence, (2) adapt: make
changes that will close the gap between the current
situation and what you are hoping to achieve, and
(3) communicate. No matter how much you diag-
nose or adapt, if you cannot communicate effec-
tively, you will probably not meet your goal (Hersey
& Campbell, 2004).
What Makes a Person a Leader?
Leadership Theories
There are many different ideas about how a person
becomes a good leader. Despite years of research on
this subject, no one idea has emerged as the clear
winner. The reason for this may be that different
qualities and behaviors are most important in dif-
ferent situations. In nursing, for example, some
situations require quick thinking and fast action.
Others require time to figure out the best solution
to a complicated problem. Different leadership
qualities and behaviors are needed in these two
instances. The result is that there is not yet a single
best answer to the question, “What makes a person
a leader?”
Consider some of the best-known leadership
theories and the many qualities and behaviors that
have been identified as those of the effective nurse
leader (Pavitt, 1999; Tappen, 2001):
Trait Theories
At one time or another, you have probably heard
someone say, “She’s a born leader.” Many believe
that some people are natural leaders, while others
are not. It is true that leadership may come
more easily to some than to others, but everyone
can be a leader, given the necessary knowledge
and skill.
An important 5-year study of 90 outstanding
leaders by Warren Bennis published in 1984 identi-
fied four common traits. These traits hold true
today:
1. Management of attention. These leaders
communicated a sense of goal direction that
attracted followers.
2. Management of meaning. These leaders created
and communicated meaning and purpose.
3. Management of trust. These leaders
demonstrated reliability and consistency.
4. Management of self. These leaders knew
themselves well and worked within their
strengths and weaknesses (Bennis, 1984).
Behavioral Theories
The behavioral theories focus on what the leader
does. One of the most influential behavioral theo-
ries is concerned with leadership style (White &
Lippitt, 1960) (Table 1-1).
The three styles are:
1. Autocratic leadership (also called directive,
controlling, or authoritarian). The autocratic
leader gives orders and makes decisions for the
group. For example, when a decision needs to
be made, an autocratic leader says, “I’ve decided
that this is the way we’re going to solve our
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chapter 1 ■ Leadership and Followership 5
problem.” Although this is an efficient way to
run things, it squelches creativity and may
reduce team member motivation.
2. Democratic leadership (also called
participative). Democratic leaders share
leadership. Important plans and decisions are
made with the team (Chrispeels, 2004).
Although this appears to be a less efficient way
to run things, it is more flexible and usually
increases motivation and creativity. In fact,
involving team members, giving them
“permission to think, speak and act” brings out
the best in them and makes them more
productive, not less (Wiseman & McKeown,
2010, p. 3). Decisions may take longer to make,
but once made everyone supports them
(Buchanan, 2011).
3. Laissez-faire leadership (also called permissive
or nondirective). The laissez-faire (“let someone
do”) leader does very little planning or decision
making and fails to encourage others to do it.
It is really a lack of leadership. For example,
when a decision needs to be made, a laissez-
faire leader may postpone making the decision
or never make the decision at all. In most
instances, the laissez-faire leader leaves people
feeling confused and frustrated because there is
no goal, no guidance, and no direction. Some
mature, self-motivated individuals thrive under
laissez-faire leadership because they need little
direction. Most people, however, flounder under
this kind of leadership.
Pavitt summed up the differences among these
three styles: a democratic leader tries to move the
group toward its goals; an autocratic leader tries to
move the group toward the leader’s goals; and a
laissez-faire leader makes no attempt to move the
group (1999, pp. 330ff ).
Task Versus Relationship
Another important distinction is between a task
focus and a relationship focus (Blake, Mouton, &
Tapper, 1981). Some nurses emphasize the tasks
(e.g., administering medication, completing patient
records) and fail to recognize that interpersonal
relationships (e.g., attitude of physicians toward
nursing staff, treatment of housekeeping staff by
nurses) affect the morale and productivity of
employees. Others focus on the interpersonal
aspects and ignore the quality of the job being done
as long as people get along with each other. The
most effective leader is able to balance the two,
attending to both the task and the relationship
aspects of working together.
Motivation Theories
The concept of motivation seems simple: we will
act to get what we want but avoid whatever we
don’t want to do. However, motivation is still sur-
rounded in mystery. The study of motivation as
a focus of leadership began in the 1920s with
the historic Hawthorne studies. Several experi-
ments were conducted to see if increasing light and,
later, improving other working conditions would
increase the productivity of workers in the Haw-
thorne, Illinois, electrical plant. This proved to be
true, but then something curious happened: when
the improvements were taken away, the workers
continued to show increased productivity. The
researchers concluded that the explanation was
found not in the conditions of the experiments
but in the attention given to the workers by the
experimenters.
table 1-1
Comparison of Autocratic, Democratic, and Laissez-Faire Leadership Styles
Autocratic Democratic Laissez-Faire
Amount of freedom Little freedom Moderate freedom Much freedom
Amount of control High control Moderate control Little control
Decision making By the leader Leader and group together By the group or by no one
Leader activity level High High Minimal
Assumption of responsibility Leader Shared Abdicated
Output of the group High quantity, good quality Creative, high quality Variable, may be poor quality
Efficiency Very efficient Less efficient than autocratic style Inefficient
Source: Adapted from White, R.K., & Lippitt, R. (1960). Autocracy and democracy: An experimental inquiry. New
York: Harper & Row.
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6 unit 1 ■ Professional Considerations
Frederick Herzberg and David McClelland also
studied factors that motivated workers in the work-
place. Their findings are similar to the elements in
Maslow’s Hierarchy of Needs. Table 1-2 summa-
rizes these three historical motivation theories that
continue to be used by leaders today (Herzberg,
1966; Herzberg, Mausner, & Snyderman, 1959;
Maslow, 1970; McClelland, 1961).
Emotional Intelligence
The relationship aspects of leadership are also the
focus of the work on emotional intelligence and
leadership (Goleman, Boyatzes, & McKee, 2002).
From the perspective of emotional intelligence,
what distinguishes ordinary leaders from leadership
“stars” is that the “stars” are consciously addressing
the effect of people’s feelings on the team’s emo-
tional reality.
How is this done? First, the emotionally intel-
ligent leader recognizes and understands his or her
own emotions. When a crisis occurs, he or she is
able to manage them, channel them, stay calm and
clearheaded, and suspend judgment until all the
facts are in (Baggett & Baggett, 2005).
Second, the emotionally intelligent leader
welcomes constructive criticism, asks for help
when needed, can juggle multiple demands with-
out losing focus, and can turn problems into
opportunities.
Third, the emotionally intelligent leader listens
attentively to others, recognizes unspoken concerns,
acknowledges others’ perspectives, and brings
people together in an atmosphere of respect, coop-
eration, collegiality, and helpfulness so they can
direct their energies toward achieving the team’s
goals. “The enthusiastic, caring, and supportive
leader generates those same feelings throughout the
team,” wrote Porter-O’Grady of the emotionally
intelligent leader (2003, p. 109).
Situational Theories
People and leadership situations are far more
complex than the early theories recognized. Situa-
tions can also change rapidly, requiring more
complex theories to explain leadership (Bennis,
Spreitzer, & Cummings, 2001).
Instead of assuming that one particular approach
works in all situations, situational theories recog-
nize the complexity of work situations and encour-
age the leader to consider many factors when
deciding what action to take. Adaptability is the
key to the situational approach (McNichol, 2000).
Situational theories emphasize the importance
of understanding all the factors that affect a par-
ticular group of people in a particular environment.
The most well-known is the Situational Leader-
ship Model by Dr. Paul Hersey. The appeal of this
model is that it focuses on the task and the follower.
table 1-2
Leading Motivation Theories
Theory Summary of Motivation Requirements
Maslow, 1954 Categories of Need: Lower needs (listed first below) must be fulfilled before others are activated.
Physiological
Safety
Belongingness
Esteem
Self-actualization
Herzberg, 1959 Two factors that influence motivation. The absence of hygiene factors can create job dissatisfaction, but
their presence does not motivate or increase satisfaction.
1. Hygiene factors: Company policy, supervision, interpersonal relations, working conditions, salary
2. Motivators: Achievement, recognition, the work itself, responsibility, advancement
McClelland,
1961
Motivation results from three dominant needs. Usually all three needs are present in each individual but
vary in importance depending on the position a person has in the workplace. Needs are also shaped
over time by culture and experience.
1. Need for achievement: Performing tasks on a challenging and high level
2. Need for affiliation: Good relationships with others
3. Need for power: Being in charge
Source: Adapted from Hersey, P., & Campbell, R. (2004). Leadership: A behavioral science approach. Calif.:
Leadership Studies Publishing.
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chapter 1 ■ Leadership and Followership 7
The key is to marry the readiness of the follower
with the tasks at hand. “Readiness is defined as the
extent to which a follower demonstrates the ability
and willingness to accomplish a specific task”
(Hersey & Campbell, 2004, p. 114). “The leader
needs to spell out the duties and responsibilities of
the individual and the group” (Hersey & Campbell,
2004).
Followers’ readiness levels can range from unable,
unwilling, and insecure to able, willing, and confi-
dent. The leader’s behavior will focus on appropri-
ately fulfilling the followers’ needs, which are
identified by their readiness level and the task.
Leader behaviors will range from telling, guid-
ing, and directing to delegating, observing, and
monitoring.
Where did you fall in this model during your
first clinical rotation? Compare this with where you
are now. In the beginning, the clinical instructor
gave you clear instructions, closely guiding and
directing you. Now, she or he is most likely delegat-
ing, observing, and monitoring. As you move into
your first nursing position, you may return to the
needing, guiding, and directing stage. But, you may
soon become a leader/instructor for new nursing
students, guiding and directing them.
Transformational Leadership
Although the situational theories were an improve-
ment over earlier theories, there was still something
missing. Meaning, inspiration, and vision were not
given enough attention (Tappen, 2001). These are
the distinguishing features of transformational
leadership.
The transformational theory of leadership
emphasizes that people need a sense of mission that
goes beyond good interpersonal relationships or an
appropriate reward for a job well done (Bass &
Avolio, 1993). This is especially true in nursing.
Caring for people, sick or well, is the goal of the
profession. Most people chose nursing in order to
do something for the good of humankind; this is
their vision. One responsibility of nursing leader-
ship is to help nurses see how their work helps
them achieve their vision.
Transformational leaders can communicate their
vision in a manner that is so meaningful and excit-
ing that it reduces negativity (Leach, 2005) and
inspires commitment in the people with whom
they work (Trofino, 1995). Dr. Martin Luther King
Jr. had a vision for America: “I have a dream that
one day my children will be judged by the content
of their character, not the color of their skin” (quoted
by Blanchard & Miller, 2007, p. 1). A great leader
shares his or her vision with his followers. You can
do the same with your colleagues and team. If suc-
cessful, the goals of the leader and staff will “become
fused, creating unity, wholeness, and a collective
purpose” (Barker, 1992, p. 42). See Box 1-1 for an
example of a leader with visionary goals.
Moral Leadership
A series of highly publicized corporate scandals
redirected attention to the values and ethics that
underlie the practice of leadership as well as that of
patient care (Dantley, 2005). Moral leadership
involves deciding how one ought to remain honest,
fair, and socially responsible (Bjarnason & LaSala,
2011) under any circumstances. Caring about one’s
patients and the people who work for you as people
as well as employees (Spears & Lawrence, 2004) is
part of moral leadership. This can be a great chal-
lenge in times of limited financial resources.
Molly Benedict was a team leader on the acute geri-
atric unit (AGU) when a question of moral leader-
ship arose. Faced with large budget cuts in the
middle of the year and feeling a little desperate to
f igure out how to run the AGU with fewer staff,
her nurse manager suggested that reducing the time
that unlicensed assistive personnel (UAP) spent
ambulating patients would enable UAPs to care
for 15 patients, up from the current 10 per UAP.
This is leadership on the very grandest scale. BHAGs are
Big, Hairy, Audacious Goals. Coined by Jim Collins,
BHAGs are big ideas, visions for the future. Here is an
example:
Gigi Mander, originally from the Philippines, dreams of
buying hundreds of acres of farmland for peasant families
in Asia or Africa. She would install irrigation systems,
provide seed and modern farming equipment, and help
them market their crops. This is not just a dream, however;
she has a business plan for her BHAG and is actively
seeking investors.
Imagination, creativity, planning, persistence, audacity,
courage: these are all needed to put a BHAG into
practice.
Do you have a BHAG? How would you make it real?
box 1-1
BHAGs, Anyone?
Adapted from Buchanan, L. (2012). The world needs big ideas. INC
Magazine, 34(9), 57–58.
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8 unit 1 ■ Professional Considerations
“George,” responded Molly, “you know that inactiv-
ity has many harmful effects, from emboli to disori-
entation, in our very elderly population. Let’s try to
f igure out how to encourage more self-care and even
family involvement in care so the UAPs can still
have time to walk patients and prevent their becom-
ing nonambulatory.”
Molly based her action on important values, par-
ticularly those of providing the highest quality care
possible. Stewart and colleagues (2012) urge that
caring not be sacrificed at the altar of efficiency
(p. 227). This example illustrates how great a chal-
lenge that can be for today’s nurse leaders. The
American Nurses Association Code of Ethics
(2001) provides the moral compass for nursing
practice and leadership (ANA, 2001; Bjarnason &
LaSala, 2011).
Box 1-2 summarizes a contemporary list of 13
distinctive leadership styles, most of which match
up to the eight theories just discussed.
Caring Leadership
Caring leadership in nursing comes from two
primary sources: servant leadership and emotional
intelligence in the management literature, and
caring as a foundational value in nursing (Green-
leaf, 2008; McMurry, 2012; Rhodes, Morris, &
Lazenby, 2011; Spears, 2010). While it is uniquely
suited to nursing leadership, it is hard to imagine
any situation in which an uncaring leader would be
preferred over a caring leader.
Servant-leaders choose to serve first and lead
second, making sure that people’s needs within the
work setting are met (Greenleaf, 2008). Emotion-
ally intelligent leaders are especially aware of not
only their own feelings but others’ feelings as well
(see Box 1-1). Combining these leadership and
management theories and the philosophy of caring
in nursing, you can see that caring leadership is
fundamentally people-oriented. The following are
the characteristics and behaviors of caring leaders:
■ They respect their coworkers as individuals.
■ They listen to other people’s opinions and
preferences, giving them full consideration.
■ They maintain awareness of their own and
others’ feelings.
■ They empathize with others, understanding
their needs and concerns.
■ They develop their own and their team’s
capacities.
■ They are competent, both in leadership and in
clinical practice. This includes both knowledge
and skill in leadership and clinical practice.
As you can see, caring leadership cuts across the
leadership theories discussed so far and encom-
passes some of their best features. An authoritarian
leader, for example, can be as caring as a democratic
leader (Dorn, 2011). Caring leadership is attractive
to many nurses because it applies many of the prin-
ciples of working with patients and working with
nursing staff to the interdisciplinary team.
Qualities of an Effective Leader
If leadership is seen as the ability to influence, what
qualities must the leader possess in order to be able
to do that? Integrity, courage, positive attitude, ini-
tiative, energy, optimism, perseverance, generosity,
balance, ability to handle stress, and self-awareness
are some of the qualities of effective leaders in
nursing (Fig. 1.1):
■ Integrity. Integrity is expected of health-care
professionals. Patients, colleagues, and
1. Adaptive: flexible, willing to change and devise new
approaches.
2. Emotionally Intelligent: aware of his/her own and
others’ feelings.
3. Charismatic: magnetic personalities who attract
people to follow them.
4. Authentic: demonstrates integrity, character, and
honesty in relating to others.
5. Level 5: ferociously pursues goals but gives credit to
others and takes responsibility for his/her mistakes.
6. Mindful: thoughtful, analytic, and open to new ideas.
7. Narcissistic: doesn’t listen to others and doesn’t
tolerate disagreement but may have a compelling
vision.
8. No Excuse: mentally tough, emphasizes accountability
and decisiveness.
9. Resonant: motivates others through their energy and
enthusiasm.
10. Servant: “empathic, aware and healing,” (p. 76)
leads to serve others.
11. Storyteller: uses stories to convey messages in a
memorable, motivating fashion.
12. Strength-Based: focuses and capitalizes on his/her
own and others’ talents.
13. Tribal: build a common culture with strong sharing of
values and beliefs.
box 1-2
Distinctive Styles of Leadership
Adapted from Buchanan, L. (2012/June). 13 ways of looking at a
leader. INC Magazine, 74–76.
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chapter 1 ■ Leadership and Followership 9
employers all expect nurses to be honest,
law-abiding, and trustworthy. Adherence
to both a code of personal ethics and a
code of professional ethics (Appendix 1,
American Nurses Association Code of Ethics
for Nurses) is expected of every nurse.
Would-be leaders who do not exhibit these
characteristics cannot expect them of their
followers. This is an essential component of
moral leadership.
■ Courage. Sometimes, being a leader means
taking some risks. In the story of Billie
Thomas, for example, Billie needed some
courage to speak to her nurse manager about a
problem she had observed.
■ Positive attitude. A positive attitude goes a
long way in making a good leader. In fact,
many outstanding leaders cite negative attitude
as the single most important reason for not
hiring someone (Maxwell, 1993, p. 98).
Sometimes a leader’s attitude is noticed by
followers more quickly than are the leader’s
actions.
■ Initiative. Good ideas are not enough. To be a
leader, you must act on those good ideas. No
one will make you do this; this requires
initiative on your part.
■ Energy. Leadership requires energy. Both
leadership and followership are hard but
satisfying endeavors that require effort. It
is also important that the energy be used
wisely.
■ Optimism. When the work is difficult and
one crisis seems to follow another in rapid
succession, it is easy to become discouraged. It
is important not to let discouragement keep
you and your coworkers from seeking ways to
resolve the problems. In fact, the ability to see
a problem as an opportunity is part of the
optimism that makes a person an effective
leader. Like energy, optimism is “catching.”
Holman (1995) called this being a winner
instead of a whiner (Table 1-3).
■ Perseverance. Effective leaders do not give up
easily. Instead, they persist, continuing their
efforts when others are tempted to stop trying.
This persistence often pays off.
■ Generosity. Freely sharing your time, interest,
and assistance with your colleagues is a trait of
a generous leader. Sharing credit for successes
and support when needed are other ways to be
a generous leader (Buchanan, 2013; Disch,
2013).
■ Balance. In the effort to become the best
nurses they can be, some nurses may forget
that other aspects of life are equally important.
As important as patients and colleagues are,
family and friends are important, too.
Although school and work are meaningful
activities, cultural, social, recreational, and
spiritual activities also have meaning. You need
to find a balance between work and play.
■ Ability to handle stress. There is some stress
in almost every job. Coping with stress in as
positive and healthy a manner as possible helps
to conserve energy and can be a model for
Qualities
Behaviors
Integrity
Courage
Initiative
Energy
Optimism
Perseverance
Balance
Ability to
handle stress
Self-awareness
Think critically
Solve problems
Communicate
skillfully
Set goals, share
vision
Develop self and
others
Figure 1.1 Keys to effective leadership.
table 1-3
Winner or Whiner—Which Are You?
A winner says: A whiner says:
“We have a real challenge
here.”
“This is really a problem.”
“I’ll give it my best.” “Do I have to?”
“That’s great!” “That’s nice, I guess.”
“We can do it!” “That will never succeed.”
“Yes!” “Maybe . . .”
Source: Adapted from Holman, L. (1995). Eleven lessons in self-
leadership: Insights for personal and professional success.
Lexington, Ky.: A Lesson in Leadership Book.
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10 unit 1 ■ Professional Considerations
others. Maintaining balance and handling
stress are reviewed in Chapter 11.
■ Self-awareness. How sharp is your emotional
intelligence? People who do not understand
themselves are limited in their ability to
understand people with whom they are
working. They are far more likely to fool
themselves than are self-aware people. For
example, it is much easier to be fair with a
coworker you like than with one you do not
like. Recognizing that you like some people
more than others is the first step in avoiding
unfair treatment based on personal likes and
dislikes.
Behaviors of an Effective Leader
Leadership requires action. The effective leader
chooses the action carefully. Important leadership
behaviors include setting priorities, thinking criti-
cally, solving problems, respecting people, commu-
nicating skillfully, communicating a vision for the
future, and developing oneself and others.
■ Setting priorities. Whether planning care for
a group of patients or creating a strategic plan
for an organization, priorities continually shift
and demand your attention. As a leader you
will need to remember the three E’s of
prioritization: evaluate, eliminate, and estimate.
Continually evaluate what you need to do,
eliminate tasks that someone else can do, and
estimate how long your top priorities will take
you to complete.
■ Thinking critically. Critical thinking is the
careful, deliberate use of reasoned analysis
to reach a decision about what to believe or
what to do (Feldman, 2002). The essence
of critical thinking is a willingness to ask
questions and to be open to new ideas or new
ways to do things. To avoid falling prey to
assumptions and biases of your own or others,
ask yourself frequently, “Do I have the
information I need? Is it accurate? Am I
prejudging a situation?” ( Jackson, Ignatavicius,
& Case, 2004).
■ Solving problems. Patient problems,
paperwork problems, staff problems: these and
others occur frequently and need to be solved.
The effective leader helps people identify
problems and work through the problem-
solving process to find a reasonable solution.
■ Respecting and valuing the individual.
Although people have much in common, each
individual has different wants and needs and
has had different life experiences. For example,
some people really value the psychological
rewards of helping others; other people are
more concerned about earning a decent salary.
There is nothing wrong with either of these
points of view; they are simply different. The
effective leader recognizes these differences in
people and helps them find the rewards in
their work that mean the most to them.
■ Skillful communication. This includes
listening to others, encouraging exchange of
information, and providing feedback:
1. Listening to others. Listening is separate
from talking with other people; listening
involves both giving and receiving
information. The only way to find out
people’s individual wants and needs is to
watch what they do and to listen to what
they say. It is amazing how often leaders fail
simply because they did not listen to what
other people were trying to tell them.
2. Encouraging exchange of information. Many
misunderstandings and mistakes occur
because people fail to share enough
information with each other. The leader’s
role is to make sure that the channels of
communication remain open and that
people use them.
3. Providing feedback. Everyone needs some
information about the effectiveness of their
performance. Frequent feedback, both
positive and negative, is needed so people
can continually improve their performance.
Some nurse leaders find it difficult to give
negative feedback because they fear that
they will upset the other person. How else
can the person know where improvement is
needed? Negative feedback can be given in
a manner that is neither hurtful nor
resented by the individual receiving it. In
fact, it is often appreciated. Other nurse
leaders, however, fail to give positive
feedback, assuming that coworkers will
know when they are doing a good job. This
is also a mistake because everyone
appreciates positive feedback. In fact, for
some people, it is the most important
reward they get from their jobs.
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chapter 1 ■ Leadership and Followership 11
■ Communicating a vision for the future. The
effective leader has a vision for the future.
Communicating this vision to the group and
involving everyone in working toward that
vision generate the inspiration that keeps
people going when things become difficult.
Even better, involving people in creating the
vision is not only more satisfying for
employees but also has the potential to
produce the most creative and innovative
outcomes (Kerfott, 2000). It is this vision that
helps make work meaningful.
■ Developing oneself and others. Learning
does not end upon leaving school. In fact,
experienced nurses say that school is just the
beginning, that school only prepares you to
continue learning throughout your career. As
new and better ways to care for patients are
developed, it is your responsibility as a
professional to critically analyze them and
decide whether they would be better for your
patients than current ones. Effective leaders not
only continue to learn but also encourage others
to do the same. Sometimes, leaders function as
teachers. At other times, their role is primarily
to encourage others to seek more knowledge.
Anderson, Manno, O’Connor, and Gallagher (2010)
invited five nurse managers from Penn Presbyterian
Medical Center who had received top ratings in
leadership from their staff to participate in a focus
group on successful leadership. They reported that
visibility, communication, and the values of respect
and empathy were the key elements of successful
leadership. The authors quoted participants to
illustrate each of these elements (p. 186):
Visibility: “I try to come in on the off shifts even
for an hour or two just to have them see you.”
Communication: “Candid feedback” “A lot of
rounding.” (Note: this could also be
visibility.)
Respect and Empathy: “Do I expect you to
take seven patients? No, because I wouldn’t
be able to do it.” (punctuation adjusted).
These three key elements draw on components
from several leadership qualities and behaviors:
skillful communication, respecting and valuing the
individual, and energy. Visibility is not as pro-
minent in many of the leadership theories but
deserves a place in the description of what effective
leaders do.
Followership
Followership and leadership are separate but com-
plementary roles. The roles are also reciprocal:
without followers, one cannot be a leader. One also
cannot be a follower without having a leader (Lyons,
2002).
It is as important to be an effective follower as
it is to be an effective leader. In fact, most of us
are followers: members of a team, attendees at a
meeting, staff of a nursing care unit, and so forth.
Followership Defined
Followership is not a passive role. On the contrary,
the most valuable follower is a skilled, self-directed
professional, one who participates actively in deter-
mining the group’s direction, invests his or her time
and energy in the work of the group, thinks criti-
cally, and advocates for new ideas (Grossman &
Valiga, 2000).
Imagine working on a patient care unit where
all staff members, from the unit secretary to the
assistant nurse manager, willingly take on extra
tasks without being asked (Spreitzer & Quinn,
2001), come back early from coffee breaks if they
are needed, complete their charting on time, support
ways to improve patient care, and are proud of the
high-quality care they provide. Wouldn’t it be won-
derful to be a part of that team?
Becoming a Better Follower
There are a number of things you can do to become
a better follower:
■ If you discover a problem, inform your team
leader or manager right away.
■ Even better, include a suggestion for solving
the problem in your report.
■ Freely invest your interest and energy in your
work.
■ Be supportive of new ideas and new directions
suggested by others.
■ When you disagree, explain why.
■ Listen carefully and reflect on what your leader
or manager says.
■ Continue to learn as much as you can about
your specialty area.
■ Share what you learn.
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12 unit 1 ■ Professional Considerations
Being an effective follower not only will make you
a more valuable employee but will also increase the
meaning and satisfaction that you get from your
work.
Managing Up
Most team leaders and nurse managers respond
positively to having staff who are good followers.
Occasionally, you will encounter a poor leader or
manager who can confuse, frustrate, and even dis-
tress you. Here are a few suggestions for handling
this:
■ Avoid adopting the ineffective behaviors of
this individual.
■ Continue to do your best work and to
contribute leadership to the group.
■ If the situation worsens, enlist the support of
others on your team to seek a remedy; do not
try to do this alone as a new graduate.
■ If the situation becomes intolerable, consider
the option of transferring to another unit or
seeking another position (Deutschman, 2005;
Korn, 2004).
There is still more a good follower can do. This is
called managing up. Managing up is defined as “the
process of consciously working with your boss to
obtain the best possible results for you, your boss,
and your organization” (Zuber & James quoted by
Turk, 2007, p. 21). This is not a scheme to mani-
pulate your manager or to get more rewards than
you have earned. Instead, it is a guide for better
understanding your manager, what he or she expects
of you, and what your manager’s own needs might
be.
Every manager has areas of strength and weak-
ness. A good follower recognizes these and helps
the manager capitalize on areas of strength and
compensate for areas of weakness. For example, if
your nurse manager is slow completing quality
improvement reports, you can offer to help get
them done. On the other hand, if your nurse
manager seems to be especially skilled in defusing
conflicts between attending physicians and nursing
staff, you can observe how he handles these situa-
tions and ask him how he does it. Remember that
your manager is human, a person with as many
needs, concerns, distractions, and ambitions as
anyone else. This will help you keep your expecta-
tions of your manager realistic and reduce the dis-
tance between you and your manager.
There are several other ways in which to manage
up. U.S. Army General and former Secretary of
State Colin Powell said, “You can’t make good deci-
sions unless you have good information” (Powell,
2012, p. 42). Keep your manager informed. No one
likes to be surprised, least of all a manager who
finds that you have known about a problem (a
nursing assistant who is spending too much time
in the staff lounge, for example) and not brought it
to her attention until it became critical. When you
do bring a problem to your manager’s attention,
try to have a solution to offer. This is not always
possible, but when it is, it will be very much
appreciated.
Finally, show your appreciation whenever pos-
sible (Bing, 2010). Show respect for your manager’s
authority and appreciation for what your manager
does for the staff of your unit. Let others know of
your appreciation, particularly those to whom your
manager must answer.
Conclusion
To be an effective nurse, you need to be an effective
leader. Your patients, peers, and employer are
depending on you to lead. Successful leaders
never stop learning and growing. John Maxwell
(1998), an expert on leadership, wrote, “Who we
are is who we attract” (p. xi). To attract leaders,
people need to start leading and never stop learning
to lead.
The key elements of leadership and followership
have been discussed in this chapter. Many of the
leadership and followership qualities and behaviors
mentioned here are discussed in more detail in later
chapters.
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chapter 1 ■ Leadership and Followership 13
Study Questions
1. Why is it important for nurses to be good leaders? What qualities have you observed from
nurses that exemplify effective leadership in action? How do you think these behaviors might
have improved the outcomes of their patients?
2. Why are effective followers as important as effective leaders?
3. Review the various leadership theories discussed in the chapter. Which ones especially apply to
leading in today’s health-care environment? Support your answer with specific examples.
4. Select an individual whose leadership skills you particularly admire. What are some qualities
and behaviors that this individual displays? How do these relate to the leadership theories
discussed in this chapter? In what ways could you emulate this person?
5. As a new graduate, what leadership and followership skills will you work on developing during
the first 3 months of your first nursing position? Why?
Case Study to Promote Critical Reasoning
Two new associate-degree graduate nurses were hired for the pediatric unit. Both worked three
12-hour shifts a week, Jan on the day-to-evening shift and Ronnie at night. Whenever their shifts
overlapped, they would compare notes on their experience. Jan felt she was learning rapidly,
gaining clinical skills, and beginning to feel at ease with her colleagues.
Ronnie, however, still felt unsure of herself and often isolated. “There have been times,” she told
Jan, “that I am the only registered nurse on the unit all night. The aides and LPNs are really
experienced, but that’s not enough. I wish I could work with an experienced nurse as you are doing.”
“Ronnie, you are not even finished with your 3-month orientation program,” said Jan. “You
should never be left alone with all these sick children. Neither of us is ready for that kind of
responsibility. And how will you get the experience you need with no experienced nurses to help
you? You must speak to our nurse manager about this.”
“I know I should, but she’s so hard to reach. I’ve called several times, and she’s never available.
She leaves all the shift assignments to her assistant. I’m not sure she even reviews the schedule
before it’s posted.”
“You will have to try harder to reach her. Maybe you could stay past the end of your shift one
morning and meet with her,” suggested Jan. “If something happens when you are the only nurse
on the unit, you will be held responsible.”
1. In your own words, summarize the problem that Jan and Ronnie are discussing. To what extent
is this problem due to a failure to lead? Who has failed to act?
2. What style of leadership was displayed by Jan, Ronnie, and the nurse manager? How effective
was their leadership? Did Jan’s leadership differ from that of Ronnie and the nurse manager? In
what way?
3. In what ways has Ronnie been an effective follower? In what ways has Ronnie not been so
effective as a follower?
4. If an emergency occurred and was not handled well while Ronnie was the only nurse on the
unit, who would be responsible? Explain why this person or persons would be responsible.
5. If you found yourself in Ronnie’s situation, what steps would you take to resolve the problem?
Show how the leader characteristics and behaviors found in this chapter support your solution
to the problem.
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14 unit 1 ■ Professional Considerations
References
American Nurses Association (ANA). (2001). Code of
Ethics for Nurses. Retrieved from www.nursingworld.org/
MainMenuCategories/EthicsStandards/CodeofEthics
forNurses
Anderson, B.J., Manno, M., O’Connor, P., & Gallagher, E.
(2010). Listening to nursing leaders. Journal of Nursing
Administration, 40(4), 182–187.
Baggett, M.M., & Baggett, F.B. (2005). Move from
management to high-level leadership. Nursing
Management, 36(7), 12.
Barker, A.M. (1992). Transformational nursing leadership:
A vision for the future. New York: National League for
Nursing Press.
Bass, B.M., & Avolio, B.J. (1993). Transformational
leadership: A response to critiques. In Chemers, M.M.,
& Ayman, R. (eds.). Leadership Theory and Research:
Perspectives and Direction. San Diego: Academic Press.
Bennis, W. (1984). The four competencies of leadership.
Training and Development Journal, August 1984,
15–19.
Bennis, W., Spreitzer, G.M., & Cummings, T.G. (2001).
The Future of Leadership. San Francisco: Jossey-Bass.
Bing, S. (2010). Stanley Bing’s top 10 strategies for
managing up. CBS News. Retrieved from www
.cbsnews.com
Bjarnason, D., & LaSala, C.A. (2011/March). Moral
Leadership in Nursing. Journal of Radiology Nursing,
30(1), 18–24.
Blake, R.R., Mouton, J.S., & Tapper, M., et al. (1981). Grid
Approaches for Managerial Leadership in Nursing. St.
Louis: C.V. Mosby.
Blanchard, K., & Miller, M. (2007/September 11). The
higher plane of leadership. Leader to Leader Journal,
46, 25–30.
Buchanan, L. (2012). The world needs big ideas. INC
Magazine, 34(9), 57–58.
Buchanan, L. (2012/June). 13 ways of looking at a leader.
INC Magazine, 74–76.
Buchanan, L. (2011/June). Care values. INC Magazine,
60–61.
Buchanan, L. (2013, June). Between Venus and Mars:
7 traits of true leaders. INC Magazine, 35(5), 64.
Retrieved from http://www.inc.com/magazine/
201306/leigh-buchanan/traits-of-true-leaders.html
Chrispeels, J.H. (2004). Learning to Lead Together.
Thousand Oaks, Calif.: Sage Publications.
Code of Ethics for Nurses. (2001). Nursing World. Retrieved
from www.nursingworld.org/MainMenuCategories/
EthicsStandards/CodeofEthicsforNurses.
Dantley, M.E. (2005). Moral leadership: Shifting the
management paradigm. In English, F.W., The Sage
Handbook of Educational Leadership (pp. 34–46).
Thousand Oaks, Calif.: Sage Publications.
Deutschman, A. (2005). Is your boss a psychopath?
Making Change. Fast Company, 96, 43–51.
Disch, J. (2013). President’s Message: Professional
Generosity. Nursing Outlook, 61, 196–204.
Dorn, M. (2011). Characteristics of caring leadership.
Retrieved from www.thecareguys.com Feldman, D.A.
(2002). Critical Thinking: Strategies for Decision
Making. Menlo Park, Calif.: Crisp Publications.
Feldman, D. (2002). Critical thinking: Strategies for decision
making. Crisp Learning.
Goleman, D., Boyatzes, R., & McKee, A. (2002). Primal
Leadership: Realizing the Power of Emotional
Intelligence. Boston: Harvard Business School Press.
Greenleaf, R.K. (2008). Nine characteristics of effective,
caring leaders. Greenleaf Center for Servant Leadership.
Retrieved from www.greenleaf.org
Grossman, S., & Valiga, T.M. (2000). The New Leadership
Challenge: Creating the Future of Nursing. Philadelphia:
F.A. Davis.
Hersey, P., & Campbell, R. (2004). Leadership: A
Behavioral Science Approach. Calif.: Leadership Studies
Publishing.
Herzberg, F. (1966). Work and the nature of man.
Cleveland: World Publishing.
Herzberg, F., Mausner, B., & Snyderman, B. (1959). The
motivation to work (2nd ed.). New York: John Wiley &
Sons.
Holman, L. (1995). Eleven Lessons in Self-Leadership:
Insights for Personal and Professional Success. Lexington,
Ky.: A Lesson in Leadership Book.
Jackson, M., Ignatavicius, D., & Case, B. (eds.). (2004).
Conversations in Critical Thinking and Clinical
Judgement. Pensacola, Fla.: Pohl.
Kerfott, K. (2000). Leadership: Creating a shared destiny.
Dermatological Nursing, 12(5), 363–364.
Korn, M. (2004). Toxic Cleanup: How to Deal with a
Dangerous Leader. Fast Company, 88, 17.
Leach, L.S. (2005). Nurse executive transformational
leadership and organizational commitment. Journal of
Nursing Administration, 35(5), 228–237.
Lyons, M.F. (2002). Leadership and followership. The
Physician Executive, Jan/Feb, 91–93.
Maslow, A.H. (1970). Motivation and personality (2nd
ed.). New York: Harper & Row.
Maxwell, J.C. (1993). Developing the Leader Within You.
Tenn.: Thomas Nelson Inc.
Maxwell, J.C. (1998). The 21 Irrefutable Laws of
Leadership. Tenn.: Thomas Nelson Inc.
McClelland, D. (1961). The Achieving Society. Princeton,
NJ: D. Van Nostrand.
McMurry (2012). Be a caring leader. Managing People at
Work. Retrieved from www.managingpeopleatwork
.com/article.php?art_num=3982
McNichol, E. (2000). How to be a model leader. Nursing
Standard, 14(45), 24.
Pavitt, C. (1999). Theorizing about the group
communication-leadership relationship. In Frey, L.R. (Ed.),
The Handbook of Group Communication Theory and
Research. Thousand Oaks, Calif.: Sage Publications.
Porter-O’Grady, T. (2003). A different age for leadership,
Part II. Journal of Nursing Administration, 33(2),
105–110.
Powell, C. (2012/May 21). The general’s orders. (Features)
(Excerpts) from book, It worked for me: In life and
leadership. Harper Collins Pub. Newsweek, 40–44.
Rhodes, M.K., Morris, A.H., & Lazenby, R.B. (2011).
Nursing at its best: Competent and caring. Online
Journal of Issues in Nursing, 16(2), 10.
Scott, E., & Miles, J. (2013) Advancing Leadership
Capacity in Nursing. Nursing Administration Quarterly,
37(1), 77–82.
Spears, L.C. (2010). Character and servant leadership: Ten
characteristics of effective, caring leaders. Journal of
Virtues & Leadership, 1(1), 25–30.
Spears, L.C., & Lawrence, M. (2004). Practicing Servant-
Leadership. New York: Jossey-Bass.
Spreitzer, G.M., & Quinn, R.E. (2001). A Company of
Leaders: Five Disciplines for Unleashing the Power in
Your Workforce. San Francisco: Jossey-Bass.
Stewart, L., Holmes, C., & Usher, K. (2012). Reclaiming
Caring in Nursing Leadership: A Deconstruction of
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Process CyanProcess CyanProcess MagentaProcess MagentaProcess YellowProcess YellowProcess BlackProcess Black
chapter 1 ■ Leadership and Followership 15
Leadership Using a Habermasian Lens. Collegian, 19,
223–229.
Tappen, R.M. (2001). Nursing Leadership and Management:
Concepts and Practice. Philadelphia: F.A. Davis.
Trofino, J. (1995). Transformational leadership in health
care. Nursing Management, 26(8), 42–47.
Turk, W. (2007, March/April). The art of managing up.
Defense AT&L, 21–23.
White, R.K., & Lippitt, R. (1960). Autocracy and
democracy: An experimental inquiry. New York: Harper
& Row.
Wiseman, L., & McKeown, G. (2010/May). Managing
yourself: Bringing out the best in your people. Harvard
Business Review. Retrieved from http://hbr.org/2010/
05/managing-yourself-bringing-out-the-best-in-your
-people/ar/1
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17
chapter 2
Manager
OBJECTIVES
After reading this chapter, the student should be able to:
■ Define the term management.
■ Distinguish scientific management and human relations–
based management.
■ Explain servant leadership.
■ Discuss the qualities and behaviors that contribute to
effective management.
OUTLINE
Management
Are You Ready to Be a Manager?
What Is Management?
Management Theories
Scientific Management
Human Relations–Based Management
Servant Leadership
Qualities of an Effective Manager
Behaviors of an Effective Manager
Interpersonal Activities
Decisional Activities
Informational Activities
Conclusion
Every nurse needs to be a good leader and a good
follower. In Chapter 1 we defined leadership and
followership, and showed that even as a new nurse,
you can be an effective leader. Not everyone needs
to be a manager, however. New graduates are not
ready to take on management responsibilities. Once
you have had time to develop your clinical and
leadership skills, then you can begin to think about
taking on management responsibilities (Table 2-1).
Management
Are You Ready to Be a Manager?
For most new nurses, the answer is no, you should
not accept managerial responsibility. Your clinical
skills are still underdeveloped. You need to direct
your energies to building your own skills, including
your leadership skills, before you begin supervising
other people.
What Is Management?
The essence of management is getting work done
through others. The classic definition of manage-
ment was Henri Fayol’s 1916 list of managerial
tasks: planning, organizing, commanding, coordi-
nating, and controlling the work of a group of
employees (Wren, 1972). But Mintzberg (1989)
argued that managers really do whatever is needed
to make sure that employees do their work and do
it well. Lombardi (2001) added that two-thirds of
a manager’s time is spent on people problems. The
rest is taken up by budget work, going to meetings,
preparing reports, and other administrative tasks.
Management Theories
There are two major but opposing schools of
thought in management: scientific management
and the human relations–based approach. As its
name implies, the human-relations approach
emphasizes the interpersonal aspects of managing
people, whereas scientific management emphasizes
the task aspects.
Scientific Management
Almost 100 years ago, Frederick Taylor argued that
most jobs could be done more efficiently if they
were analyzed thoroughly (Lee, 1980; Locke, 1982).
Given a well-designed task and enough incentive
to get the work done, workers will be more produc-
tive. For example, Taylor promoted the concept of
paying people by the piece instead of by the hour.
In health care, the equivalent of what Taylor recom-
mended would be paying by the number of patients
bathed or visited at home rather than by the number
of hours worked. This creates an incentive to get
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18 unit 1 ■ Professional Considerations
the most work done in the least amount of time.
Taylorism stresses that there is a best way to do
a job, which is usually the fastest way to do the job
as well (Dantley, 2005).
Work is analyzed to improve efficiency. In health
care, for example, there has been much discussion
about the time and effort it takes to bring a disabled
patient to physical therapy versus sending the ther-
apist to the patient’s home or inpatient unit. Reduc-
ing staff or increasing the productivity of existing
employees to save money is also based on this kind
of thinking.
Nurse managers who use the principles of sci-
entific management will pay particular attention to
the types of assessments and treatments done on
the unit, the equipment needed to do them effi-
ciently, and the strategies that would facilitate more
efficient accomplishment of these tasks. Typically,
these nurse managers keep careful records of the
amount of work accomplished and reward those
who accomplish the most.
Human Relations–Based Management
McGregor’s theories X and Y provide a good con-
trast between scientific management and human
relations–based management. Like Taylorism,
Theory X reflects a common attitude among man-
agers that most people do not want to work very
hard and that the manager’s job is to make sure that
they do work hard (McGregor, 1960). To accom-
plish this, according to Theory X, a manager needs
to employ strict rules, constant supervision, and the
threat of punishment (reprimands, withheld raises,
and threats of job loss) to create industrious, con-
scientious workers.
Theory Y, which McGregor preferred, is the
opposite viewpoint. Theory Y managers believe
that the work itself can be motivating and that
people will work hard if their managers provide a
supportive environment. A Theory Y manager
emphasizes guidance rather than control, develop-
ment rather than close supervision, and reward
rather than punishment (Fig. 2.1). A Theory Y
nurse manager is concerned with keeping employee
morale as high as possible, assuming that satisfied,
motivated employees will do the best work. Employ-
ees’ attitudes, opinions, hopes, and fears are impor-
tant to this type of nurse manager. Considerable
effort is expended to work out conflicts and promote
mutual understanding to provide an environment
in which people can do their best work.
Servant Leadership
The emphasis on people and interpersonal rela-
tionships is taken one step further by Greenleaf
(2004), who wrote an essay in 1970 that began the
servant leadership movement. Like transforma-
tional and caring leadership, servant leadership has
a special appeal to nurses and other health-care
table 2-1
Differences Between Leadership and Management
Leadership Management
Based on influence and shared meaning Based on authority
An informal role A formally designated role
An achieved position As assigned position
Part of every nurse’s responsibility Usually responsible for budgets, appraising, hiring, and firing people
Requires initiative and independent thinking Improved by the use of effective leadership skills
THEORY X
Work is something to be avoided
People want to do as little as possible
Use control-supervision-punishment
THEORY Y
The work itself can be motivating
People really want to do their job well
Use guidance-development-reward
Figure 2.1 Theory X versus Theory Y.
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chapter 2 ■ Manager 19
professionals. Despite its name, servant leadership
applies more to people in supervisory or adminis-
trative positions than to people in staff positions.
The servant leader–style manager believes that
people have value as people, not just as workers
(Spears & Lawrence, 2004). The manager is com-
mitted to improving the way each employee is
treated at work. The attitude is “employee first,” not
“manager first.” So the manager sees himself or
herself as being there for the employee. Here is an
example:
Hope Marshall is a relatively new staff nurse at
Jefferson County Hospital. When she was invited to
be the staff nurse representative on the search com-
mittee for a new chief nursing off icer, she was very
excited about being on a committee with so many
managerial and administrative people. As the
interviews of candidates began, she focused on what
they had to say. All the candidates had impressive
résumés and spoke confidently about their accom-
plishments. Hope was impressed but did not yet
prefer one over the other. Then the f inal candidate
spoke to the committee. “My primary job,” he said,
“is to make it possible for each nurse to do the very
best job he or she can do. I am here to make their
work easier, to remove barriers, and to provide them
with whatever they need to provide the best patient
care possible.” Hope had never heard the term
servant leadership, but she knew immediately that
this candidate, who articulated the essence of servant
leadership, was the one she would support for this
important position.
Qualities of an Effective Manager
Two-thirds of people who leave their jobs say the
main reason was an ineffective or incompetent
manager (Hunter, 2004). A survey of 3,266 newly
licensed nurses found that lack of support from
their manager was the nurses’ primary reason for
leaving their position, followed by a stressful work
environment. Following are some of the indicators
of their stressful work environment:
■ 25% reported at least one needle stick in their
first year.
■ 39% reported at least one strain or sprain.
■ 62% reported experiencing verbal abuse.
■ 25% reported a shortage of supplies needed to
do their work.
These results underscore the importance of having
effective nurse managers who can create an envi-
ronment in which new nurses thrive (Kovner,
Brewer, Fairchild, et al., 2007).
Nurse managers hold pivotal positions in hospi-
tals, nursing homes, and other health-care facilities.
They report to the administration of these facilities,
coordinate with a myriad of departments (the lab,
dietary, pharmacy, and so forth) and care providers
(physicians, nurse practitioners, therapists, and so
forth), and supervise a staff that provides care
around the clock. You can see why their effective-
ness has considerable influence on the quality of
the care provided under their direction (Trossman,
2011).
Consider for a moment the knowledge and skills
needed by a nurse manager:
■ Leadership, especially relationship building,
teamwork, and mentoring skills
■ Professionalism, including advocacy for nursing
staff and support of nursing roles and ethical
practice
■ Advanced clinical expertise including quality
improvement and evidence-based practice
■ Human resource management expertise
including staff development, and performance
appraisals
■ Financial management
■ Coordination of patient care, including
scheduling, work flow, work assignments,
monitoring the quality of care provided, and
documentation of that care ( Jones, 2010;
Fennimore & Wolf, 2011)
The effective nurse manager possesses a combi na-
tion of qualities: leadership, clinical expertise, and
business sense. None of these alone is enough; it is
the combination that prepares an individual for the
complex task of managing a unit or team of health-
care providers. Consider each of these briefly:
■ Leadership. All of the people skills of the
leader are essential to the effective manager.
■ Clinical expertise. Without possessing clinical
expertise oneself, it is very difficult to help
others develop their skills and evaluate how
well they have done. It is probably not
necessary (or even possible) to know
everything all other professionals on the team
know, but it is important to be able to assess
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20 unit 1 ■ Professional Considerations
the effectiveness of their work in terms of
patient outcomes.
■ Business sense. Nurse managers also need to
be concerned with the “bottom line,” with the
cost of providing the care that is given,
especially in comparison with the benefit
received from that care and the funding
available to pay for it, whether from private
insurance, Medicare, Medicaid, or out of the
patient’s own pocket. This is a complex task
that requires knowledge of budgeting, staffing,
and measurement of patient outcomes.
There is some controversy over the amount of clini-
cal expertise versus business sense that is needed to
be an effective nurse manager. Some argue that a
person can be a “generic” manager, that the job of
managing people is the same no matter what tasks
he or she performs. Others argue that managers
must understand the tasks themselves, better than
anyone else in the work group. Our position is that
both clinical skill and business acumen are needed,
along with excellent leadership skills.
Behaviors of an Effective Manager
Mintzberg (1989) divided a manager’s activities
into three categories: interpersonal, decisional, and
informational. We use these categories and have
added some activities suggested by other authors
(Dunham-Taylor, 1995; Montebello, 1994) and
from our own observations of nurse managers
(Fig. 2.2).
Interpersonal Activities
The interpersonal category is one in which leaders
and managers have overlapping concerns. However,
the manager has some additional responsibilities
that are seldom given to leaders. These include the
following:
■ Networking. As we mentioned earlier, nurse
managers are in pivotal positions, especially in
inpatient settings where they have contact with
virtually every service of the institution as well
as with most people above and below them in
the organizational hierarchy. This provides
them with many opportunities to influence the
status and treatment of staff nurses and the
quality of the care provided to their patients. It
is important that they “maintain the line of
sight,” or connection, between what they do as
managers, patient care, and the mission of the
organization (Mackoff & Triolo, 2008, p. 123).
In other words, they need to keep in mind
how their interactions with both their staff
members and with administration affects the
care provided to the patients for whom they
are responsible.
■ Conflict negotiation and resolution. Managers
often find themselves resolving conflicts
among employees, patients, and administration.
Ineffective managers often ignore people’s
emotional side or mismanage feelings in the
workplace (Welch & Welch, 2008).
■ Employee development. Managers are
responsible for providing for the continuing
learning and upgrading of the skills of their
employees.
■ Coaching. It is often said that employees are
the organization’s most valuable asset (Shirey,
2007). Coaching is one way in which nurse
managers can share their experience and
expertise with the rest of the staff. The goal is
to nurture the growth and development of the
Informational
Interpersonal
Representing employees
Representing the organization
Public relations monitoring
Networking
Conflict negotiation and resolution
Employee development and coaching
Rewards and punishment
Decisional
Employee evaluation
Resource allocation
Hiring and firing employees
Planning
Job analysis and redesign
Figure 2.2 Keys to effective management.
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chapter 2 ■ Manager 21
employee (the “coachee”) to do a better job
through learning (McCauley & Van Velson,
2004; Shirey, 2007).
Some managers use a directive approach: “This is
how it’s done. Watch me.” or “Let me show you
how to do this.” Others prefer a problem-solving
approach: “Let’s try to figure out what’s wrong
here” (Hart & Waisman, 2005). “How do you think
we can improve our outcomes?”
You can probably see the parallel with demo-
cratic and autocratic leadership styles described in
Chapter 1. The decision whether to be directive
(e.g., in an emergency) or mutual problem-solving
(e.g., when developing a long-term plan to improve
infection control) will depend on the situation.
■ Rewards and punishments. Managers are in a
position to provide specific rewards (e.g., salary
increases, time off ) and general rewards (e.g.,
praise, recognition) as well as punishments
(withhold pay raises, deny promotions).
Decisional Activities
Nurse managers are responsible for making many
decisions:
■ Employee evaluation. Managers are
responsible for conducting formal performance
appraisals of their staff members. Traditionally,
formal reviews have been conducted once a
year, but people need to know much sooner
than that if they are doing well or need to
improve. Effective managers are like coaches,
regularly giving their staff feedback (Suddath,
2013).
■ Resource allocation. In decentralized
organizations, nurse managers are often given
an annual budget for their units and must
allocate these resources wisely. This can be
difficult when resources are very limited.
■ Hiring and firing employees. Nurse managers
either make the hiring and firing decisions or
participate in employment and termination
decisions for their units.
■ Planning for the future. Not only is the day-
to-day operation of most units complex and
time-consuming, nurse managers must also
look ahead to prepare themselves and their
units for future changes in budgets,
organizational priorities, and patient
populations. They need to look beyond the
four walls of their own organization to become
aware of what is happening to their
competition and to the health-care system
(Kelly & Nadler, 2007).
■ Job analysis and redesign. In a time of extreme
cost sensitivity, nurse managers are often
required to analyze and redesign the work of
their units to make them as efficient as possible.
Informational Activities
Nurse managers often find themselves in positions
within the organizational hierarchy in which they
acquire much information that is not available to
their staff. They also have much information about
their staff that is not readily available to the admin-
istration, placing them in a strategic position within
the information web of any organization. The
effective manager uses this knowledge for the
benefit of both the staff and the organization.
The following are some examples:
■ Spokesperson. Nurse managers often speak
for administration when relaying information
to their staff members. Likewise, they often
speak for staff members when relaying
information to administration. You could think
of them as central information clearinghouses,
acting as gatherers and disseminators of
information to people above and below them
in the organizational hierarchy (Shirey,
Ebright, & McDaniel, 2008, p. 126).
■ Monitoring. Nurse managers are also expert
“sensors,” picking up early signs (information)
of problems before they grow too big (Shirey,
Ebright, & McDaniel, 2008). They are
expected to monitor the many and various
activities of their units or departments,
including the number of patients seen, average
length of stay, and important patient outcomes
such as infection rates, fall rates, and so forth.
They also monitor the staff (e.g., absentee
rates, tardiness, unproductive time), the budget
(e.g., money spent, money left in comparison
with money needed to operate the unit), and
the costs of procedures and services provided,
especially those that are variable such as
overtime or disposable vs. nondisposable
medical supplies (Dowless, 2007).
■ Reporting. Nurse managers share information
with their patients, staff members, and
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22 unit 1 ■ Professional Considerations
employers. This information may be related to
the results of their monitoring efforts, new
developments in health care, policy changes,
and so forth.
Review Table 2-2, Bad Management Styles, to
compare what you have just read about effective
nurse managers with descriptions of some of the
most common ineffective approaches to being a
manager.
Conclusion
Nurse managers have complex, responsible posi-
tions in health-care organizations. Ineffective man-
agers may do harm to their employees, their
patients, and to the organization, while effective
managers can help their staff members grow and
develop as health-care professionals providing the
highest quality care to their patients.
If you have wondered why there are so many
conflicting and overlapping theories of leadership
and management, it is because management theory
is still at an immature (not fully developed) stage
as well as being prone to fads (Micklethwait in
Wooldridge, 2011). Even so, there is still much that
is useful in the theories and much to be learned
from them.
table 2-2
Bad Management Styles
These are the types of managers you do not want to be and for whom you do not want to work:
Know-it-all Self-appointed experts on everything, these managers do not listen to anyone else.
Emotionally remote Isolated from the staff and the work going on, these managers do not know what is going on in the
workplace and cannot inspire others.
Purely mean Mean, nasty, and dictatorial, these managers look for problems and reasons to criticize. They
diminish people instead of developing them.
Overly nice Desperate to please everyone, these managers agree to every idea and request, causing confusion
and spending too much money on useless projects.
Afraid to decide Indecisive managers may announce goals for their unit but fail to be clear about their expectations,
assign responsibility, or set deadlines for accomplishment. In the name of fairness, these managers
may not distinguish between competent and incompetent, or hardworking and unproductive
employees, thus creating an unfair reward system.
Source: Based on Welch, J. & Welch, S. (2007, July 23). Bosses who get it all wrong. Bloomberg Businessweek,
88; Schaffer, R.H. (2010/September). Mistakes leaders keep making. Harvard Business Review, 87–91;
Wiseman, L., & McKeown, A. (2010/May). Bringing out the best in your people. Harvard Business Review,
Reprint R1005K, 1–5.
Study Questions
1. Why should new graduates decline nursing management positions? At what point do you think
a nurse is ready to assume managerial responsibilities?
2. Which theory, scientific management or human relations, do you believe is most useful to nurse
managers? Explain your choice.
3. Compare servant leadership with scientific management. Which approach do you prefer? Why?
4. Describe your ideal nurse manager in terms of the person for whom you would most like to
work. Then describe the worst nurse manager you can imagine, and explain why this person
would be very difficult to work with.
5. List 10 behaviors of nurse managers and then rank them from least to most important. What
rationale(s) did you use in ranking them?
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chapter 2 ■ Manager 23
Case Studies to Promote Critical Reasoning
Case I
Joe Garcia has been an operating room nurse for 5 years. He is often on call on Saturdays and
Sundays, but he enjoys his work and knows that he is good at it.
Joe was called to come in on a busy Saturday afternoon just as his 5-year-old daughter’s
birthday party was about to begin. “Can you find someone else just this once?” he asked the nurse
manager who called him. “I should have let you know in advance that we have an important
family event today, but I just forgot. If you can’t find someone else, call me back, and I’ll come
right in.” Joe’s manager was furious. She said, “I don’t have time to make a dozen calls. If you
knew that you wouldn’t want to come in today, you should not have accepted on-call duty. We pay
you to be on call, and I expect you to be here in 30 minutes, not 1 minute later, or there will be
consequences.”
Joe decided that he no longer wanted to work in that institution. With his 5 years of operating
room experience, he quickly found another position in an organization that was more supportive
of its staff.
1. What style of leadership and school of management seemed to be preferred by Joe Garcia’s
manager?
2. What style of leadership and school of management were preferred by Joe?
3. Which of the listed qualities of leaders and managers did the nurse manager display? Which
behaviors? Which ones did the nurse manager not display?
4. If you were Joe, what would you have done? If you were the nurse manager, what would you
have done? Why?
5. Who do you think was right, Joe or the nurse manager? Why?
Case II
Sung Lee completed her 2-year associate degree in nursing right after high school. Upon
graduation, she was offered a staff position at Harbordale nursing home and rehabilitation center
where she had volunteered during high school. Most of her classmates accepted positions in local
hospitals, but Sung Lee felt comfortable at Harbordale and had loved her volunteer work there.
She thought it would be an advantage to already know many of the staff at Harbordale.
The director of nursing thought it would be best to place Sung Lee on a short-term unit. Most
of the patients in the unit were recently discharged from the hospital and still recovering from an
acute event such as stroke, injury, or extensive surgery. Sung Lee found her assignment challenging
but satisfying. She admired her nurse manager, an experienced clinical nurse leader who became
her mentor.
Six months later, the director of nursing called Sung Lee into her office. “Sung Lee,” she said,
“we are very pleased with your work. You have been a quick learner and very caring nurse. Your
colleagues, patients, and physicians all speak well of you.”
“Thank you,” replied Sung Lee. “I know there’s still a lot for me to learn, but I really love my
work here.”
“You may not be aware of this,” continued the director of nursing, “but your nurse manager will
be retiring next month. Our policy at Harbordale is to promote from within whenever possible,
and I’d like to offer you her position. It’s a little soon after graduation, but I’m sure you can handle
it.”
Sung Lee gasped. “I’m honored that you would consider me for this position. May I have a few
days to think it over?”
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24 unit 1 ■ Professional Considerations
1. Why did the director of nursing at Harbordale offer the nurse manager position to Sung Lee?
If you had been in the director’s position, would you have selected Sung Lee for the nurse
manager position? Why or why not?
2. If Sung Lee does accept the nurse manager position, what do you think her first month will be
like? Write a scenario that describes her first month as a nurse manager.
3. If Sung Lee declines this offer, how do you think the director of nursing will respond?
4. Write a list of typical nurse manager roles and responsibilities. For each one indicate how
prepared you are to assume each role or responsibility and what you would need to prepare
yourself to assume this responsibility.
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chapter 2 ■ Manager 25
References
Dantley, M.E. (2005). Moral leadership: Shifting the
management paradigm. In English, F.W., The sage
handbook of educational leadership (pp. 34–46).
Thousand Oaks, Calif.: Sage Publications.
Dowless, R.M. (2007). Your guide to costing methods and
terminology. Nursing Management, 38(4), 52–57.
Dunham-Taylor, J. (1995). Identifying the best in nurse
executive leadership. Journal of Nursing Administration,
25(7/8), 24–31.
Fennimore, L., & Wolf, G. (2011). Nurse manager
leadership development, Journal of Nursing
Administration, 41(5), 204–210.
Greenleaf, R.K. (2004). Who is the servant-leader? In
Spears, L.C., & Lawrence, M., Practicing servant-
leadership. New York: Jossey-Bass.
Hart, L.B., & Waisman, C.S. (2005). The leadership
training activity book. New York: AMACOM.
Hunter, J.C. (2004). The world’s most powerful leadership
principle. New York: Crown Business.
Jones, R.A. (2010). Preparing tomorrow’s leaders. Journal of
Nursing Administration, 40(4), 154–157.
Kelly, J., & Nadler, S. (2007, March 3–4). Leading from
below. Wall Street Journal, R4.
Kovner, C.T., Brewer, C.S., Fairchild, S., et al. (2007).
Newly licensed RNs’ characteristics, work attitudes, and
intentions to work. American Journal of Nursing, 107(9),
58–70.
Lee, J.A. (1980). The gold and the garbage in
management theories and prescriptions. Athens, Ohio:
Ohio University Press.
Locke, E.A. (1982). The ideas of Frederick Taylor: An
evaluation. Academy of Management Review, 7(1), 14.
Lombardi, D.N. (2001). Handbook for the new health care
manager. San Francisco: Jossey-Bass/AHA Press.
Mackoff, B.L., & Triolo, P.K. (2008). Why do nurse
managers stay? Building a model engagement. Part I:
Dimensions of engagement. Journal of Nursing
Administration, 38(3), 118–124.
McCauley, C.D., & Van Velson, E. (eds.) (2004). The
center for creative leadership handbook of leadership
development. New York: Jossey-Bass.
McGregor, D. (1960). The Human Side of Enterprise. New
York: McGraw-Hill.
Micklethwait, J. (2011). Foreword in Wooldridge, A.
Masters of management, NY: Harper Collins.
Mintzberg, H. (1989). Mintzberg on management: Inside
our strange world of organizations. New York: Free
Press.
Montebello, A. (1994). Work teams that work.
Minneapolis: Best Sellers Publishing.
Schaffer, R.H. (2010/September). Mistakes leaders keep
making. Harvard Business Review, 87–91.
Shirey, M.R. (2007). Competencies and tips for effective
leadership. Journal of Nursing Administration, 37(4),
167–170.
Shirey, M.R., Ebright, P.R., & McDaniel, A.M. (2008).
Sleepless in America: Nurse managers cope with stress
and complexity. Journal of Nursing Administration, 38(3),
125–131.
Spears, L.C., & Lawrence, M. (2004). Practicing servant-
leadership. New York: Jossey-Bass.
Suddath, C. (2013, November 11–17). You get a D+ in
teamwork. Bloomberg Businessweek, 91.
Trossman, S. (2011). Complex role in complex times. The
American Nurse, 43(4), 1, 6, 7.
Welch, J., & Welch, S. (2007, July 23). Bosses who get it
all wrong. Bloomberg Businessweek, 88.
Welch, J., & Welch, S. (2008, July 28). Emotional
mismanagement. Bloomberg Businessweek, 84.
Wiseman, L., & McKeown, G. (2010/May). Bringing out
the best in your people. Harvard Business Review,
Reprint R1005k, 1–5.
Wren, D.A. (1972). The evolution of management thought.
New York: Ronald Press.
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chapter 3
Nursing Practice and the Law
OBJECTIVES
After reading this chapter, the student should be able to:
■ Identify three major sources of laws.
■ Explain the differences between various types of laws.
■ Differentiate between negligence and malpractice.
■ Explain the difference between an intentional and an
unintentional tort.
■ Explain how standards of care are used in determining
negligence and malpractice.
■ Describe how nurse practice acts guide nursing practice.
■ Explain the purpose of licensure.
■ Discuss issues of licensure.
■ Explain the difference between internal standards and
external standards.
■ Discuss advance directives and how they pertain to clients’
rights.
■ Discuss the legal implications of the Health Insurance
Portability and Accountability Act (HIPAA).
OUTLINE
General Principles
Meaning of Law
Sources of Law
The Constitution
Statutes
Administrative Law
Types of Laws
Criminal Law
Civil Law
Tort
Quasi-Intentional Tort
Negligence
Malpractice
Other Laws Relevant to Nursing Practice
Good Samaritan Laws
Confidentiality
Social Networking
Slander and Libel
False Imprisonment
Assault and Battery
Standards of Practice
Use of Standards in Nursing Negligence Malpractice
Actions
Patient’s Bill of Rights
Informed Consent
Staying Out of Court
Prevention
Appropriate Documentation
Common Actions Leading to Malpractice Suits
If a Problem Arises
Professional Liability Insurance
End-of-Life Decisions and the Law
Do Not Resuscitate Orders
Advance Directives
Living Will and Durable Power of Attorney for Health
Care (Health-Care Surrogate)
Nursing Implications
Legal Implications of Mandatory Overtime
Licensure
Qualifications for Licensure
Licensure by Examination
NCLEX-RN
Preparing for the NCLEX-RN
Licensure Through Endorsement
Multistate Licensure
Disciplinary Action
Conclusion
The courtroom seemed cold and sterile. Scanning her
surroundings with nervous eyes, Lialla decided she
knew how Alice must have felt when the Queen of
Hearts screamed for her head. The image of the
White Rabbit running through the woods, looking
at his watch, yelling, “I’m late! I’m late!” flashed
before her eyes. For a few moments, she indulged
herself in thoughts of being able to turn back the
clock and rewrite the past. The future certainly
looked grim at that moment. The calling of her
name broke her reverie. Mr. Marsh, the attorney for
the plaintiff, wanted her undivided attention
regarding the auspicious day when she committed a
fatal medication error. That day, the client died
following a cardiac arrest because Lialla failed to
check the appropriate dosage and route for the medi-
cation. Although she thought she should question the
order, Lialla “followed the health-care provider’s
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28 unit 1 ■ Professional Considerations
order” and administered 40 mEq of potassium chlo-
ride by intravenous push. Her 15 years of nursing
experience meant little to the court. Because she had
not followed hospital protocol and had violated an
important standard of practice, Lialla stood alone.
She was being sued for malpractice with the possi-
bility of criminal charges should she be found guilty
of contributing to the client’s death.
As client advocates, nurses have a responsibility to
deliver safe care to their clients. This expectation
requires that nurses have professional knowledge at
their expected level of practice and be proficient in
technological skills. A working knowledge of the
legal system, client rights, and behaviors that may
result in lawsuits helps nurses to act as client advo-
cates. As long as nurses practice according to estab-
lished standards of care, they may be able to avoid
the kind of day in court that Lialla experienced.
General Principles
Meaning of Law
The word law has several meanings. For the pur-
poses of this chapter, law refers to any system of
regulations that govern the conduct of individuals
within a community and/or society, in response to
the need for regularity, consistency, and justice (Hill
& Hill, 2009). In other words, law means those
rules that prescribe and control social conduct in a
formal and legally binding manner. Laws are
created in one of three ways:
1. Statutory laws are created by various legislative
bodies, such as state legislatures or Congress.
Some examples of federal statutes include the
Patient Self-Determination Act of 1990 and
the Americans With Disabilities Act. State
statutes include the state nurse practice acts,
the state boards of nursing, and the Good
Samaritan Act. Laws that govern nursing
practice are statutory laws.
2. Common law is the traditional unwritten law of
England, based on custom and usage, which
began to develop over a thousand years before
the founding of the United States (Hill & Hill,
2009). It develops within the court system as
judicial decisions are made in various cases and
precedents for future cases are set. In this way,
a decision made in one case can affect decisions
made in later cases of a similar nature. Many
times a judge in a subsequent case will follow
the reasoning of a judge in a previous case.
Therefore, one case sets a precedent for another.
3. Administrative law includes the procedures
created by administrative agencies
(governmental bodies of the city, county, state,
or federal government) involving rules,
regulations, applications, licenses, permits,
available information, hearings, appeals, and
decision making (Hill & Hill, 2009). These
laws are established through the authority
given to government agencies, such as state
boards of nursing, by a legislative body. These
governing boards have the duty to meet the
intent of laws or statutes.
Sources of Law
The Constitution
The U.S. Constitution is the foundation of Ameri-
can law. The Bill of Rights, comprising the first 10
amendments to the Constitution, is the basis for
protection of individual rights. These laws define
and limit the power of the government and protect
citizens’ freedom of speech, assembly, religion, and
the press, and freedom from unwarranted intrusion
by government into personal choices. State consti-
tutions can expand individual rights but cannot
deprive people of rights guaranteed by the U.S.
Constitution.
Constitutional law evolves. As individuals or
groups bring suit to challenge interpretations of
the Constitution, decisions are made concerning
application of the law to that particular event. An
example is the protection of freedom of speech. Are
obscenities protected? Can one person threaten or
criticize another person? The freedom to criticize
is protected; threats are not protected. The defini-
tion of what constitutes obscenity is often debated
and has not been fully clarified by the courts.
Statutes
Statutes are written laws created by a government
or accepted governing body. Localities, state legis-
latures, and the U.S. Congress create statutes. Local
statutes are usually referred to as ordinances. An
example of a local ordinance might be a require-
ment that all garbage dumpsters must be covered
at all times.
At the federal level, conference committees
comprising representatives of both houses of Con-
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chapter 3 ■ Nursing Practice and the Law 29
gress negotiate the resolution of any differences on
wording of a bill before it is voted upon by both
Houses of Congress and sent to the president to be
signed into law. If the bill does not meet with the
approval of the executive branch of government, the
president can veto it. If that occurs, the legislative
branch must have enough votes to override the veto
or the bill will not become law.
Nurses have an opportunity to influence the
development of statutory law both as citizens and
as health-care providers. Writing to or meeting
with state legislators or members of Congress is a
way to demonstrate interest in such issues and their
outcomes in terms of the laws passed. Passage of a
new law is often a long process that includes some
compromise of all interested individuals.
Administrative Law
The Department of Health and Human Services,
the Department of Labor, and the Department of
Education are the federal agencies that administer
health-care–related laws. At the state level are
departments of health and mental health and
licensing boards.
Administrative agencies are staffed with profes-
sionals who develop the specific rules and regula-
tions that direct the implementation of statutory
law. These rules must be reasonable and consistent
with existing statutory law and the intent of the
legislature. Usually, the rules go into effect only
after review and comment by affected persons or
groups. For example, specific statutory laws give
state nursing boards the authority to issue and
revoke licenses, which means that each board of
nursing has the responsibility to oversee the profes-
sional nurse’s competence.
Types of Laws
Another way to look at the legal system is to divide
laws into two categories: criminal law and civil
law.
Criminal Law
Criminal laws were developed to protect society
from actions that threaten its existence. Criminal
acts, although directed toward individuals, are con-
sidered offenses against the state. The perpetrator
of the act is punished, and the victim receives no
compensation for injury or damages. There are
three categories of criminal law:
1. Felony: the most serious category, including
such acts as homicide, grand larceny, and nurse
practice act violation
2. Misdemeanor: includes lesser offenses such as
traffic violations or shoplifting of a small dollar
amount
3. Juvenile: crimes carried out by individuals
younger than 18 years; specific age varies by
state and crime
There are occasions when a nurse breaks a law and
is tried in criminal court. A nurse who obtains and/
or distributes controlled substances illegally, either
for personal use or for the use of others, is violating
the law. Falsification of records of controlled sub-
stances is a criminal action. In some states, altering
a patient record may lead to both civil and criminal
action depending upon the treatment outcome. For
example:
In New Jersey State v. Winter V, Nurse needed to
administer a blood transfusion. Because she was in
a hurry, she did not check the paperwork properly
and therefore did not follow the standard of practice
established for blood administration. The client was
transfused with incompatible blood, suffered from a
transfusion reaction, and died. Nurse V then inten-
tionally attempted to conceal her conduct. She falsi-
fied the records, disposed of the blood and
administration equipment, and failed to notify the
patient’s health-care provider of the error. The jury
found Nurse V guilty of simple manslaughter and
sentenced her to 5 years in prison (Sanbar, 2007).
Civil Law
Civil laws usually involve the violation of one per-
son’s rights by another person. Areas of civil law
that particularly affect nurses are tort law, contract
law, antitrust law, employment discrimination, and
labor laws.
Tort
The remainder of this chapter focuses primarily on
tort law. By definition, tort law consists of a body
of rights, obligations, and remedies that is applied
by courts in civil proceedings for the purpose of
providing relief for persons who have suffered harm
from the wrongful acts of others. Simply put, a tort
is a legal or civil wrong carried out by one person
against the person or property of another. The
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30 unit 1 ■ Professional Considerations
person who sustains injury or suffers financial
damage as the result of the conduct is known as the
plaintiff, and the person who is responsible for
causing the injury and incurs liability for the
damage is known as the defendant (Loiacono,
2005). Tort law recognizes that individuals in their
relationships with each other have a general duty
not to harm each other. For example, as drivers of
automobiles, everyone has a duty to drive safely so
that others will not be harmed. A roofer has a duty
to install a roof properly so that it will not collapse
and injure individuals inside the structure. Nurses
have a duty to deliver care in such a manner that
the consumers of care are not harmed. These legal
duties of care may be violated intentionally or
unintentionally.
Quasi-Intentional Tort
A quasi-intentional tort has its basis in speech.
These are voluntary acts that directly cause injury
or anguish without meaning to harm or to cause
distress. The elements of cause and desire are
present, but the element of intent is missing.
Qua si-intentional torts usually involve problems
in communication that result in damage to a
person’s reputation, violation of personal privacy, or
infringement of an individual’s civil rights. These
include defamation of character, invasion of pri-
vacy, and breach of confidentiality (Aiken, 2004,
p. 139).
Negligence
Negligence is the unintentional tort of acting or
failing to act as an ordinary, reasonable, prudent
person, resulting in harm to the person to whom
the duty of care is owed (Black, 2009). The legal
elements of negligence consist of duty, breach of
duty, causation, and harm or injury (Gic, 2009).
All four elements must be present in the determi-
nation. For example, if a nurse administers the
wrong medication to a client but the client is not
injured, then the element of harm has not been met.
However, if a nurse administers appropriate pain
medication but fails to put up the side rails of the
patient’s bed, and the client falls and breaks a hip,
all four elements have been satisfied. The duty of
care is the standard of care. The law defines stan-
dard of care as that which a reasonable, prudent
practitioner with similar education and experience
would do or not do in similar circumstances (Gic,
2009).
Malpractice
Malpractice is the term used for professional negli-
gence. When fulfillment of duties requires special-
ized education, the term malpractice is used. In most
malpractice suits, the facilities employing the nurses
who cared for a client are named as defendants in
the suit. Vicarious liability is the legal principle
cited in these cases. Three doctrines, respondeat
superior, the borrowed servant doctrine, and the
captain of the ship doctrine fall under vicarious
liability. The captain of the ship doctrine, which is
an adaptation from the “borrowed servant” rules
came about in a case known as McConnell v Wil-
liams and refers to medical malpractice. The ruling
declared that the person in charge is held account-
able for all those falling under his or her supervi-
sion, regardless of whether the “captain” is directly
responsible for an alleged error or act of alleged
negligence, and despite the others’ positions as hos-
pital employees.
An important principle in understanding negli-
gence is respondeat superior (“let the master answer”)
(Aiken, 2004, p. 279). This doctrine holds employ-
ers liable for any negligence by their employees
when the employees were acting within the realm
of employment and when the alleged negligent acts
happened during employment (Aiken, 2004). The
borrowed servant doctrine comes into play when an
employee may be subject to the control and direc-
tion of an entity other than the primary employer.
In this situation someone other than an individual’s
primary employer is responsible for his or her ac-
tions. For example, an anesthesiologist supervising
a resident may be held liable for the resident’s error.
Consider the following scenario:
A nursing instructor on a clinical unit in a busy
metropolitan hospital instructed his students not to
administer any medications unless he was present.
Marcos, a second-level student, was unable to f ind
his instructor, so he decided to administer digoxin to
his client without supervision. The ordered dose was
0.125 mg. The unit dose came as digoxin 0.5 mg/
mL. Marcos administered the entire amount
without checking the digoxin dose or the client’s
blood digoxin and potassium levels. The client
became toxic, developed a dysrhythmia, and was
transferred to the intensive care unit. The family
sued the hospital and the nursing school for malprac-
tice. The nursing instructor was also sued under the
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chapter 3 ■ Nursing Practice and the Law 31
principle of respondeat superior, even though specif ic
instructions had been given to the students regard-
ing administering medications without direct
supervision.
Other Laws Relevant
to Nursing Practice
Good Samaritan Laws
Fear of being sued has often prevented trained pro-
fessionals from assisting during an emergency. To
encourage physicians and nurses to respond to
emergencies, many states developed what are now
known as the Good Samaritan laws. When admin-
istering emergency care, nurses and physicians are
protected from civil liability by Good Samaritan
laws as long as they behave in the same manner as
an ordinary, reasonable, and prudent professional in
the same or similar circumstances (Glannon, 2005).
In other words, when assisting during an emer-
gency, nurses must still observe professional stan-
dards of care. However, if a payment is received for
the care given, the Good Samaritan laws do not
hold.
Confidentiality
It is possible for nurses to be involved in lawsuits
other than those involving negligence. For example,
clients have the right to confidentiality, and it is the
duty of the professional nurse to ensure this right.
This assures the client that information obtained
by a nurse while providing care will not be com-
municated to anyone who does not have a need to
know. This includes giving information by tele-
phone to individuals claiming to be related to
a client, giving information without a client’s
signed release, or removing documents from a
health-care provider with a client’s name or other
information.
The Health Insurance Portability and Account-
ability Act (HIPAA) of 1996 was passed as an
effort to preserve confidentiality, protect the privacy
of health information, and improve the portability
and continuation of health-care coverage. The
HIPAA gave Congress until August 1999 to pass
this legislation. Congress failed to act, and the
Department of Health and Human Services took
over developing the appropriate regulations (Char-
ters, 2003). The latest version of this privacy act was
published in the Federal Register in 2002 (Charters,
2003).
The increased use of electronic sources of do-
cumentation and transfer of client information
presents many confidentiality issues. It is impor-
tant for nurses to be aware of the guidelines pro-
tecting the sharing and transfer of information
through electronic sources. Most health-care insti-
tutions have internal procedures to protect client
confidentiality.
Consider the following example:
Bill was admitted to the hospital for pneumonia.
With Bill ’s permission, an HIV test was per-
formed, and the result was positive. This infor-
mation was available on the computerized
laboratory result printout. A nurse inadvertently
left the laboratory results on the computer screen,
which was partially facing the hallway. One of
Bill ’s coworkers, who had come to visit him, saw
the report on the screen. This individual reported
the test results to Bill ’s supervisor. When Bill
returned to work, he was f ired for “poor job perfor-
mance,” although he had had superior job evalua-
tions. In the process of f iling a discrimination suit
against his employer, Bill discovered that the infor-
mation on his health status had come from this
source. A lawsuit was f iled against the hospital
and the nurse involved based on a breach of
confidentiality.
Social Networking
Another issue affecting confidentiality involves
social networking. The increased use of smart-
phones has led to increased violations of confiden-
tiality. These infractions often occur without intent
yet pose a risk to clients and health-care person-
nel. Posting pictures and information on social net-
working sites that involve clinical experiences and/
or work experiences can present a risk to patient
confidentiality and violate HIPAA regulations.
Many institutions have implemented policies that
affect employees and student affiliations. These
policies may result in employee termination and/
or cancelling agreements with outside agencies
using the health-care institution. Take the following
example:
Several nursing students who received scholarships
from an aff iliating health-care institution were
working their required shift in the emergency
department. The staff brought in a birthday cake for
one of the emergency department physicians. One of
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32 unit 1 ■ Professional Considerations
the students snapped a picture of the staff with
the physician and posted it on her social network
page. The computer screen with the names and
information of the clients in the emergency depart-
ment at the time was clearly visible behind the phy-
sician and the staff. Another staff member discovered
this and notif ied the chief nursing off icer of the
hospital. The nursing student lost her scholarship,
was terminated from her job, and was required to
return all monies back to the institution. Disciplin-
ary actions were taken against the staff involved in
the incident.
Slander and Libel
Slander and libel are categorized as quasi-inten-
tional torts. The term slander refers to the spoken
word, and libel refers to the written word. Nurses
rarely think of themselves as being guilty of slander
or libel, but making a false verbal statement about
a client’s condition that may result in an injury to
that client is considered slander. Making a false
written statement is libel. For example, verbally
stating that a client who had blood drawn for drug
testing has a substance abuse problem, when in fact
the client does not carry that diagnosis, could be
considered a slanderous statement.
Slander and libel also refer to statements made
about coworkers or other individuals whom you
may encounter in both your professional and edu-
cational life. Think before you speak and write.
Sometimes what may appear to be harmless to you,
such as a complaint, may contain statements that
damage another person’s credibility personally and
professionally. Consider this example:
Several nurses on a unit were having diff iculty
with the nurse manager. Rather than approach
the manager or follow the chain of command, they
decided to send a written statement to the chief
executive off icer (CEO) of the hospital. In this
letter, they embellished some of the incidents that
occurred and took out of context statements that
the nurse manager had made, changing the mean-
ings of the remarks. The nurse manager was
called to the CEO’s off ice and reprimanded for
these events and statements, which in fact had
not occurred. The nurse manager sued the nurses
for slander and libel based on the premise that her
personal and professional reputation had been
tainted.
False Imprisonment
False imprisonment is confining an individual
against his or her will by either physical (restrain-
ing) or verbal (detaining) means. The following are
examples:
■ Using restraints on individuals without the
appropriate written consent
■ Restraining mentally challenged individuals
who do not represent a threat to themselves or
others
■ Detaining unwilling clients in an institution
when they desire to leave
■ Keeping persons who are medically cleared for
discharge for an unreasonable amount of time
■ Removing clients’ clothing to prevent them
from leaving the institution
■ Threatening clients with some form of
physical, emotional, or legal action if they
insist on leaving
Sometimes clients are a danger to themselves and
to others. Nurses need to decide on the appropri-
ateness of restraints as a protective measure. Nurses
should try to obtain the cooperation of the client
before applying any type of restraint. The first step
is to attempt to identify a reason for the risky or
threatening behavior and resolve the problem. If
this fails, document the need for restraints, consult
with the physician, and carefully follow the institu-
tion’s policies and standards of practice. Systematic
documentation and continual assessment are of
highest importance when caring for clients who
have restraints. Any changes in client status must
be reported and documented. Failure to follow
these guidelines may result in greater harm to the
client and possibly a lawsuit for the staff. Consider
the following:
Mr. Harrison, who is 87 years old, was admitted to
the hospital through the emergency department with
severe lower abdominal pain of 3 days’ duration.
Physical assessment revealed severe dehydration and
acute distress. A surgeon was called, and an abdomi-
nal laparotomy was performed, revealing a rup-
tured appendix. Surgery was successful, and the
client was sent to the intensive care unit for 24
hours. On transfer to the surgical floor the next day,
Mr. Harrison was in stable condition. Later that
night, he became confused, irritable, and anxious.
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chapter 3 ■ Nursing Practice and the Law 33
He attempted to climb out of bed and pulled out his
indwelling urinary catheter. The nurse restrained
him. The next day, his irritability and confusion
continued. Mr. Harrison’s nurse placed him in a
chair, tying him in and restraining his hands. Three
hours later he was found in cardiopulmonary arrest.
A lawsuit of wrongful death and false imprison-
ment was brought against the nurse manager, the
nurses caring for Mr. Harrison, and the institution.
During discovery, it was determined that the
primary cause of Mr. Harrison’s behavior was
hypoxemia. A violation of law occurred with the
failure of the nursing staff to notify the physician of
the client’s condition and to follow the institution’s
standard of practice on the use of restraints.
To protect themselves against charges of negligence
or false imprisonment in such cases, nurses should
discuss safety needs with clients, their families, or
other members of the health-care team. Careful
assessment and documentation of client status are
imperative and also components of good nursing
practice. Confusion, irritability, and anxiety often
have metabolic causes that need correction, not
restraint.
There are statutes and case laws specific to the
admission of clients to psychiatric institutions.
Most states have guidelines for emergency involun-
tary hospitalization for a specific period of time.
Involuntary admission is considered necessary
when clients demonstrate a danger to themselves
or others. Specific procedures and legal guidelines
must be followed. A determination by a judge or
administrative agency and/or certification by a
specified number of health-care providers that a
person’s mental health justifies his or her detention
and treatment may be required. Once admitted,
these clients may not be restrained unless the guide-
lines established by state law and the institution’s
policies provide for this possibility. Clients who
voluntarily admit themselves to psychiatric institu-
tions are also protected against false imprisonment.
Nurses working in areas such as emergency depart-
ments, mental health facilities, and so forth need to
be cognizant of these issues and find out the policies
of their state and employing institution.
Assault and Battery
Assault is threatening to do harm. Battery is touch-
ing another person without his or her consent.
The significance of an assault lies in the threat:
“If you don’t stop pushing that call bell, I’ll give
you this injection with the biggest needle I can
find” is considered an assaultive statement. Bat-
tery would occur if the injection were given when
it was refused, even if medical personnel deemed it
was for the “client’s good.” With few exceptions,
clients have a right to refuse treatment. Holding
down a violent client against his or her will and
injecting a sedative is battery. Most medical treat-
ments, particularly surgery, would be considered
battery if clients failed to provide informed consent.
Standards of Practice
Avedis Donabedian (1988) said, “Standards are
professionally developed expressions of the range of
acceptable variations from a norm or criterion.”
Concern for the quality of care is a major part of
nursing’s responsibility to the public. Therefore, the
nursing profession is accountable to the consumer
for the quality of its services.
One of the defining characteristics of a profes-
sion is the ability to set its own standards. Nursing
standards were established as guidelines for the
profession to ensure acceptable quality of care
(Beckman, 1995). Standards of practice are also
used as criteria to determine whether appropriate
care has been delivered. In practice, they repre-
sent the minimum acceptable level of care. Nurses
are judged on generally accepted standards of prac-
tice for their level of education, experience, posi-
tion, and specialty area. Standards take many forms.
Some are written and appear as criteria of pro-
fessional organizations, job descriptions, agency
policies and procedures, and textbooks. Others,
which may be intrinsic to the custom of practice,
are not found in writing (Beckman, 1995).
State boards of nursing and professional organi-
zations vary by role and responsibility in relation to
standards of development and implementation
(ANA, 1998; 2011). Statutes written by the gov-
ernment, professional organizations, and health-
care institutions establish standards of practice. The
nurse practice acts of individual states define the
boundaries of nursing practice within the state. In
Canada, the provincial and territorial associations
define practice.
The courts have upheld the authority of boards
of nursing to regulate standards. The boards ac-
complish this through direct or delegated statutory
language (ANA, 1998; 2004; 2011). The American
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34 unit 1 ■ Professional Considerations
Nurses Association (ANA) also has specific stan-
dards of practice in general and in several clinical
areas (ANA, 2010) (see Appendix 2). In Canada,
the colleges of registered nurses and the registered
nurses associations of the various provinces and
territories have published practice standards. These
may be found at www.cna-aiic.ca.
Institutions develop internal standards of prac-
tice. The standards are usually explained in a spe-
cific institutional policy (for example, guidelines for
the appropriate administration of a specific chemo-
therapeutic agent), and the institution includes
these standards in its policy and procedure manuals.
The guidelines are based on current literature and
research. It is the nurse’s responsibility to meet the
institution’s standards of practice. It is the institu-
tion’s responsibility to notify the health-care per-
sonnel of any changes and instruct the personnel
about the changes. Institutions may accomplish this
task through written memos or meetings and in-
service education.
With the expansion of advanced nursing prac-
tice, it has become particularly important to clarify
the legal distinction between nursing and medi-
cal practice. It is important to be aware of the
boundaries between these professional domains be-
cause crossing them can result in legal conse-
quences and disciplinary action. The nurse practice
act and related regulations developed by most
state legislatures and state boards of nursing help
to clarify nursing roles at the various levels of
practice.
Use of Standards in Nursing Negligence
Malpractice Actions
When omission of prudent care or acts committed
by a nurse or those under his or her supervision
cause harm to a client, standards of nursing prac-
tice are among the elements used to determine
whether malpractice or negligence exists. Other
criteria may include but are not limited to (ANA,
1998; 2011):
■ State, local, or national standards
■ Institutional policies that alter or adhere to the
nursing standards of care
■ Expert opinions on the appropriate standard of
care at the time
■ Available literature and research that
substantiates a standard of care or changes in
the standard
Patient’s Bill of Rights
In 1973 the American Hospital Association
approved a statement called the Patient’s Bill of
Rights. It was revised in October 1992. Patient
rights were developed with the belief that hospitals
and health-care institutions would support these
rights with the goal of delivering effective client
care. In 2003 the Patient’s Bill of Rights was
replaced by the Patient Care Partnership. These
standards were derived from the ethical principle of
autonomy. This document may be found at www
.aha.org/advocacy-issues/communicatingpts/pt
-care-partnership.shtml.
Informed Consent
Informed consent is a legal document in all 50
states. It requires physicians to divulge the benefits,
risks, and alternatives to a suggested treatment,
nontreatment, or procedure. It allows for fully
informed, rational persons to be involved in choices
about their health care (Marr, 2003).
Without consent, many of the procedures per-
formed on clients in a health-care setting may be
considered battery or unwarranted touching. When
clients consent to treatment, they give health-care
personnel the right to deliver care and perform
specific treatments without fear of prosecution.
Although physicians are responsible for obtaining
informed consent, nurses often find themselves
involved in the process.
It is the physician’s responsibility to give infor-
mation to a client about a specific treatment or
medical intervention (Giese v. Stice, 1997). While
the nurse may witness the signature of a patient for
a procedure, or surgery, the nurse should not be
providing the details such as the benefits, risk, or
possible outcomes. The individual institution is not
responsible for obtaining the informed consent
unless (1) the physician or practitioner is employed
by the institution or (2) the institution was aware
or should have been aware of the lack of informed
consent and did not act on this fact (Guido, 2001).
Some institutions require the physician or indepen-
dent practitioner to obtain his or her own informed
consent by obtaining the client’s signature at the
time the explanation for treatment is given.
Although some nurses may believe that they
only need to obtain the client’s signature on the
informed consent document, nursing professionals
have a larger responsibility in evaluating a client’s
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chapter 3 ■ Nursing Practice and the Law 35
ability to give informed consent. The nurse’s role is
to: (a) act as the patient’s advocate, (b) protect the
patient’s dignity, (c) identify any fears, and (d)
determine the patient’s level of understanding and
approval of the proposed care.
Every client brings a different and unique
response depending on his or her personality, level
of education, emotions, and cognitive status. A
good practice is to ask a client to restate the infor-
mation offered. This helps confirm that the client
has received an appropriate amount of information
and has understood it. The nurse is obliged to
report any concerns about the client’s understand-
ing regarding what he or she has been told, or
any concerns about the client’s ability to make
decisions.
The informed consent form should contain all
the possible negative outcomes as well as the posi-
tive ones. The following are some criteria to help
ensure that a client has given an informed consent
(Berman & Snyder, 2012):
■ A mentally competent adult has voluntarily
given the consent.
■ The client understands exactly to what he or
she is consenting.
■ The consent includes the risks involved in the
procedure, alternative treatments that may be
available, and the possible result if the
treatment is refused.
■ The consent is written.
■ A minor’s parent or guardian usually gives
consent for treatment.
Ideally, a nurse should be present when the health-
care provider who is performing the treatment,
surgery, or procedure is explaining the benefits and
risks to the client.
To be able to give informed consent, the client
must be fully informed. Clients have the right to
refuse treatment, and nurses must respect this right.
If a client refuses the recommended treatment, he
or she must be informed of the possible conse-
quences of this decision.
Implied consent occurs when consent is assumed.
This may be an issue in an emergency when an
individual is unable to give consent, as in the fol-
lowing scenario:
An elderly woman is involved in a car accident on
a major highway. The paramedics called to the scene
f ind her unresponsive and in acute respiratory dis-
tress; her vital signs are unstable. The paramedics
immediately intubate her and begin treating her
cardiac dysrhythmias. Because she is unconscious and
unable to give verbal consent, there is an implied
consent for treatment.
Staying Out of Court
Prevention
Unfortunately, the public’s trust in the medical pro-
fession has declined over recent years. Consumers
are better informed and more assertive in their
approach to health care. They demand good and
responsible care. If clients and their families per-
ceive that behaviors are uncaring or that attitudes
are impersonal, they are more likely to sue for what
they view as errors in treatment.
The same applies to nurses. If nurses demon-
strate an interest in clients and their families and
display caring behaviors toward clients, a relation-
ship develops. Individuals usually do not initiate
lawsuits against those they view as “caring friends.”
The potential to change the attitudes of health-care
consumers is within the power of health-care per-
sonnel. Demonstrating care and concern and
making clients and families aware of choices and
methods help decrease liability. Nurses who involve
clients and their families in decisions about care
reduce the likelihood of a lawsuit. Tips to prevent
legal problems are listed in Box 3-1.
All health-care personnel are accountable for
their own actions and adherence to the accepted
• Keep yourself informed regarding new research related
to your area of practice.
• Insist that the health-care institution keep personnel
apprised of all changes in policies and procedures and
in the management of new technological equipment.
• Always follow the standards of care or practice for the
institution.
• Delegate tasks and procedures only to appropriate
personnel.
• Identify clients at risk for problems, such as falls or the
development of decubiti.
• Establish and maintain a safe environment.
• Document precisely and carefully.
• Write detailed incident reports, and file them with the
appropriate personnel or department.
• Recognize certain client behaviors that may indicate the
possibility of a lawsuit.
box 3-1
Tips for Avoiding Legal Problems
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36 unit 1 ■ Professional Considerations
standards of health care. Most negligence and mal-
practice cases arise from a violation of the accepted
standards of practice and the policies of the employ-
ing institution. Common causes of negligence are
listed in Table 3-1. Expert witnesses are called to
cite the accepted standards and assist attorneys in
formulating the legal strategies pertaining to those
standards. For example, most medication errors can
be traced to a violation of the accepted standard of
medication administration, originally referred to as
the Five Rights (Kozier et al., 1995; Taylor, Lillis,
& LeMone, 2008). These were later amended to
Seven Rights (Balas, Scott, & Rogers, 2004). In
2011, one more criterion was added, now making
Eight Rights (Eisenhauer et al., 2007).
More recently Elliot and Liu (2010) proposed
Nine Rights.
1. Right drug
2. Right dose
3. Right route
4. Right time
5. Right client
6. Right reason
7. Right documentation
8. Right form
9. Right response
Marcos, the nursing student described earlier in
this chapter, violated the right-dose principle and
therefore made a medication error.
Appropriate Documentation
The adage “not documented, not done” holds true
in nursing. According to the law, if something has
not been documented, then the responsible party
did not do whatever needed to be done. If a nurse
did not “do” something, he or she will be left open
to negligence or malpractice charges.
Nursing documentation needs to be legally
credible. Legally credible documentation is an
accurate accounting of the care the client received.
It also indicates the competence of the individual
who delivered the care.
Charting by exception creates defense difficul-
ties. When this method of documentation is used,
investigators need to review the entire patient
record in an attempt to reconstruct the care given
to the client. Clear, concise, and accurate docu-
mentation helps nurses when they are named in
lawsuits. Often, this documentation clears the indi-
vidual of any negligence or malpractice. Documen-
tation is credible when it is:
■ Contemporaneous (documenting at the time
care was provided)
■ Accurate (documenting exactly what was done)
■ Truthful (documenting only what was done)
■ Appropriate (documenting only what could be
discussed comfortably in a public setting)
Box 3-2 lists some documentation tips.
table 3-1
Common Causes of Negligence
Problem Prevention
Client falls Identify clients at risk.
Place notices about fall precautions.
Follow institutional policies on the use of restraints.
Always be sure beds are in their lowest positions.
Use side rails appropriately.
Equipment injuries Check thermostats and temperature in equipment used for heat or cold application.
Check wiring on all electrical equipment.
Failure to monitor Observe IV infusion sites as directed by institutional policy.
Obtain and record vital signs, urinary output, cardiac status, etc., as directed by institutional policy
and more often if client condition dictates.
Check pertinent laboratory values.
Failure to communicate Report pertinent changes in client status.
Document changes accurately.
Document communication with appropriate source.
Medication errors Follow the Seven Rights.
Monitor client responses.
Check client medications for multiple drugs for the same actions.
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chapter 3 ■ Nursing Practice and the Law 37
It is not good practice to sign off on medications
for all patients for a shift before the medications
are administered. Doing so is considered a fraudu-
lent act and may leave a nurse open to charges of
negligence in the form of a medication error if the
medications are then not administered as docu-
mented. If injury occurs because the patient never
received a medication, and the nurse documented
that the patient received it, the nurse can be charged
with criminal negligence.
Nursing units are busy and often understaffed.
These realities exist but should not be allowed to
interfere with the safe delivery of health care.
Clients have a right to safe and effective health care,
and nurses have an obligation to deliver this care.
Common Actions Leading to Malpractice Suits
■ Failure to assess a client appropriately
■ Failure to report changes in client status to the
appropriate personnel
■ Failure to document in the patient record
■ Altering or falsifying a patient record
■ Failure to obtain informed consent
■ Failure to report a coworker’s negligence or
poor practice
■ Failure to provide appropriate education to a
client and/or family members
■ Violation of internal or external standards of
practice
In the case Tovar v. Methodist Healthcare (2005), a
75-year-old female client came to the emergency
department complaining of a headache and weak-
ness in the right arm. Although an order for admis-
sion to the neurological care unit was written, the
client was not transported until 3 hours later. After
the client was in the unit, the nurses called one
physician regarding the client’s status. Another
physician returned the call 90 minutes later. Three
hours later, the nurses called to report a change in
the client’s neurological status. A STAT computed
tomography scan was ordered, which revealed a
massive brain hemorrhage. The nurses were cited
for the following:
1. Delay in transferring the client to the
neurological unit
2. Failure to advocate for the client
The client presented with an acute neurological
problem requiring admission to an intensive care
unit where appropriate observation and interven-
tions were available. A delay in transfer may lead to
delay in appropriate treatment. According to the
American Association of Neuroscience Nursing
standards of practice (2012), nurses need to accu-
rately assess the client’s changing neurological
status and advocate for the client. In this instance,
the court stated that the nurses should have been
Medications
• Always chart the time, route, dose, and response.
• Always chart PRN medications and the client response.
• Always chart when a medication was not given, the reason (e.g., client in Radiology, Physical Therapy; do not chart that
the medication was not on the floor), and the nursing intervention.
• Chart all medication refusals, and report them.
Physician Communication
• Document each time a call is made to a physician, even if he or she is not reached. Include the exact time of the call. If
the physician is reached, document the details of the message and the physician’s response.
• Read verbal orders back to the physician, and confirm the client’s identity as written on the chart. Chart only verbal
orders that you have heard from the source, not those told to you by another nurse or unit personnel.
Formal Issues in Charting
• Before writing on the chart, check to be sure you have the correct patient record.
• Check to make sure each page has the client’s name and the current date stamped in the appropriate area.
• If you forgot to make an entry, chart “late entry,” and place the date and time at the entry.
• Correct all charting mistakes according to the policy and procedures of your institution.
• Chart in an organized fashion, following the nursing process.
• Write legibly and concisely, and avoid subjective statements.
• Write specific and accurate descriptions.
• When charting a symptom or situation, chart the interventions taken and the client response.
• Document your own observations, not those that were told to you by another party.
• Chart frequently to demonstrate ongoing care, and chart routine activities.
• Chart client and family teaching and their response.
box 3-2
Some Documentation Guidelines
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38 unit 1 ■ Professional Considerations
more assertive in attempting to reach the physician
and request a prompt medical evaluation. The court
sided with the family, agreeing with the plaintiff ’s
medical expert’s conclusion that the client’s death
was related to improper management by the nursing
staff.
If a Problem Arises
When served with a summons or complaint, people
often panic, allowing fear to overcome reason.
First, simply answer the complaint. Failure to do
this may result in a default judgment, causing
greater distress and difficulties.
Second, many things can be done to protect
oneself if named in a lawsuit. Legal representation
can be obtained to protect personal property. Never
sign any documents without consulting the mal-
practice insurance carrier or a legal representative.
If you are personally covered by malpractice insur-
ance, notify the company immediately and follow
its instructions carefully.
Institutions usually have lawyers to defend
themselves and their employees. Whether or not
you are personally insured, contact the legal depart-
ment of the institution where the act took place.
Maintain a file of all papers, proceedings, meetings,
and telephone conversations about the case. Do not
withhold any information from your attorneys,
even if that information can be harmful to you. A
pending or ongoing legal case should not be dis-
cussed with coworkers or friends.
Let the attorneys and the insurance company
help decide how to handle the difficult situation.
They are in charge of damage control. Concealing
information usually causes more damage than dis-
closing it.
Sometimes, nurses believe they are not being
adequately protected or represented by the attor-
neys from their employing institution. If this
happens, consider hiring a personal attorney who is
experienced in malpractice law. This information
can be obtained through either the state bar asso-
ciation or the local trial lawyers association.
Anyone has the right to sue; however, that does
not mean that there is a case. Many negligence and
malpractice cases find in favor of the health-care
providers, not the client or the client’s family. The
following case demonstrates this situation:
The Supreme Court of Arkansas heard a case that
originated from the Court of Appeals in Arkansas.
A client died in a single-car motor vehicle accident
shortly after undergoing an outpatient colonoscopy
performed under conscious sedation. The family sued
the center for performing the procedure and permit-
ting the client to drive home. The court agreed that
sedation should not be administered without the
confirmation of a designated driver for later. It also
agreed that an outpatient facility needs to have
directives stating that nurses and physicians may
not administer sedation unless transportation is
available for later. However, the court ruled physi-
cians and nurses may rely on information from the
client. If the client states that someone will be avail-
able for transportation after the procedure, sedation
may be administered. The second aspect of the case
revolved around the client’s insistence on leaving the
facility and driving himself. When a client leaves
against medical advice, the health-care personnel
have a legal duty to warn and strongly advise the
client against the highly dangerous action. However,
nurses and physicians do not have a legal right to
restrain the client physically, keep his clothes, or take
away car keys. Nurses are not obligated to call a
taxi, call the police, admit the client to the hospital,
or personally escort the client home if the client
insists on leaving. Clients have some responsibility
for their own safety (Young v GastroIntestinal
Center, Inc., 2005). In this case, the nurses acted
appropriately. They adhered to the standard of prac-
tice, documented that the client stated that someone
would be available to transport him home, and ful-
filled the duty to warn.
Professional Liability Insurance
We live in a litigious society. Although there are a
variety of opinions on the issue, in today’s world
nurses need to consider obtaining professional lia-
bility insurance (Aiken, 2004). Various forms of
professional liability insurance are available. These
policies have been developed to protect nurses
against personal financial losses if they are involved
in a medical malpractice suit. If a nurse is charged
with malpractice and found guilty, the employing
institution has the right to sue the nurse to reclaim
damages. Professional malpractice insurance pro-
tects the nurse in these situations.
End-of-Life Decisions and the Law
When a heart ceases to beat, a client is in a state
of cardiac arrest. In health-care institutions and in
the community, it is common to begin cardiopul-
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chapter 3 ■ Nursing Practice and the Law 39
monary resuscitation (CPR) when cardiac arrest
occurs. In health-care institutions, an elaborate
mechanism is put into action when a client “codes.”
Much controversy exists concerning when these
mechanisms should be used and whether individu-
als who have no chance of regaining full viability
should be resuscitated.
Do Not Resuscitate Orders
A do not resuscitate (DNR) order is a specific
directive to health-care personnel not to initiate
CPR measures. Only a physician can write a DNR
order, usually after consulting with the client or
family. Other members of the health-care team are
expected to comply with the order. Clients have the
right to request a DNR order. However, they may
make this request without a full understanding of
what it really means. Consider the following
example:
When Mrs. Vincent, 58 years old, was admitted to
the hospital for a hysterectomy, she stated, “I want
to be made a DNR.” The nurse, concerned by the
statement, questioned Mrs. Vincent’s understanding
of a DNR order. The nurse asked her, “Do you mean
that if you are walking down the hall after your
surgery and your heart stops beating, you do not
want the nurses or physicians to do anything? You
want us to just let you die?” Mrs. Vincent responded
with a resounding, “No, that is not what I mean. I
mean if something happens to me and I won’t be
able to be the way I am now, I want to be a DNR!”
The nurse then explained the concept of a DNR
order.
New York state has one of the most complete laws
regarding DNR orders for acute and long-term care
facilities. The New York law sets up a hierarchy of
surrogates who may ask for a DNR status for
incompetent clients. The state has also ordered that
all health-care facilities ask clients their wishes
regarding resuscitation (www.ny.gov). The ANA
advocated that every facility have a written policy
regarding the initiation of such orders (ANA,
1992). The client, or if the client is unable to speak
for himself or herself, a family member or guardian
should make clear the client’s preference for either
having as much as possible done or withholding
treatment (see the next section, Advance Direc-
tives). After the Terri Schiavo case the ANA recon-
firmed its stance on this issue (ANA, 2005).
Elements to include in a DNR order are listed in
Box 3-3.
Advance Directives
The legal dilemmas that may arise in relation to
DNR orders often require court decisions. For this
reason, in 1990, Senator John Danforth of Missouri
and Senator Daniel Moynihan of New York intro-
duced the Patient Self-Determination Act to
address questions regarding life-sustaining treat-
ment. The act was created to allow people the
opportunity to make decisions about treatment in
advance of a time when they might become unable
to participate in the decision-making process.
Through this mechanism, families can be spared
the burden of having to decide what the family
member would have wanted.
Federal law requires that health-care institutions
that receive federal money (from Medicare, for
example) inform clients of their right to create
advance directives. The Patient Self-Determination
Act (S.R. 13566) provides guidelines for develop-
ing advance directives concerning what will be
done for individuals if they are no longer able to
participate actively in making decisions about care
options. The act states that institutions must:
■ Provide information to every client. On
admission, all clients must be informed in
writing of their rights under state law to
accept or refuse medical treatment while they
are competent to make decisions about their
care. This includes the right to execute advance
directives.
■ Document. All clients must be asked whether
they have a living will or have chosen a
durable power of attorney for health care (also
• Statement of the institution’s policy that resuscitation will
be initiated unless there is a specific order to withhold
resuscitative measures
• Statement from the client regarding specific desires
• Description of the client’s medical condition to justify a
DNR order
• Statement about the role of family members or
significant others
• Definition of the scope of the DNR order
• Delineation of the roles of various caregivers
American Nurses Association. (1992). Position statement on nursing
care and do not resuscitate decisions. Washington, DC: ANA.
box 3-3
Elements to Include in a DNR Order
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40 unit 1 ■ Professional Considerations
known as a health-care surrogate). The
response must be indicated on the medical
record, and a copy of the documents, if
available, should be placed on the client’s chart.
■ Educate. Nurses, other health-care personnel,
and the community need to understand what
the Patient Self-Determination Act and state
laws regarding advance directives require.
■ Be respectful of clients’ rights. All clients are
to be treated with respectful care regardless of
their decision regarding life-prolonging
treatments.
■ Have cultural humility. Recognize that
culture affects clients’ decisions regarding end-
of-life care. Nurses should familiarize
themselves with the cultural and spiritual
beliefs of their clients in order to deliver
culturally sensitive care.
Living Will and Durable Power of Attorney for
Health Care (Health-Care Surrogate)
The two most common forms of advance directives
are living wills and durable power of attorney for
health care (health-care surrogate). Living wills and
other advance directives describe individual prefer-
ences regarding treatment in the event of a serious
accident or illness. These legal documents indicate
an individual’s wishes regarding care decisions
(www.mayoc linic.com/health/l iving-wil ls/
HA00014).
A living will is a legally executed document that
states an individual’s wishes regarding the use of
life-prolonging medical treatment in the event that
he or she is no longer competent to make informed
treatment decisions on his or her own behalf and
is suffering from a terminal condition (Catalano,
2000; Flarey, 1991). A condition is considered ter-
minal when, to a reasonable degree of medical cer-
tainty, there is little likelihood of recovery or the
condition is expected to cause death. A terminal
condition may also refer to a persistent vegetative
state characterized by a permanent and irreversible
condition of unconsciousness in which there is (1)
absence of voluntary action or cognitive behavior
of any kind and (2) an inability to communicate or
interact purposefully with the environment (Hickey,
2008).
Another function of an advance directive is to
designate a health-care surrogate. The role of the
health-care surrogate is to make the client’s wishes
known to medical and nursing personnel. Chosen
by the client, the health-care surrogate is usually a
family member or close friend. Imperative in the
designation of a health-care surrogate is a clear
understanding of the client’s wishes should the
need arise to know them.
In some situations, clients are unable to express
themselves adequately or competently, although
they are not terminally ill. For example, clients with
advanced Alzheimer’s disease or other forms of
dementia cannot communicate their wishes; clients
under anesthesia are temporarily unable to com-
municate; and the condition of comatose clients
does not allow for expression of health-care wishes.
In these situations, the health-care surrogate can
make treatment decisions on behalf of the client.
However, when a client regains the ability to make
his or her own decisions and is capable of ex-
pressing them effectively, he or she resumes con-
trol of all decision making pertaining to medical
treatment (Reigle, 1992). Nurses and physicians
may be held accountable when they go against a
client’s wishes regarding DNR orders and advance
directives.
In the case of Wendland v. Sparks (1998), the
physician and nurses were sued for “not initiating
CPR.” In this case, the client had been in the hos-
pital for more than 2 months for lung disease and
multiple myeloma. Although improving at the
time, during the hospitalization the client had
experienced three cardiac arrests. Even after this,
she had not requested a DNR order. Her family
had not discussed this either. After one of the
arrests, the client’s husband had told the physician
that he wanted his wife placed on artificial life
support if it was necessary (Guido, 2001). The
client had a fourth cardiac arrest. One nurse went
to obtain the crash cart, and another went to get
the physician who happened to be in the area. The
physician checked the client’s heart rate, pupils, and
respirations and stated, “I just cannot do it to her.”
(Guido, 2001, p. 158). She ordered the nurses to
stop the resuscitation, and the physician pro-
nounced the death of the client. The nurses stated
that if they had not been given a direct order they
would have continued their attempts at resuscita-
tion. “The court ruled that the physician’s judgment
was faulty and that the family had the right to sue
the physician for wrongful death” (Guido, 2001, p.
158). The nurses were cleared in this case because
they were following a physician’s order.
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chapter 3 ■ Nursing Practice and the Law 41
Nursing Implications
The Patient Self-Determination Act does not
specify who should discuss treatment decisions or
advance directives with clients. Because directives
are often implemented on nursing units, however,
nurses must be knowledgeable about living wills
and health-care surrogates and be prepared to
answer questions that clients may have about direc-
tives and the forms used by the health-care
institution.
The responsibility for creating an awareness of
individual rights often falls on nurses because they
are client advocates. It is the responsibility of the
health-care institution to educate personnel about
its policies so that nurses and others involved in
client care can inform health-care consumers of
their choices. Nurses who are unsure of the policies
in their health-care institution should contact the
appropriate department.
Legal Implications of
Mandatory Overtime
Although mostly a workplace and safety issue, there
are legal implications to mandatory overtime. Due
to nursing shortages, hospitals have increasingly
forced nurses to work overtime (ANA, 2011). The
ANA conducted a survey of almost 220,000 RNs
from 13,000 nursing units in over 550 hospitals.
The survey produced a 70% report rate and the
results indicated that:
■ 54% of nurses in adult medical units and
emergency rooms revealed that they do not
have sufficient time with patients;
■ The amount of overtime has increased during
the past year with 43% of all RNs working
extra hours because the unit is short staffed or
busy; and
■ Inadequate staffing affected unit admissions,
transfers, and discharges more than 20% of the
time (ANA, 2011).
Overtime causes physical and mental fatigue,
increased stress, and decreased concentration. Sub-
sequently, these conditions lead to medical errors
such as failure to assess appropriately, report, docu-
ment, and administer medications safely. This prac-
tice of overtime ignores other responsibilities nurses
have outside of their professional lives, which
affects their mood, motivation, and productivity
(Bae, Brewer, & Kovner, 2011).
Forced overtime causes already fatigued nurses
to deliver nursing care that may be less than
optimum, which in turn may lead to negligence and
malpractice. This can result in the nurse losing his
or her license and perhaps even facing a wrongful
death suit due to an error in judgment. Needleman,
Buerhaus, Pankratz, Liebson, Stevens, and Harris
(2011) found that patient mortality increased by
2% on nursing units that had nurses working shifts
8 hours or more over their scheduled time due to
registered nurse short staffing issues. Many states
have implemented legislation restricting manda-
tory overtime for nurses. It is important for nurses
to know and understand the laws of their particular
state dealing with this issue.
Nurses practice under state or provincial
(Canada) nurse practice acts, which state that
nurses are held accountable for the safety and
welfare of their clients. Once a nurse accepts an
assignment for the client, that nurse becomes liable
under his or her license.
Licensure
Licensure is defined by the National Council of
State Boards of Nursing as “the process by which
boards of nursing grant permission to an indi-
vidual to engage in nursing practice after determin-
ing that the applicant has attained the competency
necessary to perform a unique scope of practice.
Licensure is necessary when the regulated activi-
ties are complex, require specialized knowledge
and skill and independent decision making.”
(NCSBN, 2012). Licenses are given by a govern-
ment agency to allow an individual to engage in a
professional practice and use a specific title. State
boards of nursing issue nursing licenses, thus limit-
ing practice to a specific jurisdiction (Blais &
Hayes, 2011).
Licensure can be mandatory or permissive.
Permissive licensure is a voluntary arrangement
whereby an individual chooses to become licensed
to demonstrate competence. However, the license
is not required to practice. Mandatory licensure
requires a nurse to be licensed in order to practice.
In the United States and Canada, licensure is
mandatory.
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42 unit 1 ■ Professional Considerations
Qualifications for Licensure
The basic qualification for licensure requires gradu-
ation from an approved nursing program. In the
United States, states may add additional require-
ments, such as disclosures regarding health or med-
ications that could affect practice. Most states
require disclosure of criminal conviction.
Licensure by Examination
A major accomplishment in the history of nursing
licensure was the creation of the Bureau of State
Boards of Nurse Examiners. The formation of this
agency led to the development of an identical
examination in all states. The original examination,
called the State Board Test Pool Examination,
was created by the testing department of the
National League for Nursing. This was done
through a collaborating contract with the state
boards. Initially, each state determined its own
passing score; however, the states did adopt a
common passing score. The examination is called
the NCLEX-RN and is used in all states and ter-
ritories of the United States. This test is prepared
and administered through a testing company,
Pearson Professional Testing of Minnesota (Ellis &
Hartley, 2004).
NCLEX-RN
The NCLEX-RN is administered through com-
puterized adaptive testing (CAT). Candidates must
register to take the examination at an approved
testing center in their area. Because of a large test
bank, CAT permits a variety of questions to be
administered to a group of candidates. Candidates
taking the examination at the same time may not
necessarily receive the same questions. Once a can-
didate answers a question, the computer analyzes
the response and then chooses an appropriate ques-
tion to ask next. If the question was answered cor-
rectly, the following question may be more difficult;
if the question was answered incorrectly, the next
question may be easier.
In April 2013 the new test plan was imple-
mented. Changes in the test plan were based on the
Findings from the 2011 RN Practice Analysis: Linking
the NCLEX Examination to Practice (NCSBN,
2012). The minimum number of questions any can-
didate may receive is 75, and the maximum is 265.
Although the maximum amount of time for taking
the examination is 6 hours, candidates who do well
or those who are not performing well may finish as
soon as 1 hour. The test ends once the analysis of
the examination clearly determines that the candi-
date has successfully passed, has undoubtedly failed,
has answered the maximum number of questions,
or has reached the time limit (NCSBN, 2012). The
computer scores the test at the time it is taken;
however, candidates are not notified of their status
at the time of completion. The infor mation first
goes to the testing service, which in turn notifies
the appropriate state board. The state board notifies
the candidate of the examination results.
Nursing practice requires the application of
knowledge, skills, and abilities (NCSBN, 2012).
The items are written to reflect the levels of Bloom’s
taxonomy and are organized around client needs to
reflect the candidates’ ability to make nursing deci-
sions regarding client care through application and
analysis of information. The examination is orga-
nized into four major client need categories. Two
of these categories, safe and effective care and physi-
ological needs, include subdivisions (NCSBN,
2012). Integrated processes incorporate “nursing
process, caring, communication and documen-
tation and teaching/learning” (NCSBN, 2012,
p. 3). Table 3-2 summarizes the categories and
subcategories.
table 3-2
Major Categories and Subcategories of Client Needs
Category Subcategories
Safe Effective Care Environment Management of Care Safety and Infection Control
Health Promotion and Maintenance Basic Care and Comfort
Psychosocial Integrity Pharmacological and Parenteral Therapies
Physiological Integrity Reduction of Risk Potential
Physiological Adaptation
Source: Adapted from NCSBN NCLEX-RN test plan (NCSBN, 2007, pp. 3–4.)
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chapter 3 ■ Nursing Practice and the Law 43
Earlier, all questions were written in a multiple-
choice format. In 2003, alternative formats were
introduced. These alternative-format questions
include fill-in-the-blank; multiple-response an-
swers; audio and video type; “hot spots” that re-
quire the candidate to identify an area on a picture,
graph, or chart; and drag-and-drop (NCSBN,
2012). More information on alternative formats
can be found on the NCSBN Web site: www
.ncsbn.org.
Preparing for the NCLEX-RN
There are several ways to prepare for the NCLEX-
RN. Some candidates attend review courses, others
view videos and DVDs, and others review books.
These methods assist in reviewing information that
was learned during the classroom education. Each
individual needs to decide what works best for him
or her. It is helpful to take practice tests, because it
familiarizes one with the computer and the exami-
nation format. The NCSBN offers an online
NCLEX-RN study program.
To prepare for the NCLEX, take time to look
at the test blueprint provided by the NCSBN. This
gives candidates a comprehensive overview of the
types of questions to expect on the examination.
Candidates can review alternative test formats by
accessing www.pearsonvue.com/nclex/. Some test-
taking tips follow.
■ Be positive. Remind yourself that you worked
hard to reach this milestone and how prepared
you are to take the licensure examination.
■ Turn negative thoughts into positive ones.
Rather than saying, “I hope I pass,” tell
yourself, “I know I will do well.”
■ Acknowledge your feelings regarding the
NCLEX. It is fine to admit that you are
anxious; however, use your positive thoughts to
control the anxiety.
■ Also use diaphragmatic breathing (deep
breathing) to control anxiety. Deep breathing
augments the relaxation response of the body.
Use this method at the beginning of the test
or if you encounter a question that you find
confusing.
■ Control the situation by making a list of the
items you may need to take the test. Pack
them in a bag several days before, and keep
them in a place where you will remember to
take them.
■ Eat well and get a good night’s sleep before
the test. Avoid foods high in sugar and
caffeine. Contrary to popular belief, caffeine
interferes with your ability to concentrate. Eat
complex carbohydrates and protein to maintain
your blood glucose level.
■ Several days before you are scheduled to take
the test, travel to the test site along the same
route at the time you plan to go. Have an
alternate itinerary in case there is a disruption
in your route. This will alleviate any
unnecessary stress in arriving at the
examination site.
■ Leave early and give yourself plenty of time to
get to your destination. Arriving early also
gives you a sense of control.
■ Finally, remember your own basic needs.
Testing centers tend to be cold. Pack a jacket
or sweater. Check with the testing center to
see if you are allowed to bring water or snacks.
Licensure Through Endorsement
Nurses licensed in one state may obtain a license in
another state through the process of endorsement.
Each application is considered independently and
is granted a license based on the rules and regula-
tions of the state.
States differ in the number of continuing educa-
tion credits required, legal requirements, and other
educational requirements. Some states require that
nurses meet the current criteria for licensure at the
time of application, whereas others may grant the
license based on the criteria in effect at the time of
the original licensure (Ellis & Hartley, 2004).
When applying for a license through endorsement,
a nurse should always contact the board of nursing
for the state and find out the exact requirements
for licensure. This information can usually be found
on the board of nursing Web site for that particular
state.
Multistate Licensure
The concept of multistate licensure allows a nurse
licensed in one state to practice in additional states
without obtaining additional licenses. NCSBN
created a Multistate Licensure Compact, now
referred to as the Nurse Licensure Compact, that
permits this practice. States that belong to the
compact have passed legislation adopting the terms
of this agreement and are known as party states
(https://www.ncsbn.org/nlc.htm). The nurse’s home
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44 unit 1 ■ Professional Considerations
state is the state where he or she lives and received
his or her original license. Renewal of the license is
completed in the home state.
A nurse can hold only one home-state license.
If the nurse moves to another state that belongs to
the compact, the nurse applies for licensure within
that state based on residency. The nurse is expected
to follow the guidelines for nursing practice for that
new state. The multistate licensure applies only to
a basic registered nurse license, not to advanced
practice. More information on multistate licensure
can be found on the NCSBN Web site.
Disciplinary Action
State boards of nursing maintain rules and regula-
tions for the practice of nursing. These may be
found in the state’s nurse practice acts. Violation of
these regulations results in disciplinary actions as
delineated by these boards. Issues of primary con-
cern include but are not limited to the following:
■ Falsifying documents to obtain a license
■ Being convicted of a felony
■ Practicing while under the influence of drugs
or alcohol
■ Functioning outside the scope of practice
■ Engaging in child or elder abuse
Nurses convicted of a felony or found guilty in a
malpractice action may find themselves before their
state board of nursing or, in Canada, the provincial
or territorial regulatory body.
Disciplinary action may include but is not
limited to the suspension or revocation of a nursing
license, mandatory fines, and mandatory continu-
ing education. For more information regarding the
regulations that guide nursing practice, consult the
board of nursing in your state or, in Canada, your
provincial or territorial regulatory body.
Conclusion
Nurses need to understand the legalities involved
in the delivery of safe health care. It is important
to know the standards of care established within
your institution and the rules and regulations in the
nurse practice acts of your state, province, or terri-
tory because these are the standards to which you
will be held accountable. Health-care consumers
have a right to quality care and the ex pectation that
all information regarding diagnosis and treatment
will remain confidential. Nurses have an obligation
to deliver quality care and res pect client confiden-
tiality. Caring for clients safely and avoiding legal
difficulties require nurses to adhere to the expected
standards of care and document changes in client
status carefully. Licensure helps to ensure that
health-care consumers are receiving competent and
safe care from their nurses.
Study Questions
1. How do federal laws, court decisions, and state boards of nursing affect nursing practice? Give
an example of each.
2. Obtain a copy of the nurse practice act in your state. What are some of the penalties for
violation of the rules and regulations?
3. Review the minutes and/or documents of a state board meeting. What were the most common
issues for nurses to be called before the board of nursing? What were the resulting disciplinary
actions?
4. The next time you are on your clinical unit, look at the nursing documentation done by several
different staff members. Do you believe it is adequate? Explain your rationale.
5. How does your clinical institution handle medication errors?
6. If a nurse is found to be less than proficient in the delivery of safe care, how should the nurse
manager remedy the situation?
7. Discuss where appropriate standards of care may be found. Explain whether each is an
example of an internal or external standard of care.
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chapter 3 ■ Nursing Practice and the Law 45
8. Explain the importance of federal agencies in setting standards of care in health-care
institutions.
9. What is the difference between consent and informed consent?
10. Look at the forms for advance directives and DNR policies in your institution. Do they follow
the guidelines of the Patient Self-Determination Act?
11. What are the most common errors nurses commit that lead to negligence and/or malpractice?
12. What impact would a law that prevents mandatory overtime have on nurses, nursing care, and
the health-care industry? Find out if your state has mandatory overtime legislation.
Case Study to Promote Critical Reasoning
Mr. Evans, 40 years old, was admitted to the hospital’s medical-surgical unit from the emergency
department with a diagnosis of acute abdomen. He had a 20-year history of Crohn’s disease and
had been on prednisone, 20 mg, every day for the past year. Three months ago he was started on
the new biological agent etanercept, 50 mg, subcutaneously every week. His last dose was 4 days
ago. Because he was allowed nothing by mouth (NPO), total parenteral nutrition was started
through a triple-lumen central venous catheter line, and his steroids were changed to Solu-Medrol,
60 mg, by intravenous (IV) push every 6 hours. He was also receiving several IV antibiotics and
medication for pain and nausea.
Over the next 3 days, his condition worsened. He was in severe pain and needed more
analgesics. One evening at 9 p.m., it was discovered that his central venous catheter line was out.
The registered nurse notified the physician, who stated that a surgeon would come in the morning
to replace it. The nurse failed to ask the physician what to do about the IV steroids, antibiotics,
and fluid replacement; the client was still NPO. She also failed to ask about the etanercept. At
7 a.m., the night nurse noticed that the client had had no urinary output since 11 p.m. the night
before. She documented that the client had no urinary output but forgot to report this
information to the nurse assuming care responsibilities on the day shift.
The client’s physician made rounds at 9 a.m. The nurse for Mr. Evans did not discuss the fact
that the client had not voided since 11 p.m., did not request orders for alternative delivery of the
steroids and antibiotics, and did not ask about administering the etanercept. At 5 p.m. that
evening, while Mr. Evans was having a computed tomography scan, his blood pressure dropped to
70 mm Hg, and because no one was in the scan room with him, he coded. He was transported to
the ICU and intubated. He developed severe sepsis and acute respiratory distress syndrome.
1. List all the problems you can find with the nursing care in this case.
2. What were the nursing responsibilities in reporting information?
3. What do you think was the possible cause of the drop in Mr. Evans’ blood pressure and his
subsequent code?
4. If you worked in risk management, how would you discuss this situation with the nurse
manager and the staff ?
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46 unit 1 ■ Professional Considerations
Case Study on Mandatory Overtime
Juan was completing his charting on his three babies in the neonatal intensive care unit. He had
just finished orientation and this was his third day working. He was very tired and looking
forward to his time off the next several days. Usually the nurse-to-baby ratio in the NICU was
1:2; however, the unit had been running short staffed and each nurse assumed additional patient
responsibilities. Prior to him giving report, Juan’s nurse manager came to him and stated, “Ada
called in sick. We do not have anyone else to cover the unit and we are under our nurse-to-patient
ratio. I need you to stay and work today.” When Juan protested that he had already worked three
12-hour shifts and one 8-hour shift, the nurse manager told him that if he refused, she could “fire
him” and report him for patient abandonment.
1. If you were Juan, how would you respond to the nurse manager?
2. What options does Juan have in this situation?
3. What information should Juan find out regarding “mandatory overtime”?
4. If Juan makes an error that results in harm to a patient, can he be held accountable?
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chapter 3 ■ Nursing Practice and the Law 47
References
Aiken, T.D. (2004). Legal, Ethical and political issues in
nursing, 2nd ed. Philadelphia: F.A. Davis.
American Association of Neuroscience Nurses, (2012).
Neuroscience nursing scope and standards of practice.
Washington, DC: ANA.
American Nurses Association (ANA). (1992). Position
statement on nursing care and do not resuscitate
decisions. Washington, DC: ANA.
American Nurses Association (ANA). (1998). Legal aspects
of standards and guidelines for clinical nursing practice.
Washington, DC: ANA.
American Nurses Association (ANA). (2005). American
Nurses Association Statement on the Terri Schiavo Case.
Retrieved on October 2, 2012, from http://
nursingworld.org/FunctionalMenuCategories/
MediaResources/PressReleases/2005/pr03238523
.aspx
American Nurses Association (ANA). (2010). Nursing:
scope and standards of practice. Pub 03SSNP.
Washington, DC: ANA.
American Nurses Association (ANA). (2011). Nurse staffing
plans and ratios. Retrieved on September 28, 2012,
from www.nursingworld.org/MainMenuCategories/
Policy-Advocacy/State/Legislative-Agenda-Reports/
State-StaffingPlansRatios
Bae, S.H., Brewer, C.S., & Kovner, C.T. (2011). State
mandatory overtime regulations and newly licensed
nurses’ mandatory and voluntary overtime and total work
hours. Nursing Outlook (doi:10.1016/j), pp. 1–12.
Retrieved on October 2, 2012, from www
.nursingoutlook.org
Balas, M., Scott, L., & Rogers, A. (2004). The prevalence
and nature of errors and near errors reported by hospital
staff nurses. Applied Nursing Research, 17(4),
224–230.
Beckman, J.P. (1995). Nursing malpractice: Implications for
clinical practice and nursing education. Seattle:
Washington University Press.
Berman, A.J., & Snyder, S. (2012). Kozier and Erb’s
fundamentals of nursing: Concepts, process and practice
(9th ed.). Upper Saddle River, N.J.: Prentice-Hall.
Black, H.C. (2009). In Gardner, B.A. (ed.), Black’s Law
dictionary (9th ed.). St. Paul: West Publishing.
Blais, K.K., & Hayes, J.S. (2011). Professional nursing
practice: Concepts and perspectives (6th ed.). Upper
Saddle River, N.J.: Prentice-Hall.
Catalano, J.T. (2000). Nursing now! Today’s issue,
tomorrow’s trends, 2nd ed. Philadelphia: F.A. Davis.
Charters, K.G. (2003). HIPAA’s latest privacy rule. Policy,
Politics & Nursing Practice, 4(1), 75–78.
Donabedian, A. (1988). The quality of care: How can it
be assessed? Journal of the American Medical
Association, 260(12), 1743–1748.
Eisenhauer, L.A., Hurley, A.C., & Dolan, N. (2007).
Nurses’ reported thinking during medication
administration. Journal of Nursing Scholarship, 39(1),
82–87.
Elliott, M., & Liu, Y. (2010). The nine rights of medication
administration: An overview. British Journal of Nursing,
19(5), 300.
Ellis, J.R., & Hartley, C.L. (2004). Nursing in today’s world:
trends, issues and management, 8th ed. Philadelphia:
Lippincott, Williams & Wilkins.
Flarey, D. (1991). Advanced directives: In search of self-
determination. Journal of Nursing Administration, 21(11),
17.
Gic, J. (2009). Nursing and the Law. In Shafeek, S., Legal
medicine. Philadelphia: Mosby Elsevier.
Giese v. Stice. 567 N.W. 2d 156 (Nebraska, 1997).
Glannon, J.W. (2005). The law of torts: Examples and
explanations (3rd ed.). Frederick, MD: Aspen Publishers.
Guido, G.W. (2001). Legal and ethical issues in nursing,
3rd ed. Upper Saddle River, N.J.: Prentice-Hall.
Hickey, J. (2008). Clinical practice of neurological and
neurosurgical nursing, 6th ed. Philadelphia: Lippincott,
Williams and Wilkins.
Hill, G.N., & Hill, K.T. (2009). The people’s law
dictionary: Taking the mystery out of legal language.
Retrieved on September 28, 2012, from http://
dictionary.law.com/Default.aspx?searched=common%20
law&type=1
Kozier, B., Erb, G., Blais, K., et al. (1995). Fundamentals
of nursing: Concepts, process and practice, 15th ed.
Menlo Park, Calif.: Addison-Wesley.
Loiacono, K. (2005). A good fight in the house over
medical malpractice ‘reform.’ Trial, 11. Retrieved June
18, 2014, from http://www.thefreelibrary.com/A
+good+fight+in+the+House+over+medical+malpractice
+’reform’.-a0115404605
Marr, S. (2003). Protect your practice: Informed consent.
Plastic Surgical Nursing, 22(4), pp. 180–197.
Mayo Clinic. Living wills and advance directives. Available
from www.mayoclinic.com/health/living-wills/
HA00014
National Council of State Boards of Nursing. (2012). Fast
facts about alternative item formats and the NCLEX
examination. Retrieved on October 2, 2012, from
www.ncsbn.org
National Council of State Boards of Nursing. (2012).
Nursing regulation. Retrieved on October 1, 2012, from
www.ncsbn.org.
National Council of State Boards of Nursing. (2012).
2013 NCLEX-RN test plan. Retrieved on October 2,
2012, from www.ncsbn.org.
National Council of State Boards of Nursing (2012). Nurse
licensure compact. Retrieved on October 4, 2012, from
https://www.ncsbn.org/nlc.htm.
Needleman, J., Buerhaus, P., Pankratz, S., Liebson, C.L.,
Stevens, S.R., and Harris, M. (2011). Nurse staffing
and inpatient hospital mortality. New England Journal of
Medicine, 364(11), 1037–1045.
New York state end-of-life laws (2012). Retrieved October
3, 2012, from www.nyc.gov/html/doh/html/hca/
advance-directives.shtml
Reigle, J. (1992). Preserving patient self-determination
through advance directives. Heart Lung, 21(2),
196–198.
Sanbar, S.S. (2007). Legal medicine (7th ed.). Philadelphia:
Mosby Elsevier.
Taylor, C., Lillis, C., & LeMone, P. (2008). Fundamentals of
nursing: The art and science of nursing care.
Philadelphia: Lippincott, Williams & Wilkins.
Tovar v. Methodist Healthcare. (2005). S.W. 3d WL
3079074 (Texas App., 2005).
Wendland v. Sparks. (1998). 574 N.W. 2d 327 (Iowa,
1998).
Young v. GastroIntestinal Center, Inc. (2005). S.W. 3d WL
675751 (Arkansas, 2005).
3663_Chapter 3_0027-0048.indd 473663_Chapter 3_0027-0048.indd 47 9/15/2014 4:37:08 PM9/15/2014 4:37:08 PM
Process CyanProcess CyanProcess MagentaProcess MagentaProcess YellowProcess YellowProcess BlackProcess Black
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chapter 4
Questions of Values and Ethics
OBJECTIVES
After reading this chapter, the student should be able to:
■ Discuss the way values are formed.
■ Differentiate between personal ethics and professional ethics.
■ Compare and contrast various ethical theories.
■ Discuss virtue ethics.
■ Apply the seven basic ethical principles to an ethical issue.
■ Analyze the impact that sociocultural factors have on ethical
decision making by nursing personnel.
■ Discuss the influence organizational ethics have on nursing
practice.
■ Identify an ethical dilemma in the clinical setting.
■ Discuss current ethical issues in health care and possible
solutions.
OUTLINE
Values
Morals
Values and Moral Reasoning
Value Systems
How Values Are Developed
Values Clarification
Belief Systems
Ethics and Morals
Ethics
Ethical Theories
Ethical Principles
Autonomy
Nonmaleficence
Beneficence
Justice
Fidelity
Confidentiality
Veracity
Accountability
Ethical Codes
Virtue Ethics
Nursing Ethics
Organizational Ethics
Ethical Issues on the Nursing Unit
Moral Distress in Nursing Practice
Ethical Dilemmas
Resolving Ethical Dilemmas Faced by Nurses
Assessment
Planning
Implementation
Evaluation
Current Ethical Issues
Practice Issues Related to Technology
Genetics and the Limitations of Technology
Stem Cell Use and Research
Professional Dilemmas
Conclusion
It is 1961. In a large metropolitan hospital, a group
is meeting to consider the cases of three individuals.
Ironically, the cases have something in common.
Martin Curtin, age 76; Irina Kresnick, age 31; and
Lucretia Singleton, age 5, are all suffering from
chronic renal failure and need hemodialysis. Equip-
ment is scarce, the cost of the treatment is prohibi-
tive, and it is doubtful that treatment will be
covered by health insurance. The hospital is able to
provide this treatment to only one of these individu-
als. Who shall live, and who shall die? In a novel
of the same name, Noah Gordon called this decision-
making group The Death Committee (Gordon,
1963). Today, such groups are referred to as ethics
committees.
In previous centuries, health-care practitioners had
neither the knowledge nor the technology to
prolong life. The main function of nurses and phy-
sicians was to support patients through times of
illness, help them toward recovery, or keep them
comfortable until death. There were few “who shall
live, and who shall die?” decisions. Over the last 20
years, technological advances such as multiple
organ transplantation, use of stem cells, and sophis-
ticated life support systems created unique situa-
tions stimulating serious conversations and debates
over the use of such techniques.
Health care saw its first technological advances
during 1947 and 1948 as the polio epidemic
raged through Europe and the United States. This
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50 unit 1 ■ Professional Considerations
devastating disease initiated the development of
units for patients who required manual ventilation
(the “iron lung”). During this period, Danish physi-
cians invented a method of manual ventilation by
using a tube placed in the trachea of polio patients.
This was the beginning of mechanical ventilation
as we know it today. The development of mechani-
cal ventilation required more intensive nursing care
and patient observation. The care and monitoring
of patients proved to be more efficient when they
were kept in a single care area; hence the term
intensive care.
The late 1960s brought greater technological
advances. Open heart surgery, in its infancy at the
time, became available for patients seriously ill with
cardiovascular disease. These patients required spe-
cialized nursing care and nurses specifically edu-
cated in the use of advancing technology. These
new therapies and monitoring methods provided
the impetus for the development of intensive care
units and the emerging critical care nursing spe-
cialty (AACN.org, 2006).
In the past, a vast majority of individuals receiv-
ing critical care services would have died. However,
the development of new drugs and advances
in biomechanical technology permit physicians
and nurses to challenge nature. These advances
have enabled health-care professionals to provide
patients with treatments that in many cases increase
their life expectancy and enhance their quality of
life. However, this progress is not without its draw-
backs as it also brings new, perplexing questions.
The ability to prolong life has created some
heartbreaking situations for families and complex
ethical dilemmas for health-care professionals.
Decisions regarding terminating life support on a
teenager involved in a motor vehicle accident, insti-
tuting life support on a 65-year-old active produc-
tive father, or providing stem cell transplants to a
terminally ill child are a few examples. At what
point do new parents say good-bye to their neonate
who was born far too early to survive outside of the
womb? Families and professionals face some of the
most difficult ethical decisions at times like this.
How is death defined? When does it occur? Perhaps
these questions need to be asked: What is life? Is
there a difference between life and living?
To help find answers to some of these questions,
health-care professionals have looked to philoso-
phy, especially the branch that deals with human
behavior. Over time, to assist in dealing with these
issues, the field of biomedical ethics (or, simply,
bioethics), a subdiscipline of ethics—the philo-
sophical study of morality—has evolved. In essence,
bioethics is the study of medical morality, which
concerns the moral and social implications of
health care and science in human life (DeGrazia,
Mappes, & Brand-Ballard, 2010).
In order to understand biomedical ethics, it is
important to appreciate the basic concepts of values,
belief systems, ethical theories, and morality. The
following sections will define these concepts and
then discuss ways nurses can help the interprofes-
sional team and families resolve ethical dilemmas.
Values
Individuals talk about value and values all the time.
The term value refers to the worth of an object or
thing. However, the term values refers to how indi-
viduals feel about ideas, situations, concepts. Mer-
riam-Webster’s Collegiate Dictionary defines value as
the “estimated or appraised worth of something, or
that quality of a thing that makes it more or less
desirable, useful” (http://www.merriam-webster
.com/dictionary/value). Values, then, are judgments
about the importance or unimportance of objects,
ideas, attitudes, and attributes. Values become a part
of a person’s conscience and worldview. They
provide a frame of reference and act as pilots to
guide behaviors and assist people in making choices.
Morals
Morals arise from an individual’s conscience. They
act as a guide for individual behavior and are
learned through family systems, instruction, and
socialization. Morals find their basis within indi-
vidual values. Morals have a larger social compo-
nent than values and focus more on good versus
bad behaviors (Kirschenbaum, 2000). For example,
if you value fairness and integrity, then your morals
include those values and you judge others based on
your concept of morality.
Values and Moral Reasoning
Reasoning is the process of making inferences from
a body of information and entails forming con-
clusions, making judgments, or making infer-
ences from knowledge for the purpose of answering
questions, solving problems, and formulating a
plan that determines actions (Butts & Rich, 2012).
Reasoning allows individuals to think for them-
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chapter 4 ■ Questions of Values and Ethics 51
selves and not to take the beliefs and judgments of
others at face value. Moral reasoning relates to the
process of forming conclusions and creating action
plans centered around moral and/or ethical issues.
Values, viewpoints, and methods of moral rea-
soning have developed over time. Older worldviews
have now emerged in modern history, such as the
emphasis on virtue ethics or a focus on what type
of person one would like to become (Butts & Rich,
2012). Virtue ethics are discussed later in this
chapter.
Value Systems
A value system is a set of related values. For example,
one person may value (believe to be important)
societal aspects of life, such as money, objects, and
status. Another person may value more abstract
concepts, such as kindness, charity, and caring.
Values may vary significantly, based on an indi-
vidual’s culture, family teachings, and religious
upbringing. An individual’s system of values fre-
quently affects how he or she makes decisions. For
example, one person may base a decision on cost,
and another person placed in the same situation
may base the decision on a more abstract quality,
such as kindness. There are different categories of
values:
■ Intrinsic values are those related to sustaining
life, such as food and water (Zimmerman,
2010).
■ Extrinsic values are not essential to life. They
include the value of objects, both physical and
abstract. Extrinsic values are not an end in
themselves but offer a means of achieving
something else. Things, people, and material
items are extrinsically valuable (Zimmerman,
2010).
■ Personal values are qualities that people
consider important in their private lives.
Concepts such as strong family ties and
acceptance by others are personal values.
■ Professional values are qualities considered
important by a professional group. Autonomy,
integrity, and commitment are examples of
professional values.
People’s behaviors are motivated by values. Indi-
viduals take risks, relinquish their own comfort
and security, and generate extraordinary efforts
because of their values (Edge & Groves, 2005).
Patients with traumatic brain injury may overcome
tremendous barriers because they value indepen-
dence. Race-car drivers may risk death or other
serious injury because they value competition and
winning.
Values also generate the standards by which
people judge others. For example, someone who
values work over leisure activities will look unfavor-
ably on the coworker who refuses to work through-
out the weekend. A person who believes that health
is more important than wealth would approve of
spending money on a relaxing vacation or perhaps
joining a health club rather than putting the money
in the bank.
Often people adopt the values of individuals
they admire. For example, a nursing student may
begin to value humor after observing it used effec-
tively with patients. Values provide a guide for deci-
sion making and give additional meaning to life.
Individuals develop a sense of satisfaction when
they work toward achieving values that they believe
are important.
How Values Are Developed
Values are learned (Csongradi, 2012). Ethicists
attribute the basic question of whether values are
taught, inherited, or passed on by some other
mechanism to Plato, who lived more than 2,000
years ago. A recent theory suggests that values and
moral knowledge are acquired much in the same
manner as other forms of knowledge, through real-
world experience.
Values can be taught directly, incorporated
through societal norms, and modeled through
behavior. Children learn by watching their parents,
friends, teachers, and religious leaders. Through
continuous reinforcement, children eventually learn
about and then adopt values as their own. Because
of the values they hold dear, people often make
great demands on themselves and others, ignoring
the personal cost. For example:
Lora grew up in a family in which educational
achievement was highly valued. Not surprisingly,
she adopted this as one of her own values. Lora
became a physician, married, and had a son named
Davis. She placed a great deal of effort on teaching
her son educational skills in order to get him into
“the best private school” in the area. As he moved
through the program, his grades did not reflect his
mother’s great effort, and he felt as though he had
disappointed his mother as well as himself. By the
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52 unit 1 ■ Professional Considerations
time David reached the age of nine, he had devel-
oped many somatic complaints such as stomachaches
and headaches.
Values change with experience and maturity. For
example, young children often value objects, such
as a favorite blanket or stuffed animal. Older chil-
dren are more likely to value a particular event, such
as a family trip. As they enter adolescence, they may
value peer opinion over the opinions of their
parents. Young adults often value certain ideals,
such as beauty and heroism. The values of adults
are formed from all of these experiences as well as
from learning and thought.
The number of values that people hold is not as
important as what values they consider important.
Choices are influenced by values. The way people
use their own time and money, choose friends, and
pursue a career are all influenced by values.
Values Clarification
Values clarification is deciding what one believes is
important. It is the process that helps people
become aware of their values. Values play an impor-
tant role in everyday decision making. For this
reason, nurses need to be aware of what they do and
do not value. This process helps them to behave in
a manner that is consistent with their values.
Both personal and professional values influence
nurses’ decisions. Understanding one’s own values
simplifies solving problems, making decisions, and
developing better relationships with others when
one begins to realize how others develop their
values. Kirschenbaum (2000) suggested using a
three-step model of choosing, prizing, and acting,
with seven substeps, to identify one’s own values
(Box 4-1).
You may have used this method when making
the decision to go to nursing school. For some
people, nursing is a first career; for others, it is a
second career. Using the model in Box 4-1, the
valuing process is analyzed:
1. Choosing. After researching alternative career
options, you freely chose nursing school. This
choice was most likely influenced by such
factors as educational achievement and abilities,
finances, support and encouragement from
others, time, and feelings about people.
2. Prizing. Once the choice was made, you were
satisfied with it and told your friends about it.
3. Acting. You have entered school and begun the
journey to your new career. Later in your career,
you may decide to return to school for a
bachelor’s or master’s degree in nursing.
As you progressed through school, you probably
started to develop a new set of values—your profes-
sional values. Professional values are those estab-
lished as being important in your practice. These
values include caring, quality of care, and ethical
behaviors.
Belief Systems
Belief systems are an organized way of thinking
about why people exist in the universe. The purpose
of belief systems is to explain such issues as life and
death, good and evil, and health and illness. Usually
these systems include an ethical code that speci-
fies appropriate behavior. People may have a per-
sonal belief system, participate in a religion that
provides such a system, or follow a combination of
the two.
Members of primitive societies worshipped
events in nature. Unable to understand the science
of weather, for example, early civilizations believed
these events to be under the control of someone or
something that needed to be appeased, and they
developed rituals and ceremonies to appease these
unknown entities. They called these entities gods
and believed that certain behaviors either pleased
or angered the gods. Because these societies associ-
ated certain behaviors with specific outcomes, they
created a belief system that enabled them to func-
tion as a group.
Choosing
1. Choosing freely
2. Choosing from alternatives
3. Deciding after giving consideration to the
consequences of each alternative
Prizing
4. Being satisfied about the choice
5. Being willing to declare the choice to others
Acting
6. Making the choice a part of one’s worldview and
incorporating it into behavior
7. Repeating the choice
Adapted from Raths, L.E., Harmon, M., & Simmons, S.B. (1979).
Values and teaching. New York: Charles E. Merrill.
box 4-1
Values Clarification
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As higher civilizations evolved, belief systems
became more complex. Archeology has provided
evidence of the religious practices of ancient civili-
zations that support the evolution of belief sys-
tems (Wack, 1992). The Aztec, Mayan, Incan, and
Polynesian cultures each had a religious belief
system composed of many gods and goddesses for
the same functions. The Greek, Roman, Egyptian,
and Scandinavian societies believed in a hierarchy
of gods and goddesses. Although given different
names by different cultures, it is very interesting
that most of the deities had similar purposes. For
example, the Greeks looked to Zeus as the king of
the gods, and Thor represented the king of the
Norse gods. Both used a thunderbolt as their
symbol. Sociologists believe that these religions
developed to explain what was then unexplainable.
Human beings have a deep need to create order
from chaos and to have logical explanations for
events. Religion offers theological explanations to
answer questions which cannot be explained by
“pure” science.
Along with the creation of rites and rituals, reli-
gions also developed codes of behaviors, or ethical
codes. These codes contribute to the social order
and provide rules regarding how to treat family
members, neighbors, the young, and the old. Many
religions also developed rules regarding marriage,
sexual practices, business practices, property owner-
ship, and inheritance.
For some individuals, the advancement of
science has minimized the need for belief systems,
as science can now provide explanations for many
previously unexplainable phenomena. In fact, the
technology explosion has created an even greater
need for these belief systems. Technological
advances often place people in situations where
they may welcome rather than oppose religious
convictions to guide difficult decisions. Many reli-
gions, particularly Christianity, focus on the will of
a supreme being, and technology, for example, is
considered a gift that allows health-care personnel
to maintain the life of a loved one. Other religions,
such as certain branches of Judaism, focus on free
choice or free will, leaving such decisions in the
hands of humankind. For example, many Jewish
leaders believe that if genetic testing indicates that
an infant will be born with a disease such as Tay-
Sachs that causes severe suffering and ultimately
death, terminating the pregnancy may be an accept-
able option.
Belief systems often help survivors in making
decisions and living with them afterward. So far,
technological advances have created more questions
than answers. As science explains more and more
previously unexplainable phenomena, people need
beliefs and values to guide their use of this new
knowledge.
Ethics and Morals
Although the terms morals and ethics are often used
interchangeably, ethics usually refers to a standard-
ized code as a guide to behaviors, whereas morals
usually refers to an individual’s own code for accept-
able behavior.
Ethics
Ethics is the part of philosophy that deals with the
rightness or wrongness of human behavior. It is also
concerned with the motives behind behaviors. Bio-
ethics, specifically, is the application of ethics to
issues that pertain to life and death. The implica-
tion is that judgments can be made about the right-
ness or goodness of health-care practices.
Ethical Theories
Several ethical theories have emerged to justify
moral principles (Guido, 2001). Deontological theo-
ries take their norms and rules from the duties that
individuals owe each other by the goodness of the
commitments they make and the roles they take
upon themselves. The term deontological comes
from the Greek word deon (duty). This theory is
attributed to the 18th-century philosopher Imman-
uel Kant (Kant, 1949). Deontological ethics con-
siders the intention of the action, not the
consequences of the action. In other words, it is the
individual’s good intentions or goodwill (Kant,
1949) that determines the worthiness or goodness
of the action.
Teleological theories take their norms or rules for
behaviors from the consequences of the action. This
theory is also called utilitarianism. According to
this concept, what makes an action right or wrong
is its utility, or usefulness. Usefulness is considered
to be the amount of happiness the action carries.
“Right” encompasses actions that have good out-
comes, whereas “wrong” is composed of actions
that result in bad outcomes. This theory had its
origins with David Hume, a Scottish philosopher.
According to Hume, “Reason is and ought to be
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54 unit 1 ■ Professional Considerations
the slave of the passions” (Hume, 1978, p. 212).
Based on this idea, ethics depends on what people
want and desire. The passions determine what is
right or wrong. However, individuals who follow
teleological theory disagree on how to decide on
the “rightness” or “wrongness” of an action (Guido,
2001) because individual passions differ.
Principalism is an arising theory receiving a great
deal of attention in the biomedical ethics commu-
nity. This theory integrates existing ethical princi-
ples and tries to resolve conflicts by relating one or
more of these principles to a given situation. Ethical
principles actually influence professional decision
making more than ethical theories.
Ethical Principles
Ethical codes are based on principles that can be
used to judge behavior. Ethical principles assist
decision making because they are a standard for
measuring actions. They may be the basis for laws,
but they themselves are not laws. Laws are rules
created by a governing body. Laws can operate
because the government has the power to enforce
them. They are usually quite specific, as are the
punishments for disobeying them. Ethical princi-
ples are not confined to specific behaviors. They
act as guides for appropriate behaviors. They also
take into account the situation in which a decision
must be made. Ethical principles speak to the
essence or fundamentals of the law rather than to
the exactness of the law (Macklin, 1987). Here is
an example:
Mrs. Van Gruen, 82 years old, was admitted to the
hospital in acute respiratory distress. She was diag-
nosed with aspiration pneumonia and soon became
septic, developing acute respiratory distress syn-
drome. She had a living will, and her attorney was
her designated health-care surrogate. Her compe-
tence to make decisions was uncertain because of her
illness. The physician presented the situation to the
attorney, indicating that without a feeding tube
and tracheostomy, Mrs. Van Gruen would die.
According to the laws governing living wills and
health-care surrogates, the attorney could have
made the decision to withhold all treatments.
However, he believed he had an ethical obligation
to discuss the situation with his client. The client
requested that the tracheostomy and the feeding tube
be inserted, which was done.
Following are several of the ethical principles that
are most important to nursing practice: autonomy,
nonmaleficence, beneficence, justice, fidelity, confi-
dentiality, veracity, and accountability. In some situ-
ations, two or more principles may conflict with
each other, leading to an ethical dilemma. Making
a decision under these circumstances is very
difficult.
Autonomy
Autonomy is the freedom to make decisions for
oneself. This ethical principle requires that nurses
respect patients’ rights to make their own choices
about treatment. Informed consent before treat-
ment, surgery, or participation in research is an
example. To be able to make an autonomous choice,
individuals need to be informed of the purpose,
benefits, and risks of the procedures to which they
are agreeing. Nurses accomplish this by providing
information and supporting patients’ choices.
Closely linked to the ethical principle of auton-
omy is the legal issue of competence. A patient
needs to be deemed competent in order to make
a decision regarding treatment options. When
patients refuse treatment, health-care personnel
and family members who think differently often
question the patient’s “competence” to make a
decision. Of note is the fact that when patients
agree with health-care treatment decisions, rarely
is their competence questioned (AACN News,
2006).
Nurses are often in a position to protect a
patient’s autonomy. They do this by ensuring that
others do not interfere with the patient’s right to
proceed with a decision. If a nurse observes that a
patient has insufficient information to make an
appropriate choice, is being forced into a decision,
or is unable to understand the consequences of the
choice, then the nurse may act as a patient advocate
to ensure the principle of autonomy.
Sometimes nurses have difficulty with the prin-
ciple of autonomy because it also requires respect-
ing another’s choice, even if the nurse disagrees
with it. According to the principle of autonomy,
a nurse cannot replace a patient’s decision with his
or her own, even when the nurse honestly believes
that the patient has made the wrong choice. A
nurse can, however, discuss concerns with patients
and make sure patients have thought about the
consequences of the decision they are about to
make.
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Nonmalef icence
The ethical principle of nonmaleficence requires
that no harm be done, either deliberately or unin-
tentionally. This rather complicated word comes
from Latin roots: non, which means not; male (pro-
nounced mah-leh), which means bad; and facere,
which means to do.
The principle of nonmaleficence also requires
that nurses protect from danger individuals who are
unable to protect themselves because of their physi-
cal or mental condition. An infant, a person under
anesthesia, and a person with Alzheimer’s disease
are examples of people with limited ability to
protect themselves. Nurses are ethically obligated
to protect their patients when the patients are
unable to protect themselves.
Often, treatments meant to improve patient
health lead to harm. This is not the intention of the
nurse or of other health-care personnel, but it is a
direct result of treatment. Nosocomial infections as
a result of hospitalization are harmful to patients.
The nurses did not deliberately cause the infection.
The side effects of chemotherapy or radiation
therapy may result in harm. Chemotherapeutic
agents cause a decrease in immunity that may result
in a severe infection, whereas radiation may burn
or damage the skin. For this reason, many patients
opt not to pursue treatments.
The obligation to do no harm extends to the
nurse who for some reason is not functioning at an
optimal level. For example, a nurse who is impaired
by alcohol or drugs is knowingly placing patients at
risk. Other nurses who observe such behavior have
an ethical obligation to protect patients according
to the principle of nonmaleficence.
Benef icence
The word beneficence also comes from Latin: bene,
which means well, and facere, which means to
do.
The principle of beneficence demands that good
be done for the benefit of others. For nurses, this
means more than delivering competent physical or
technical care. It requires helping patients meet all
their needs, whether physical, social, or emotional.
Beneficence is caring in the truest sense, and caring
fuses thought, feeling, and action. It requires
knowing and being truly understanding of the situ-
ation and the thoughts and ideas of the individual
(Benner & Wrubel, 1989).
Sometimes physicians, nurses, and families
withhold information from patients for the sake of
beneficence. The problem with doing this is that it
does not allow competent individuals to make their
own decisions based on all available information. In
an attempt to be beneficent, the principle of auton-
omy is violated. This is just one of many examples
of the ethical dilemmas encountered in nursing
practice. For instance:
Mrs. Liu has just been admitted to the oncology unit
with ovarian cancer. She is scheduled to begin che-
motherapy treatment. Her two children and her
husband have requested that the physician ensure
that Mrs. Liu not be told her diagnosis because they
believe she would not be able to cope with it. The
information is communicated to the nursing staff.
After the f irst treatment, Mrs. Liu becomes very ill.
She refuses the next treatment, stating that she did
not feel sick until she came to the hospital. She asks
the nurse what could possibly be wrong with her
that she needs a medicine that makes her sick when
she does not feel sick. Only people who get cancer
medicine get this sick! Mrs. Liu then asks the nurse,
“Do I have cancer?”
As the nurse, you understand the order that the
patient not be told her diagnosis. You also under-
stand your role as a patient advocate.
1. To whom do you owe your duty: the family or
the patient?
2. How do you think you may be able to be a
patient advocate in this situation?
3. What information would you communicate to
the family members, and how can you assist
them in dealing with their mother’s concerns?
Justice
The principle of justice obliges nurses and other
health-care professionals to treat every person
equally regardless of gender, sexual orientation, reli-
gion, ethnicity, disease, or social standing (Edge &
Groves, 2005). This principle also applies in the
work and educational setting. Everyone should be
treated and judged by the same criteria according
to this principle. Here is an example:
Mr. Johnson, found on the street by the police, was
admitted through the emergency room to a medical
unit. He was in deplorable condition: his clothes were
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56 unit 1 ■ Professional Considerations
dirty and ragged, he was unshaven, and he was
covered with blood. His diagnosis was chronic alcohol-
ism, complicated by esophageal varices and end-stage
liver disease. Several nursing students overheard the
staff discussing Mr. Johnson. The essence of the con-
versation was that no one wanted to care for him
because he was dirty and smelly and brought this
condition on himself. The students, upset by what
they heard, went to their instructor about the situa-
tion. The instructor explained that every indivi dual
has a right to good care despite his or her econo mic
or social position. This is the principle of justice.
The concept of distributive justice necessitates the
fair allocation of responsibilities and advantages,
especially in a society where resources may be
limited. Considered as an ethical principle, distribu-
tive justice refers to what society or a larger group
feels indebted to its individual members regard-
ing: (1) individual needs, contribution, and respon-
sibility; (2) the resources available to the society
or organization; and (3) the society’s or organiza-
tion’s responsibility to the common good (www
.ascensionhealth.org/; Davis, Arokar, Liaschenko,
& Drought, 1997). Health-care costs have increased
tremendously over the years, and access to care has
become a social and political issue. In order to
understand distributive justice, certain concepts
need to be addressed: need, individual effort, ability
to pay, contribution to society, and age.
Age has become an extremely controversial issue
as it leads to quality-of-life questions, particularly
technological care at the end of life (Ensign, 2012).
The other issue regarding age revolves around tech-
nology in neonatal care. How do health-care pro-
viders place value on one person’s quality of life over
that of another? Should millions of dollars be spent
preserving the life of an 80-year-old man who vol-
unteers in his community, plays golf twice a week,
and teaches reading to underprivileged children, or
should that money be spent on a 26-week-old fetus
that will most likely require intensive therapies and
treatments for a lifetime, adding up to more mil-
lions of health-care dollars? In the social and busi-
ness world, welfare payments are based on need,
and jobs and promotions are usually distributed on
the basis of an individual’s contributions and
achievements. Is it possible to apply these measures
to health-care allocations?
Philosopher John Rawls addressed the issues of
justice as fairness and justice as the foundation of
social structures (Nussbaum, 2002). According to
Rawls, the idea of the original position should be
used to negotiate the principles of justice. The
original position based on Kant’s social contract
theory presents a hypothetical situation in which
individuals act as a trustee for the interests of all
individuals. The individuals, known as negotiators,
are knowledgeable in the areas of sociology, politi-
cal science, and economics. However, they are
placed under certain limitations referred to as the
veil of ignorance. These limitations represent the
moral essentials of original position arguments.
The veil of ignorance eliminates information
about age, gender, socioeconomic status, and re-
ligious convictions from the issues. Once this in-
formation is unavailable to the negotiators, the
vested interests of involved parties disappear. Ac-
cording to Rawls, in a just society the rights pro-
tected by justice are not issues for political
bargaining or subject to the calculations of social
interests. Simply put, everyone has the same rights
and liberties.
Fidelity
The principle of fidelity requires loyalty. It is a
promise that the individual will fulfill all commit-
ments made to himself or herself and to others. For
nurses, fidelity includes the professional’s loyalty to
fulfill all responsibilities and agreements expected
as part of professional practice. Fidelity is the basis
for the concept of accountability—taking responsi-
bility for one’s own actions (Shirey, 2005).
Conf identiality
The principle of confidentiality states that any-
thing said to nurses and other health-care provid-
ers by their patients must be held in the strictest
confidence. Confidentiality presents both a legal
and an ethical issue. Exceptions exist only when
patients give permission for the release of infor-
mation or when the law requires the release of
specific information. Sometimes, just sharing infor-
mation without revealing an individual’s name can
be a breach in confidentiality if the situation and
the individual are identifiable. It is important to
realize that what seems like a harmless statement
can become harmful if other people can piece
together bits of information and identify the patient.
Nurses come into contact with people from dif-
ferent walks of life. Within communities, people
know other people who know other people, and so
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chapter 4 ■ Questions of Values and Ethics 57
on. Individuals have lost families, jobs, and insur-
ance coverage because nurses shared confidential
information and others acted on that knowledge
(AIDS Update Conference, 1995).
In today’s electronic environment, the principle
of confidentiality has become a major concern.
Many health-care institutions, insurance compa-
nies, and businesses use electronic media to transfer
information. These institutions store sensitive and
confidential information in computer databases.
These databases need to have security safeguards to
prevent unauthorized access. Health-care institu-
tions have addressed the situation through the use
of limited access, authorization passwords, and
security tracking systems. However, even the most
secure system is vulnerable and can be accessed by
an individual who understands the complexities of
computer systems.
Veracity
Veracity requires nurses to be truthful. Truth is
fundamental to building a trusting relationship.
Intentionally deceiving or misleading a patient is a
violation of this principle. Deliberately omitting a
part of the truth is deception and violates the prin-
ciple of veracity. This principle often creates ethical
dilemmas. When is it permissible to lie? Some ethi-
cists believe it is never appropriate to deceive
another individual. Others think that if another
ethical principle overrides veracity, then lying is
permissible. Consider this situation:
Ms. Allen has just been told that her father has
Alzheimer’s disease. The nurse practitioner wants to
come into the home to discuss treatment. Ms. Allen
refuses, saying that the nurse practitioner should
under no circumstances tell her father the diagnosis.
She explains to the practitioner that she is sure he
will kill himself if he learns that he has Alzheimer’s
disease. She bases this concern on statements he has
made regarding this disease. The nurse practitioner
replies that medication is available that might help
her father. However, it is available only through a
research study being conducted at a nearby univer-
sity. To participate in the research, the patient must
be informed of the purpose of the study, the medica-
tion to be given and its side effects, and follow-up
procedures. Ms. Allen continues to refuse to allow
her father to be told his diagnosis because she is
certain he will commit suicide.
The nurse practitioner faces a dilemma: does he
abide by Ms. Allen’s wishes based on the principle
of beneficence, or does he abide by the principle of
veracity and inform his patient of the diagnosis.
What would you do?
Accountability
Accountability is linked to fidelity and means
accepting responsibility for one’s actions. Nurses are
accountable to their patients and to their colleagues.
When providing care to patients, nurses are respon-
sible for their actions, good and poor. If something
was not done, do not chart or tell a colleague that
it was. An example of violating accountability is the
story of Anna:
Anna was a registered nurse who worked nights on
an acute care unit. She was an excellent nurse, but
as the acuity of the patients’ conditions increased, she
was unable to keep up with both patients’ needs and
the technology, particularly intravenous (IV) lines.
She began to chart that all the IVs were infusing as
they should, even when they were not. Each
morning, the day shift would f ind that the actual
infused amount did not agree with what the paper-
work showed. One night, Anna allowed an entire
liter to be infused in 2 hours into a patient who had
congestive heart failure. When the day staff came on
duty, they found the patient expired, the bag empty,
and the tubing f illed with blood. Anna’s IV sheet
showed 800 mL left in the bag. It was not until a
lawsuit was f iled that Anna took responsibility for
her behavior.
The idea of a standard of care evolves from the
principle of accountability. Standards of care
provide a rule for measuring nursing actions. This
action also involves safety issues. According to the
Institute of Medicine, organizations also have
accountability for patient care and the actions
of personnel. The organization has a duty to ensure
a safe environment and that the personnel re-
ceive appropriate training and education ( Jerak-
Zuident, 2012).
Ethical Codes
A code of ethics is a formal statement of the rules
of ethical behavior for a particular group of indi-
viduals. A code of ethics is one of the hallmarks of
a profession. This code makes clear the behavior
expected of its members.
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58 unit 1 ■ Professional Considerations
The Code of Ethics for Nurses with Interpretive
Statements provides values, standards, and prin-
ciples to help nursing function as a profession. The
original code was developed in 1985. In 1995 the
American Nurses Association Board of Directors
and the Congress on Nursing Practice initiated
the Code of Ethics Project (ANA, 2002). The code
may be viewed online at www.nursingworld.org.
Ethical codes are subject to change. They reflect
the values of the profession and the society for
which they were developed. Changes occur as
society and technology evolve. For example, years
ago no thought was given to do not resuscitate
(DNR) orders or withholding food and fluids.
Technological advances have since made it possible
to keep people in a kind of twilight life, comatose
and unable to participate in living in any way, but
nevertheless making DNR and withholding very
important issues in health care. Technology has
increased knowledge and skills, but the ability to
make decisions regarding care is still guided by the
principles of autonomy, nonmaleficence, benefi-
cence, justice, confidentiality, fidelity, veracity, and
accountability.
Virtue Ethics
Virtue ethics focuses on virtues, or moral character,
rather than on duties or rules that emphasize the
consequences of actions. Consider the following
example:
Norman is driving along the road and f inds a
crying child sitting by a fallen bicycle. It is obvious
that the child needs assistance. From one ethical
standpoint (utilitarianism), helping the child will
increase Norman’s personal feelings of “doing good.”
The deontological stance states that by helping,
Norman is behaving in accordance with a moral
rule such as “Do unto others . . . .” Virtue ethics looks
at the fact that helping the person would be chari-
table or benevolent.
Plato and Aristotle are considered the founders of
virtue ethics. Its roots can be found in Chinese
philosophy. During the 1800s, virtue ethics disap-
peared, but in the late 1950s it reemerged as an
Anglo-American philosophy. Neither deontology
nor utilitarianism considered the virtues of moral
character and education and the question: “What
type of person should I be, and how should I
live” (Hooker, 2000; Driver, 2001). Virtues include
such qualities as honesty, generosity, altruism, and
reliability. They are concerned with many other ele-
ments as well, such as emotions and emotional
reactions, choices, values, needs, insights, attitudes,
interests, and expectations. To embrace a virtue
means that you are a person with a certain complex
way of thinking. Nursing has practiced virtue ethics
for many years.
Nursing Ethics
Up to this point, the ethical principles discussed
apply to ethics for nurses; however, nurses do not
customarily find themselves enmeshed in the bio-
medical ethical decision-making processes that
gain the attention of the news media. However, the
ethical principles that guide nursing practice are
rooted in the philosophy and science of health care
and are considered a subcategory of bioethics (Butts
& Rich, 2012).
Nursing ethics deals with the experiences and
needs of nurses and nurses’ perceptions of their
experiences (Varcoe et al., 2007). It is viewed from
the perspective of nursing theory and practice
( Johnstone, 1999). Relationships are the center of
nursing ethics. These relationships focus on ethical
issues that impact nurses and their patients.
Organizational Ethics
Organizational ethics focus on the workplace and
are aimed at the organizational level. Every orga-
nization, even one with hundreds of thousands of
employees, consists of individuals. Each individual
makes his and her own decisions about how to
behave in the workplace. Each person has the
opportunity to make the organization a more or
less ethical place. These individual decisions can
have a powerful effect on the lives of many others
in the organization as well as in the surrounding
community. Shirey (2005) explains that employees
need to experience uniformity between what the
organization states and what it practices.
Research conducted by the Ethics Research
Center concluded the following:
■ If positive outcomes are desired, ethical culture
is what makes the difference;
■ Leadership, especially senior leadership, is the
most critical factor in promoting an ethical
culture; and
■ In organizations that are trying to strengthen
their culture, formal program elements can
help to do that (Harned, 2005, p. 1).
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When looking for a professional position, it is
important to consider the organizational culture.
What are the values and beliefs of the organization?
Do they blend with yours, or are they in conflict
with your value system? To find out this informa-
tion, look at the organization’s mission, vision, and
value statements. Speak with other nurses who
work in the organization. Do they see consistency
between what the organization states and what it
actually expects from the employees? For example,
if an organization states that it collaborates with
the nurses in decision making, do nurses sit on
committees that have input into the decision-mak-
ing process? Conflicts between a nurse’s profes-
sional values and those of the organization result in
moral distress for the nurse.
Ethical Issues on the Nursing Unit
Organizational ethics refer to the values and
expected behaviors entrenched within the organi-
zational culture. The nursing unit represents a sub-
culture of the organization. Ideally, the nursing unit
should mirror the ethical atmosphere and culture
of the organization. This requires the individuals
that comprise the unit to hold the same values and
model the expected behaviors.
Conflicts of the values and ethics among indi-
viduals who work together on the unit often create
issues that result in moral suffering for some nurses.
Moral suffering occurs when nurses experience a
feeling of uneasiness or concern regarding behav-
iors or circumstances that challenge their own
moral beliefs and values. These situations may be
the result of unit policies, physicians’ orders that the
nurse believes may not be beneficial for the patient,
professional behaviors of colleagues, or family atti-
tudes about the patient.
Perhaps one of the most disconcerting ethical
issues nurses on the unit face is the one that chal-
lenges their professional values and ethics. Friend-
ships often emerge from work relationships, and
these friendships may interfere with judgments.
Similarly, strong negative feelings may cloud a
nurse’s ability to view a situation fairly and without
prejudice. Take the following example:
Addie and Jamie attended nursing school together
and developed a strong friendship. They work
together on the pediatric surgical unit of a large
teaching hospital. Jamie made a medication error
that caused a problem, resulting in a child having
to be transferred to the intensive care unit. Addie
realized what had happened and confronted Jamie.
Jamie begged her not to say anything. Addie knew
the error should be reported, but how would this
affect her longtime friendship with Jamie? Taking
this situation to the other extreme, if a friendship
had not been involved, would Addie react the same
way?
When working with others, it is important to hold
true to your personal values and morals. Practicing
virtue ethics, that is, “doing the right thing,” may
cause difficulty due to the possible consequences of
the action. Nurses should support each other but
not at the expense of patients or each other’s pro-
fessional duties. There are times when not acting
virtuously may cause a colleague more harm.
Moral Distress in Nursing Practice
Moral distress occurs when nurses know the action
they need to take, but for some reason are unable
to act. Therefore, the action or actions they take
cause conflict as the decision goes against their
personal and professional values, morals, and beliefs.
This challenges nurses’ integrity and authenticity.
Moral distress presents a serious problem in
nursing practice and adds to nurses feeling a loss of
integrity and dissatisfaction within the work setting.
It threatens the quality of care and may adversely
affect costs.
Moral distress occurs when nurses know the
action they need to take, but for some reason are
unable to act. Therefore, the action or actions they
take cause conflict as the decision goes against their
personal and professional values, morals, and beliefs.
This challenges nurses’ integrity and authenticity.
Studies have shown that nurses exposed to
moral distress suffer from emotional and physi-
cal problems and eventually leave the bedside and
the profession (Redman & Fry, 2000). Sources of
moral distress vary; however, contributing factors
include end-of-life challenges, nurse-physician
conflict, disrespectful interactions, and workplace
violence. Nursing organizations such as the Asso-
ciation for Critical Care Nurses (AACN) have
developed guidelines addressing the issue of moral
distress.
Ethical Dilemmas
What is a dilemma? The word dilemma is of Greek
derivation. A lemma was an animal resembling a
ram and having two horns. Thus came the saying
“stuck on the horns of a dilemma.” The story of
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60 unit 1 ■ Professional Considerations
Hugo illustrates a hypothetical dilemma, with a
touch of humor:
One day, Hugo, dressed in a bright red cape, walked
through his village into the countryside. The wind
caught the corners of the cape, and it was whipped
in all directions. As he walked down the dusty road,
Hugo happened to pass by a lemma. Hugo’s bright
red cape caught the lemma’s attention. Lowering its
head, with its two horns poised in attack position,
the animal began to chase Hugo down the road.
Panting and exhausted, Hugo reached the end of the
road, only to f ind himself blocked by a huge stone
wall. He turned to face the lemma, which was ready
to charge. A decision needed to be made, and Hugo’s
life depended on this decision. If he moved to the left,
the lemma would gore his heart. If he moved to the
right, the lemma would gore his liver. No matter
what his decision, Hugo would be “stuck on the
horns of the lemma.”
Like Hugo, nurses are often faced with difficult
dilemmas. Also, as Hugo found, an ethical dilemma
can be a choice between two serious alternatives.
An ethical dilemma occurs when a problem
exists that forces a choice between two or more
ethical principles. Deciding in favor of one princi-
ple will violate the other. Both sides have goodness
and badness to them, but neither decision satisfies
all the criteria that apply. Ethical dilemmas also
have the added burden of emotions. Feelings of
anger, frustration, and fear often override rational-
ity in the decision-making process. Consider the
case of Mr. Sussman:
Mr. Sussman, 80 years old, was admitted to the
neuroscience unit after suffering a left hemispheric
bleed. He had a total right hemiplegia and was
completely nonresponsive, with a Glasgow Coma
Scale score of 8. He had been on IV fluids for 4 days,
and the question was raised of placing a jejunostomy
tube for enteral feedings. The older of his two chil-
dren asked what were the chances of his recovery.
The physician explained that Mr. Sussman’s current
state was probably the best he could attain but
that “miracles happen every day” and stated that
tests could help in determining the prognosis. The
family asked that these tests be performed. After
the results were available, the physician explained
that the prognosis was grave and that IV fluids
were insufficient to sustain life. The jejunostomy
tube would be a necessity if the family wished to
continue with food and fluids. After the physician
left, the family asked the nurse, Gail, who had been
with Mr. Sussman during the previous 3 days, “If
this was your father, what would you do?” This
situation became an ethical dilemma for Gail as
well.
If you were Gail, what would you say to the family?
Depending on your answer, what would be the
principles that you might violate?
Resolving Ethical Dilemmas Faced
by Nurses
Ethical dilemmas can occur in any aspect of life,
personal or professional. This section focuses on the
resolution of professional dilemmas. The various
models for resolving ethical dilemmas consist of 5
to 14 sequential steps. Each step begins with the
complete understanding of the dilemma and con-
cludes with the evaluation of the implemented
decision.
The nursing process provides a helpful mecha-
nism for finding solutions to ethical dilemmas. The
first step is assessment, including identification of
the problem. The simplest way to do this is to create
a statement that summarizes the issue. The remain-
der of the process evolves from this statement
(Box 4-2).
Assessment
Ask yourself, “Am I directly involved in this
dilemma?” An issue is not an ethical dilemma for
nurses unless they are directly involved in or have
been asked for their opinion about a situation.
Some nurses involve themselves in situations even
when their opinion has not been solicited. This is
generally unwarranted, unless the issue involves a
violation of the professional code of ethics.
Nurses are frequently in the position of hearing
both sides of an ethical dilemma. Often, all that is
wanted is an empathetic listener. At other times,
• What are the medical facts?
• What are the psychosocial facts?
• What are the patient’s wishes?
• What values are in conflict?
box 4-2
Questions to Help Resolve Ethical Dilemmas
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when guidance is requested, nurses can help people
work through the decision-making process (remem-
ber the principle of autonomy).
Collecting data from all the decision makers
helps identify the reasoning process being used by
these individuals as they struggle with the issue.
The following questions assist in the information-
gathering process:
■ What are the medical facts? Find out how the
physicians, physical and occupational therapists,
dietitians, and nurses view the patient’s
condition and treatment options. Speak with
the patient, if possible, and determine his or
her understanding of the situation.
■ What are the psychosocial facts? In what
emotional state is the patient right now? The
patient’s family? What kind of relationship
exists between the patient and his or her
family? What are the patient’s living
conditions? Who are the individuals who form
the patient’s support system? How are they
involved in the patient’s care? What is the
patient’s ability to make medical decisions
about his or her care? Do financial
considerations need to be taken into account?
What does the patient value? What does the
patient’s family value? The answers to these
questions will provide a better understanding
of the situation. Ask more questions, if
necessary, to complete the picture. The social
facts of a situation also include institutional
policies, legal aspects, and economic factors.
The personal belief systems of physicians and
other health-care professionals also influence
this aspect.
■ What are the cultural beliefs? Cultural beliefs
play a major role in ethical decisions. Some
cultures do not allow surgical interventions as
they fear that the “life force” may escape. Many
cultures forbid organ donation. Other cultures
focus on the sanctity of life, thereby requesting
all methods for sustaining life be used
regardless of the futility.
■ What are the patient’s wishes? Remember the
ethical principle of autonomy. With very few
exceptions, if the patient is competent, his or
her decisions take precedence. Too often, the
family’s or physician’s worldview and belief
system overshadow those of the patient.
Nurses can assist by maintaining the focus on
the patient. If the patient is unable to
communicate, try to discover whether the
individual has discussed the issue in the past.
If the patient has completed a living will or
designated a health-care surrogate, this will
help determine the patient’s wishes. By
interviewing family members, the nurse can
often learn about conversations in which the
patient has voiced his or her feelings about
treatment decisions. Through guided
interviewing, the nurse can encourage the
family to tell anecdotes that provide relevant
insights into the patient’s values and beliefs.
■ What values are in conflict? To assess values,
begin by listing each person involved in the
situation. Then identify the values represented
by each person. Ask such questions as, “What
do you feel is the most pressing issue here?”
and “Tell me more about your feelings
regarding this situation.” In some cases, there
may be little disagreement among the people
involved, just a different way of expressing
beliefs. In others, however, a serious value
conflict may exist.
Planning
For planning to be successful, everyone involved in
the decision must be included in the process.
Thompson and Thompson (1992) listed three spe-
cific and integrated phases of this planning:
1. Determine the goals of treatment. Is cure a goal,
or is the goal to keep the patient comfortable?
Is life at any cost the goal, or is the goal a
peaceful death at home? These goals need to be
patient-focused, reality-centered, and attainable.
They should be consistent with current medical
treatment and, if possible, be measurable
according to an established period.
2. Identify the decision makers. As mentioned
earlier, nurses may or may not be decision
makers in these health-related ethical
dilemmas. It is important to know who the
decision makers are and what their belief
systems are. When the patient is a capable
participant, this task is much easier. However,
people who are ill are often too exhausted to
speak for themselves or to ensure that their
voices are heard. When this happens, the
patient needs an advocate. Family, friends,
spiritual advisers, and nurses often act as
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62 unit 1 ■ Professional Considerations
advocates. A family member may need to be
designated as the primary decision maker or
health-care surrogate.
The creation of living wills, establishment of
advance directives, and appointment of a
health-care surrogate while a person is still
healthy often ease the burden for the decision
makers during a later crisis. Patients can
exercise autonomy through these mechanisms,
even though they may no longer be able to
communicate their wishes directly. When these
documents are not available, the information
gathered during the assessment of social factors
helps identify those individuals who may be
able to act in the patient’s best interest.
3. List and rank all the options. Performing this
task involves all the decision makers. It is
sometimes helpful to begin with the least
desired choice and methodically work toward
the preferred treatment choice that is most
likely to lead to the desired outcome. Asking
all participating parties to discuss what they
believe are reasonable outcomes to be attained
with the use of available medical treatment
often helps in the decision process. By listening
to others in a controlled situation, family
members and health-care professionals discover
that they actually want the same result as the
patient but had different ideas about how to
achieve their goal.
Implementation
During the implementation phase, the patient or
the surrogate (substitute) decision maker(s) and
members of the health-care team reach a mutually
acceptable decision. This occurs through open dis-
cussion and sometimes negotiation. An example of
negotiation follows:
Elena’s mother has metastatic ovarian cancer. She
and Elena have discussed treatment options. Her
physician suggested the use of a new chemotherapeu-
tic agent that has demonstrated success in many
cases. But Elena’s mother emphatically states that
she has “had enough” and prefers to spend her
remaining time doing whatever she chooses. Elena
wants her mother to try the drug. To resolve the
dilemma, the oncology nurse practitioner and the
physician talk with Elena and her mother. Every-
one reviews the facts and expresses their feelings
about the situation. Seeing Elena’s distress, Elena’s
mother says, “OK, I will try the drug for a month.
If there is no improvement after this time, I want
to stop all treatment and live out the time I have
with my daughter and her family.” All agreed that
this was a reasonable decision.
The role of the nurse during the implementation
phase is to ensure that communication does not
break down. Ethical dilemmas are often emotional
issues, filled with guilt, sorrow, anger, and other
strong emotions. These strong feelings can cause
communication failures among decision makers.
Remind yourself, “I am here to do what is best for
this patient.”
Keep in mind that an ethical dilemma is not
always a choice between two attractive alternatives.
Many are between two unattractive, even unpleas-
ant, choices. Elena’s mother’s options did not
include the choice she really wanted: good health
and a long life.
Once an agreement is reached, the decision
makers must accept it. Sometimes, an agreement is
not reached because the parties cannot reconcile
their conflicting belief systems or values. At other
times, caregivers are unable to recognize the worth
of the patient’s point of view. Occasionally, the
patient or the surrogate may make a request that is
not institutionally or legally possible (Ensign, n.d.).
In some cases, a different institution or physician
may be able to honor the request. In other cases,
the patient or surrogate may request information
from the nurse regarding illegal acts. When this
happens, the nurse should ask the patient and
family to consider the consequences of their pro-
posed actions. It may be necessary to bring other
counselors into the discussion (with the patient’s
permission) to negotiate an agreement.
Evaluation
As in the nursing process, the purpose of evaluation
in resolving ethical dilemmas is to determine
whether the desired outcomes have occurred. In the
case of Mr. Sussman, some of the questions that
could be posed by Gail to the family are as follows:
■ “I have noticed the amount of time you have
been spending with your father. Have you
observed any changes in his condition?”
■ “I see Dr. Washburn spoke to you about the
test results and your father’s prognosis. How
do you feel about the situation?”
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chapter 4 ■ Questions of Values and Ethics 63
■ “Now that Dr. Washburn has spoken to you
about your father’s condition, have you
considered future alternatives?”
Changes in patient status, availability of medical
treatment, and social facts may call for reevaluation
of a situation. The course of treatment may need to
be altered. Continued communication and coop-
eration among the decision makers are essential.
Another model, the MORAL model created by
Thiroux (1977) and refined for nursing by Halloran
(1982), is gaining popularity. The MORAL
acronym reminds nurses of the sequential steps
needed for resolving an ethical dilemma. This
ethical decision-making model is easily imple-
mented in all patient care settings (Box 4-3).
Current Ethical Issues
During fall 1998, Dr. Jack Kevorkian (sometimes
called Dr. Death in the media) openly admitted
that at the patient’s request, he gave the patient a
lethal dose of medication, causing death. His state-
ment raised the consciousness of the American
people and the health-care system about the issues
of euthanasia and assisted suicide. Do individuals
have the right to consciously end their own lives
when they are suffering from terminal conditions?
If they are unable to perform the act themselves,
should others assist them in ending their lives?
Should assisted suicide be legal? There are no
answers to these difficult questions, and patients
and their families face these same questions every
day.
The Terri Schiavo case gained tremendous
media attention, probably becoming the most
important case of clinical ethics in more than a
decade. Her illness and death created a major
medical, legal, theological, ethical, political, and
social controversy. The case brought to the fore-
front the deep divisions and fears that reside in
society regarding life and death, the role of the
government and courts in life decisions, and
the treatment of disabled persons (Hoffman &
Schwartz, 2006). Many aspects of this case will
never be clarified; however, many questions raised
by this case need to be addressed for future ethical
decision making. Some of these are:
1. What is the true definition of a persistent
vegetative state?
2. How is cognitive recovery determined?
3. What role do the courts play when there is a
family dispute? Who has the right to make
decisions when an individual is married?
4. What are the duties of surrogate decision
makers? (Hook & Mueller, 2005)
The primary goal of nursing and other health-care
professions is to keep people alive and well or, if
this cannot be done, to help them live with their
problems and die peacefully. To accomplish this,
health-care professionals struggle to improve their
knowledge and skills so they can care for their
patients, provide them with some quality of life,
and help return them to wellness. The costs involved
in achieving this goal can be astronomical.
Questions are being raised more and more often
about who should receive the benefits of this tech-
nology. Managed care and the competition for
resources are also creating ethical dilemmas. Other
difficult questions, such as who should pay for care
when the illness may have been due to poor health-
care practices such as smoking or substance abuse,
are also being debated.
Practice Issues Related to Technology
Genetics and the Limitations of Technology
In issues of technology, the principles of benefi-
cence and nonmaleficence may be in conflict. A
specific technology administered with the intention
of “doing good” may result in enormous suffering.
Causing this type of torment is in direct conflict
with the idea of “do no harm” (Burkhardt &
Nathaniel, 2007). At times, this is an accepted con-
sequence, such as in the use of chemotherapy.
However, the ultimate outcome in this case is that
recovery is expected. In situations in which little or
no improvement is expected, the issue of whether
the good outweighs the bad prevails. Suffering
induced by technology may include physical, spiri-
tual, and emotional components for the patient and
the families.
M: Massage the dilemma
O: Outline the option
R: Resolve the dilemma
A: Act by applying the chosen option
L: Look back and evaluate the complete process,
including actions taken
box 4-3
The Moral Model
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64 unit 1 ■ Professional Considerations
Today, many infants who have low birth weight
or birth defects, who not so long ago would have
been considered unable to live, are maintained on
machines in highly sophisticated neonatal units.
This process may keep babies alive only to die
several months later or may leave them with severe
chronic disabilities. Children with chronic disabili-
ties require additional medical, educational, and
social services. These services are expensive and
often require families to travel long distances to
obtain them (Urbano, 1992).
The use of ultrasound during pregnancy is an
expected standard of care. In the past these pictures
were mostly two-dimensional and were used mostly
to determine the size of the fetus for development
and in relationship to the mother’s pelvic anatomy.
Today, with the advanced technology, visualization
of internal organs such as the heart, kidneys, and
brain is possible. If a defect is found, parents now
have additional options, which present further
ethical decisions.
Genetic diagnosis and gene therapy present new
ethical issues for nursing. Genetic diagnosis is a
process that involves analyzing parents or an
embryo for a genetic disorder. This is usually done
before in vitro fertilization for couples who run a
high risk of conceiving a child with a genetic dis-
order. The embryos are tested, and only those that
are free of genetic flaws are implanted.
Genetic screening is used as a tool to determine
whether couples hold the possibility of giving birth
to a genetically impaired infant. Testing for the
most common genetic disorders has become an
expected standard of practice of health-care provid-
ers caring for women who are planning to become
pregnant or who are pregnant. Couples are encour-
aged to seek out information regarding their genetic
health history in order to identify the possibilities
of having a child with a genetic disorder. If a couple
has one child with a genetic disorder, genetic spe-
cialists test the parents and/or the fetus for the
presence of the gene.
Genetic screening leads to issues pertaining to
reproductive rights. It also opens new issues. What
is a disability versus a disorder, and who decides
this? Is a disability a disease, and does it need to be
cured or prevented? The technology is also used to
determine whether individuals are predisposed to
certain diseases, such as breast cancer or Hunting-
ton’s chorea. This has created additional ethical
issues regarding genetic screening. For example:
Bianca, 33 years old, is diagnosed with breast
cancer. She has two daughters, ages 6 and 4 years.
Bianca’s mother and grandmother had breast cancer.
Neither survived more than 5 years post-treatment.
Bianca undergoes a lumpectomy followed by radia-
tion and chemotherapy. Her cancer is found to be
nonhormonally dependent. Due to her age and
family history, Bianca’s oncologist recommends that
she see a geneticist and have genetic testing for the
BRCA-1 and BRCA-2 genes. Bianca makes an
appointment to discuss the testing. She meets with
the nurse who has additional education in genetics
and discusses the following questions: “If I am posi-
tive for the genes, what are my options? Should I
have a bilateral mastectomy with reconstruction?”
“Will I be able to get health insurance coverage, or
will the companies consider this to be a preexisting
condition?” “What are the future implications for
my daughters?”
If you were the nurse, how would you address these
concerns?
Genetic engineering is the ability to change the
genetic structure of an organism. Through this
process, researchers have created disease-resistant
fruits and vegetables and certain medications, such
as insulin. This process theoretically allows for the
genetic alteration of embryos, eliminating genetic
flaws and creating healthier babies. This technol-
ogy enables researchers to make a brown-haired
individual blonde, to change brown eyes to blue,
and to make a short person taller. Envision being
able to “engineer” your child. Imagine, as Aldous
Huxley did in Brave New World (1932), being able
to create a society of perfect individuals: “We also
predestine and condition. We decant our babies as
socialized human beings, as Alphas or Epsilons,
as future sewage workers or future . . . he was going
to say future World controllers but correcting
himself said future directors of Hatcheries, instead”
(p. 12).
The ethical implications pertaining to genetic
technology are profound. For example, some ques-
tions raised by the Human Genome Project relate
to:
■ Fairness in the use of the genetic information.
■ Privacy and confidentiality of obtained genetic
information.
■ Genetic testing of an individual for a specific
condition due to family history. Should testing
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chapter 4 ■ Questions of Values and Ethics 65
be performed if no treatment is available?
Should parents have the right to have minors
tested for adult-onset diseases? Should parents
have the right to use gene therapy for genetic
enhancement?
The Human Genome Project (HGP) is dedicated
to mapping and identifying the genetic composi-
tion of humans. Scientists hope to identify and
eradicate many of the genetic disorders affecting
individuals. Initiated in 1990, the Human Genome
Project was projected to be a 13-year effort coordi-
nated by the U.S. Department of Energy and the
National Institutes of Health. However, because of
swift technological advances, in February 2001 the
scientists announced they had cracked the human
genetic code and accomplished the following goals
(Human Genome Project Information, 2002):
■ Identified all of the genes in human DNA
■ Determined the sequences of the three billion
chemical bases that make up human DNA
■ Stored this information in databases
■ Developed tools for data analysis
■ Addressed the ethical, legal, and social issues
that may arise from the project
Rapid advances in the science of genetics and its
applications present new and complex ethical and
policy issues for individuals, health-care personnel,
and society. Economics come into play because,
currently, only those who can afford the technology
have access to it. However, more recently many
health insurance companies will cover certain types
of prenatal genetic testing, particularly when a pro-
pensity for a disorder exists due to family history
or ethnicity. Efforts need to be directed toward
creating standards that identify the uses for genetic
data and the protection of human rights and con-
fidentiality. As of 2012, due to the amount of data
collected, the HGP has developed a “universal
storage area” so that this information is internation-
ally accessible to scientists, geneticists, and research-
ers (www.genome.gov). This is truly the new
frontier.
Stem Cell Use and Research
Over the last several years, issues regarding stem
cell research and stem cell transplant technology
have come to the forefront of ethical discussion.
Stem cell research shows promise in possibly curing
neurological disorders such as Parkinson’s disease,
spinal cord injury, and dementia. Questions have
been raised regarding the moral and ethical issues
of using stem cells from fetal tissue for research and
the treatment of disease. Stem cell transplants have
demonstrated success in helping cancer patients
recover and giving them a chance for survival when
traditional treatments have failed.
A new business has emerged from this technol-
ogy as companies now store fetal cord blood for
future use if needed. This blood is collected at the
time of delivery and may be used for the infant and
possibly future siblings if necessary. The cost for
this service is high, which limits its availability to
only those who can afford the process.
When faced with the prospect of a child who is
dying from a terminal illness, some parents have
resorted to conceiving a sibling in order to obtain
the stem cells for the purpose of using them to save
the first child. Nurses who work in pediatrics and
pediatric oncology units may find themselves
dealing with this situation. It is important for
nurses to examine their own feelings regarding
these issues and understand that, regardless of their
personal beliefs, the family is in need of sensitivity
and the best nursing care.
A primary responsibility of nursing is to help
patients and families cope with the purposes, ben-
efits, and limitations of the new technologies.
Hospice nurses and critical care nurses help patients
and their families with end-of-life decisions. Nurses
will need to have knowledge about the new genetic
technologies because they will fill the roles of coun-
selors and advisers in these areas. Many nurses now
work in the areas of in vitro fertilization and genetic
counseling.
Professional Dilemmas
Most of this chapter has dealt with patient issues,
but ethical problems may involve leadership and
management issues as well. What do you do about
an impaired coworker? Personal loyalties often
cause conflict with professional ethics, creating an
ethical dilemma. For this reason, most nurse prac-
tice acts now address this problem and require the
reporting of impaired professionals and providing
rehabilitation for them.
Other professional dilemmas may involve
working with incompetent personnel. This may be
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66 unit 1 ■ Professional Considerations
frustrating for both staff and management. Regula-
tions created to protect individuals from unjustified
loss of position and the enormous amounts of
paperwork, remediation, and time that must be
exercised to terminate an incompetent health-care
worker often make management look the other
way.
Employing institutions that provide nursing
services have an obligation to establish a process for
the reporting and handling of practices that jeop-
ardize patient safety (ANA, 1994; IOM, 2007).
The behaviors of incompetent staff place patients
and other staff members in jeopardy; eventually, the
incompetency may lead to legal action that may
have been avoidable if a different approach had
been taken.
Conclusion
Ethical dilemmas are becoming more common in
the changing health-care environment. More ques-
tions are being raised, and fewer answers are avail-
able. New guidelines need to be developed to assist
in finding viable solutions to these questions. Tech-
nology wields enormous power to alter the human
organism and enable health-care providers to
prolong human life, but economics may force the
profession to rethink answers to questions such as,
“What is life versus what is living?” and “When is
it okay to terminate human life?” Will society
become the brave new world of Aldous Huxley?
Again and again the question is raised, “Who shall
live, and who shall die?” What is your answer?
Study Questions
1. What is the difference between intrinsic and extrinsic values? Make a list of your intrinsic
values.
2. Consider a decision you made recently that was based on your values. How did you make your
choice?
3. Describe how you could use the valuing process of choosing, prizing, and acting in making the
decision considered in Question 2.
4. Which of your personal values would be primary if you were assigned to care for an anacephalic
infant whose parents have decided to donate the baby’s organs?
5. The parents of the anacephalic infant in Question 4 confront you and ask, “What would you
do if this were your baby?” What do you think would be most important for you to consider in
responding to them?
6. Your friend is single and feels that her “biological clock is ticking.” She decides to undergo in
vitro fertilization using donor sperm. She tells you that she has researched the donor’s
background extensively and wants to show you the “template” for her child. She asks for your
professional opinion about this situation. How would you respond? Identify the ethical
principles involved.
7. Over the past several weeks, you have noticed that your closest friend, Jimmy, has been erratic
and has been making poor patient-care decisions. On two separate occasions, you quietly
intervened and “fixed” his errors. You have also noticed that he volunteers to give pain
medications to other nurses’ patients, and you see him standing very close to other nurses when
they remove controlled substances from the medication distribution center. Today you watched
him go to the center immediately after another colleague and then saw him go into the men’s
room. Within about 20 minutes his behavior had changed completely. You suspect that he may
be taking controlled substances. You and Jimmy have been friends for more than 20 years. You
grew up together and went to nursing school together. You realize that if you approach him,
you may jeopardize this close friendship that means a great deal to you. Using the MORAL
ethical decision-making model, devise a plan to resolve this dilemma.
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chapter 4 ■ Questions of Values and Ethics 67
Case Study to Promote Critical Reasoning
Andy is assigned to care for a 14-year-old girl, Amanda, admitted with a large tumor located in
the left groin area. During an assessment, Amanda shares her personal feelings with Andy. She
tells him that she feels “different” from her friends. She is ashamed of her physical development
because all her girlfriends have “breasts” and boyfriends. She is very flat-chested and embarrassed.
Andy listens attentively to Amanda and helps her focus on some of her positive attributes and
talents.
A CT scan is ordered and reveals that the tumor extends to what appears to be the ovary. A
gynecological surgeon is called in to evaluate the situation. An ultrasonic-guided biopsy is
performed. It is discovered that the tumor is an enlarged lymph node and that the “ovary” is
actually a testis. Amanda has both male and female gonads.
When this information is given to Amanda’s parents, they do not want her to know. They feel
that she was raised as “their daughter.” They ask the surgeon to remove the male gonads and leave
only the female gonads. That way, “Amanda will never need to know.” The surgeon refuses to do
this. Andy believes that the parents should discuss the situation with Amanda as they are denying
her choices. The parents are adamant about Amanda not knowing anything. Andy returns to
Amanda’s room, and Amanda begins asking all types of questions regarding the tests and the
treatments. In answering, Andy hesitates, and Amanda picks up on this, demanding that he tell
her the truth.
1. How should Andy respond?
2. What are the ethical principles in conflict?
3. What are the long-term effects of Andy’s decision?
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68 unit 1 ■ Professional Considerations
References
AIDS Update Conference. (1995). Hollywood Memorial
Hospital, Hollywood, Fla.
American Association of Critical Care Nurses (AACN). At
loggerheads: Questioning patient autonomy. Retrieved
on January 11, 2006, from www.aacn.org/AACN/
aacnnews.nsf/GetArticle/ArticleThree184?
American Nurses Association (ANA). (1994). Guidelines on
Reporting Incompetent, Unethical, or Illegal Practices.
Washington, DC: ANA.
American Nurses Association (ANA). (2002). Code of
Ethics Project. Washington, DC: ANA.
Benner, P., & Wrubel, J. (1989). The Primacy of Caring:
Stress and Coping in Health and Illness. Menlo Park,
Calif.: Addison Wesley.
Burkhardt, M.A., & Nathaniel, A.K. (2007). Ethics and
Issues in Contemporary Nursing. Albany, N.Y.:
Delmar.
Butts, J.B., & Rich, K.L. (2012). Nursing Ethics: Across the
Curriculum and Into Practice, (3rd ed.). Boston: Jones &
Bartlett.
Csongradi, C. (2012). Why the Topic of Bioethics in
Science Classes? A New Look at an Old Debate.
Retrieved on December 31, 2012, from www
.actionbioscience.org/education/csongradi.html
Davis, A.J., Arokar, M.A., Liaschenko, J., & Drought, T.S.
(1997). Ethical Dilemmas and Nursing Practice, 4th ed.
Stamford, Conn.: Appleton & Lange.
DeGrazia, D., Mappes, T.A., & Brand-Ballard, J. (2010).
Biomedical Ethics, 7th ed. St. Louis: McGraw-Hill.
Driver, J. (2001). Uneasy Virtue. New York: Cambridge
University Press.
Edge, R.S., & Groves, J.R. (2005). The Ethics of
Healthcare: A Guide for Clinical Practice, 3rd ed.
Albany, N.Y.: Thomson–Delmar Learning.
Ensign, M.R. (n.d.). Ethical issues and the elderly: Guidance
for elder care providers. Retrieved on December 31,
2012, from www.ensignlaw.com/Ethical%20Issues%20
and%20Elderly.html#_ftn12
Gordon, N. (1963). The Death Committee. New York:
Fawcett Crest.
Guido, G.W. (2001). Legal and Ethical Issues in Nursing
(3rd ed.). Saddle River, N.J.: Prentice-Hall.
Halloran, M.C. (1982). Rational ethical judgments utilizing
a decision-making tool. Heart Lung, 11(6), 566–570.
Harned, P. (2005). National business ethics survey,
2005. Ethics Today Online, 4(2). Retrieved on January
13, 2005, from www.ethics.org/today/et_current. html
pres
Hoffman, D.E., & Schwartz, J. (2006). Who decides
whether a patient lives or dies? Trial, 42(10), 30–37.
Hook, C.C., & Mueller, P.S. (2005). The Terri Schiavo
saga: The making of a tragedy and lessons learned.
Retrieved on April 20, 2006, from www
.mayoclinicproceedings.com/inside
.asp?AID=1054&UID=8934
Hooker, B. (2000). Ideal Code, Real World. Oxford, U.K.:
Oxford University Press.
Human Genome Project. Retrieved on July 19, 2002, from
www.ornl.gov/hgmis/about
Hume, D. (1978). A treatise of human nature. In Johnson,
O.A, Ethics, 4th ed. New York: Holt, Rinehart, and
Winston, 212.
Huxley, A. (1932). Brave New World. New York: Harper
Row Publishers.
Jerak-Zuident, S. (2012). Certain uncertainties: Modes of
patient safety in healthcare. Social Studies of Science,
42(5), 732–752.
Johnstone, M.J. (1999). Bioethics: A nursing perspective,
3rd ed. Sydney, Australia: Harcourt Saunders.
Kant, I. (1949). Fundamental Principles of the Metaphysics
of Morals. New York: Liberal Arts.
Key Ethical Principles (2012). Retrieved on December 31,
2012, from www.ascensionhealth.org/
Kirschenbaum, H. (2000). From values clarification to
character education: A personal journey. Journal of
Humanistic Counseling, Education and Development,
39(1), 4–20.
Macklin, R. (1987). Mortal choices: Ethical dilemmas in
modern medicine. Annals in Internal Medicine, 11(8),
695–698.
Merriam-Webster Dictionary, (2012). Retrieved on
December 23, 2012, from www.merriam-webster.com/
dictionary/values
National Human Genome Research Institute. (2012). 1000
genomes project data available on Amazon Cloud.
Retrieved on December 31, 2012, from www. genome
.gov
Nussbaum, M. (2002). The enduring significance of John
Rawls. The Chronicle of Higher Education. Retrieved on
December 31, 2012, from http://chronicle.com/
article/The-Enduring-Significance-of/7360
Raths, L.E., Harmon, M., & Simmons, S.B. (1979). Values
and Teaching. New York: Charles E. Merrill.
Redman, B., & Fry, S.T. (2000). Nurses’ ethical conflicts:
What is really known about them? Journal of Nursing
Ethics, 7(4), 360–366.
Shirey, M.R. (2005). Ethical climate in nursing practice: The
leader’s role. Journal of Nursing Administration, 7(2),
59–67.
Thiroux, J. (1977). Ethics: Theory and Practice. Philadelphia:
MacMillan.
Thompson, J., & Thompson, H. (1992). Bioethical Decision
Making for Nurses. New York: Appleton-Century-Crofts.
Urbano, M.T. (1992). Preschool Children with Special
Health-Care Needs. San Diego: Singular Publishing.
Varcoe, C., Doane, G., Pauly, B., Rodney, P., et al.
(2007). Ethical practise in nursing: Working the
in-betweens. Journal of Advanced Nursing, 45(3),
316–325.
Wack, J. (1992). Sociology of Religion. Chicago: University
of Chicago Press.
Zimmerman, M.J. “Intrinsic vs. Extrinsic Value,” The Stanford
Encyclopedia of Philosophy (Winter 2010 Edition),
Edward N. Zalta (ed.). Retrieved on December 30,
2012, from http:// plato.stanford.edu/archives/
win2010/entries/value-intrinsic-extrinsic/
3663_Chapter 4_0049-0068.indd 683663_Chapter 4_0049-0068.indd 68 9/15/2014 4:37:12 PM9/15/2014 4:37:12 PM
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unit 2
Working Within
an Organization
chapter 5 Organizations, Power, and Empowerment
chapter 6 Communicating With Others and Working With
the Interprofessional Team
chapter 7 Delegation and Prioritization of Client Care
chapter 8 Dealing With Problems and Conflicts
chapter 9 People and the Process of Change
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71
chapter 5
Organizations, Power, and Empowerment
OBJECTIVES
After reading this chapter, the student should be able to:
■ Recognize the various ways in which health-care
organizations differ.
■ Explain the importance of organizational culture.
■ Define power and empowerment.
■ Identify sources of power in a health-care organization.
■ Describe several ways in which nurses can be empowered.
OUTLINE
Understanding Organizations
Types of Health-Care Organizations
Organizational Characteristics
Organizational Culture
Culture of Safety
Care Environments
Identifying an Organization’s Culture
Organizational Goals
Structure
The Traditional Approach
More Innovative Structures
Processes
Power
Definition
Sources
Power at Lower Levels of the Hierarchy
Empowering Nurses
Participation in Decision Making
Shared Governance
Professional Organizations
Collective Bargaining
Enhancing Expertise
Conclusion
The topics in this chapter—organizations, power,
and empowerment—are not as remote from a
nurse’s everyday experience as you may first think.
While it is difficult to focus on these “big picture”
factors when caught up in the busy day-to-day
work of a staff nurse, they have a significant effect
on you and your practice, as you will see in this
chapter. Consider two scenarios, which are ana-
lyzed in the scenarios.
Were the disappointments experienced by Hazel
Rivera and the critical care department staff pre-
dictable? Could they have been avoided? Without
a basic understanding of organizations and of the
part that power plays in health-care institutions,
people are doomed to be continually surprised by
the response to their well-intentioned efforts. As
you read this chapter, you will learn why Hazel
Rivera and the staff of the critical care department
were disappointed.
This chapter begins by looking at some of the
characteristics of the organizations in which nurses
work and how these organizations operate. Then it
focuses on the subject of power within organiza-
tions: what it is, how it is obtained, and how nurses
can be empowered.
Understanding Organizations
One of the attractive features of nursing as a career
is the wide variety of settings in which nurses can
work. From rural migrant health clinics to organ
transplant units, nurses’ skills are needed wherever
there are concerns about people’s health. Relation-
ships with patients may extend for months or years,
as they do in school health or in nursing homes, or
they may be brief and never repeated, as often
happens in doctors’ offices, operating rooms, and
emergency departments.
Types of Health-Care Organizations
Although some nurses work as independent prac-
titioners, as consultants, or in the corporate world,
most nurses are employed by health-care organiza-
tions. These organizations can be classified into
three types on the basis of their sponsorship and
financing:
1. Private not-for-profit. Many health-care
organizations were founded by civic, charitable,
or religious groups. Many of today’s hospitals,
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72 unit 2 ■ Working Within an Organization
long-term care facilities, home-care services,
and community agencies began this way. Some
have been in existence for generations.
Although they need sufficient money to
pay their staff and expenses, as not-for-
profit organizations they do not have to
generate a profit in addition to meeting
expenses.
2. Public. Government-operated health service
organizations range from county public health
departments to complex medical centers, such
as those operated by the Veterans
Administration, a federal agency.
3. Private for-profit. Increasing numbers of
health-care organizations are operated for
profit like other businesses. These include large
hospital and nursing home chains, health
maintenance organizations, and many
freestanding centers that provide special
services, such as surgical and diagnostic
centers.
The differences between these categories have
become blurred for several reasons:
■ All compete for patients, especially for patients
with health-care insurance or the ability to pay
their own health-care bills.
■ All experience the effects of cost constraints.
■ All may provide services that are eligible for
government reimbursement, particularly
Medicaid and Medicare funding, if they meet
government standards.
Organizational Characteristics
The size and complexity of many health-care orga-
nizations make them difficult to understand. One
way to begin is to find a metaphor or image that
describes their characteristics. Morgan (1997) sug-
gested using animals or other familiar images to
describe an organization. For example, an aggres-
sive organization that crushes its competitors is like
a bull elephant, whereas a timid organization in
The nursing staff of the critical care
department of a large urban hospital
formed an evidence-based practice group about a year
ago. They had made many changes in their practice
based on reviews of the research on several different
procedures, and they were quite pleased with the
results.
“Let’s look at the bigger picture next month,” their
nurse manager suggested. “We should consider the
research on different models of patient care. We might
get some good ideas for our unit.” The staff nurses
agreed. It would be a nice change to look at the way
they organized patient care in their department.
The nurse manager found a wealth of information
on different models for organizing nursing care. They
finally decided that a separate geriatric intensive care
unit made sense since a large proportion of their
patient population was in their 70s, 80s, and 90s.
Several nurses volunteered to form an ad hoc com-
mittee to design a similar unit for older patients
within their critical care department. When the plan
was presented, both the nurse manager and the staff
thought it was excellent. The nurse manager offered
to present the plan to the vice president for nursing.
The staff eagerly awaited the vice president’s response.
The nurse manager returned with discouraging
news. The vice president did not support their concept
and said that, although they were free to continue
developing the idea, they should not assume that it
would ever be implemented. What happened? ■
Scenario 2
In school, Hazel Rivera had always
received high praise for the quality of
her nursing care plans. “Thorough, comprehensive,
systematic, holistic—beautiful!” was the comment she
received on the last one she wrote before graduation.
Now Hazel is a staff nurse on a busy orthopedic
unit. Although her time to write comprehensive care
plans during the day is limited, Hazel often stays after
work to complete them. Her friend Carla refuses to
stay late with her. “If I can’t complete my work during
the shift, then they have given me too much to do,”
she said.
At the end of their 3-month probationary period,
Hazel and Carla received written evaluations of their
progress and comments about their value to the orga-
nization. To Hazel’s surprise, her friend Carla received
a higher rating than she did. Why? ■
Scenario 1
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chapter 5 ■ Organizations, Power, and Empowerment 73
danger of being crushed by that bull elephant is like
a mouse. Using a different kind of image, an orga-
nization adrift without a clear idea of its future in
a time of crisis could be described as a rudderless
boat on a stormy sea, whereas an organization with
its sights set clearly on exterminating its competi-
tion could be described as a guided missile.
Organizational Culture
People seek stability, consistency, and meaning in
their work. An organizational culture is an endur-
ing set of shared values, beliefs, and assumptions
(Cameron & Quinn, 2006). It is taught (often indi-
rectly) to new employees as the “right way” or “our
way” to provide care and relate to one another. As
with the cultures of societies and communities, it is
easy to observe the superficial aspects of an orga-
nization’s culture, but much of it remains hidden
from the casual observer. Perera and Peiro (2012)
note that “the real values of an organization are
those that actually govern its behavior and deci-
sion-making processes, whether they are formally
stated or not” (2012, p. 752). Edgar Schein, a well-
known scholar of organizational culture, identified
three levels of organizational culture:
1. Artifact level: visible characteristics such as
patient room layout, paint colors, lobby design,
logo, directional signs, etc.
2. Espoused beliefs: written goals, philosophy of
the organization
3. Underlying assumptions: unconscious but
powerful beliefs and feelings, such as a
commitment to cure every patient, no matter
the cost (Schein, 2004)
Organizational cultures differ greatly. Some are
very traditional, preserving their well-established
ways of doing things even when these processes no
longer work well. Others, in an attempt to be pro-
gressive, chase the newest management fad or buy
the latest high-technology equipment. Some are
warm, friendly, and open to new people and new
ideas. Others are cold, defensive, and indifferent or
even hostile to the outside world (Tappen, 2001).
These very different organizational cultures have
a powerful effect on employees and the people
served by the organization. Organizational culture
shapes people’s behavior, especially their responses
to each other, a particularly important factor in
health care.
Culture of Safety
The way in which a health-care organization’s
operation affects patient safety has been a subject
of much discussion. The shared values, attitudes,
and behaviors that are directed to preventing or
minimizing patient harm have been called the
culture of safety (Vogus & Sutcliffe, 2007). The
following are important aspects of an organization’s
culture of safety:
■ Willingness to acknowledge mistakes
■ Vigilance in detecting and eliminating error-
prone situations
■ Openness to questioning existing systems and
to changing them to prevent errors
(Armstrong & Laschinger, 2006; Vogus &
Sutcliffe, 2007).
It is not easy to change an organization’s culture.
In fact, Hinshaw (2008) points out we are trying
to create a culture of safety at a particularly dif-
ficult time, given the shortages of nurses and other
resources within the health-care system (Con-
naughton & Hassinger, 2007). Nurses who are not
well prepared, not valued by their employer or col-
leagues, not involved in decisions about organiz-
ing patient care, and are fatigued due to excessive
workloads are certainly more likely to be error-
prone. Increased workload and stress have been
found to increase adverse events by as much as 28%
(Weissman et al., 2007; Redman, 2008). Clearly,
organizational factors can contribute either to an
increase in errors or to protecting patient safety.
Care Environments
There is also much concern about the environment
in which care is provided, an issue that is closely
related to patient safety. Patients face less risk of
failure to rescue or death in better care environ-
ments (see Aiken et al., 2008). What constitutes a
better care environment? Collegial relationships
with physicians, skilled nurse managers with high
levels of leadership ability, emphasis on staff devel-
opment, and quality of care are important factors.
Mackoff and Triolo (2008) offer a list of factors
that contribute to excellence and longevity (low
turnover) of nurse managers:
■ Excellence: always striving to be better, refusing
to accept mediocrity
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74 unit 2 ■ Working Within an Organization
■ Meaningfulness: being very clear about the
purpose of the organization (serving the poor,
healing the environment, protecting abused
women, for example)
■ Regard: understanding the work people do and
valuing it
■ Learning and growth: providing mentors,
guidance, opportunities to grow and develop
Identifying an Organization’s Culture
The culture of an organization is intangible; you
cannot see it or touch it, but you will know if you
violate one of its norms. To learn about the culture
of an organization when you are applying for a new
position or trying to familiarize yourself with your
new workplace, you can ask several people who are
familiar with the organization or work there to
describe it in a few words. You could also ask about
staff workloads, participation in decision making,
or examples of nursing’s role in ensuring patient
safety.
Does it matter in what type of organization
you work? The answer, emphatically, is yes. For
example, the extreme value placed on “busyness” in
hospitals, i.e., being seen doing something at all
times, can lead to manager actions such as floating
a staff member to a “busier” unit if she or he is found
reading a new research study or looking up informa-
tion on the Internet (Scott-Findley & Golden-
Biddle, 2005). Even more important, a hospital or
nursing home with a positive work environment is
not only a better place for nurses to work but also
safer for patients, while an or ganization that ignores
threats to patient safety endangers both its staff and
those who receive their care.
Once you have grasped the totality of an orga-
nization in terms of its overall culture, you are ready
to analyze it in a little more detail, particularly its
goals, structure, and processes.
Organizational Goals
Try answering the following question:
Question: Every health-care organization has
just one goal, which is to keep people
healthy, restore them to health, or assist
them in dying as comfortably as possible,
correct?
Answer: The statement is only partially correct.
Most health-care organizations have a
mission statement similar to this but also
have a number of other goals, not all of
which are directed to providing excellent
patient care.
Does this answer surprise you? What other goals
might a health-care organization have? Following
are some examples:
■ Survival. Organizations have to maintain their
own existence. Many health-care organizations
are cash-strapped, causing them to limit hiring,
streamline work, and reduce costs, putting
enormous pressure on their staff (Roark, 2005).
The survival goal is threatened when
reimbursements are reduced, competition
increases, the organization fails to meet
standards, or patients are unable to pay their
bills (Trinh & O’Connor, 2002).
■ Growth. Chief executive officers (CEOs)
typically want their organizations to grow by
expanding into new territories, adding new
services, and bringing in new patients.
■ Profit. For-profit organizations are expected to
return some profit to their owners. Not-for-
profit organizations have to be able to pay
their bills and to avoid falling into debt. This
is sometimes difficult to accomplish.
■ Status. Many CEOs also want their health-
care organization to be known as the best in
its field, for example, by having the best
transplant unit, having the shortest wait time
in the emergency room, having world
renowned physicians, providing “the best
nursing care in the community” (Frusti,
Niesen, & Campion, 2003), providing gourmet
meals, or having the most attractive birthing
rooms in town.
■ Dominance. Some organizations also want to
drive others out of the health-care business or
acquire them, surpassing the goal of survival
and moving toward dominance of a particular
market by driving out the competition.
Problems can arise if the mission statement of a
health-care organization is not well aligned (i.e., in
agreement) with day-to-day actions of its leaders.
This disconnect can reduce morale, lead to gaps in
the quality of care provided, and tarnish its image
in the community (Nelson, 2013). The disconnect
between these goals may have profound effects on
every one of the organization’s employees, nurses
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chapter 5 ■ Organizations, Power, and Empowerment 75
included. For example, return to the story of Hazel
Rivera. Why did she receive a less favorable rating
than her friend Carla?
After comparing ratings with those of her friend
Carla, Hazel asked for a meeting with her nurse
manager to discuss her evaluation. The nurse
manager explained the rating: Hazel’s care plans
were very well done, and the nurse manager genu-
inely appreciated Hazel’s efforts to make them so.
The problem was that Hazel had to be paid over-
time for this work according to the union contract,
and this reduced the amount of overtime pay the
nurse manager had available when the patient care
load was especially high. “The corporation is very
strict about staying within the budget,” she said.
“In fact, my rating is higher when I don’t use up all
of my budgeted overtime hours.” When Hazel
asked what she could do to improve her rating, the
nurse manager offered to help her streamline the
care plans and manage her time better so that the
care plans could be done during her shift.
Staff nurses can contribute to the accomplish-
ment of organizational goals. This begins with rec-
ognition that there is a connection between the work
they do and achievement of the organization’s
goals. An example would be to reduce rehospital-
ization of discharged patients. To contribute to
achieving this goal, nurses can better prepare
patients to care for themselves when they go home.
This is a specif ic action to be taken, a change in
practice that nurses can integrate into patient care.
Monthly reports on changes in the rate of rehospi-
talization provide information about the progress
made toward achieving the goal. Recognition of this
progress motivates them to continue these efforts
(Berkow et al., 2012).
Structure
The Traditional Approach
Almost all health-care organizations have a hierar-
chical structure of some kind (Box 5-1). In a tradi-
tional hierarchical structure, employees are ranked
from the top to the bottom, as if they were on the
steps of a ladder (Fig. 5.1). The number of people
on the bottom rungs of the ladder is almost always
much greater than the number at the top. The
president or CEO is usually at the top of this
ladder; the housekeeping and maintenance crews
are usually at the bottom. Nurses fall somewhere in
Adapted from Weber, M. (1969). Bureaucratic organization. In Etzioni, A. (ed.). Readings on modern organizations. Englewood Cliffs, N.J.:
Prentice-Hall.
Although it seems as if everyone complains about “the bureaucracy,” not everyone is clear about what a bureaucracy really
is. Max Weber defined a bureaucratic organization as having the following characteristics:
• Division of labor. Specific parts of the job to be done are assigned to different individuals or groups. For example,
nurses, physicians, therapists, dietitians, and social workers all provide portions of the health care needed by an
individual.
• Hierarchy. All employees are organized and ranked according to their level of authority within the organization. For
example, administrators and directors are at the top of most hospital hierarchies, whereas aides and maintenance
workers are at the bottom.
• Rules and regulations. Acceptable and unacceptable behavior and the proper way to carry out various tasks are
defined, often in writing. For example, procedure books, policy manuals, bylaws, statements, and memos prescribe many
types of behavior, from acceptable isolation techniques to vacation policies.
• Emphasis on technical competence. People with certain skills and knowledge are hired to carry out specific parts
of the total work of the organization. For example, a community mental health center has psychiatrists, social workers,
and nurses to provide different kinds of therapies and clerical staff to do the typing and filing.
Some bureaucracy is characteristic of the formal operation of every organization, even the most deliberately informal,
because it promotes smooth operations within a large and complex group of people.
box 5-1
What Is a Bureaucracy?
Figure 5.1 The organizational ladder.
CEO
Administrators
Managers (also medical staff)
Staff nurses
Technicians
(including LPNs)
Aides; housekeeping;
maintenance
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76 unit 2 ■ Working Within an Organization
the middle of most health-care organizations,
higher than the cleaning people, aides, and techni-
cians, parallel with therapists but lower than physi-
cians and administrators. The organizational
structure of a small ambulatory care center in a
horizontal form is illustrated in Figure 5.2.
The people at the top of the ladder have author-
ity to issue orders, spend the organization’s money,
and hire and fire people. Much of this authority is
delegated to people below them, but they retain the
right to reverse a decision or regain control of these
activities whenever they deem necessary.
The people at the bottom have little authority
but do have other sources of power. They usually
play no part in deciding how money is spent or who
will be hired or fired but are responsible for carry-
ing out the directions issued by people above them
on the ladder. Their primary source of power is the
importance of the work they do: if there was no one
at the bottom, most of the work would not get
done.
Some amount of bureaucracy is characteristic of
the formal operation of every organization, even
the most deliberately informal, because it promotes
smooth and consistent operations within a large
and complex group of people.
More Innovative Structures
There is much interest in restructuring organiza-
tions, not only to save money but also to make the
best use of a health-care organization’s most valu-
able resource, its people. This begins with hiring the
right people. It also involves providing them with
the resources they need to function and the kind of
leadership that can inspire the staff and unleash
their creativity (Rosen, 1996).
Increasingly, people recognize that organiza-
tions need to be both efficient and adaptable. Orga-
nizations need to be prepared for uncertainty, for
rapid changes in their environment, and for quick,
creative responses to these challenges. In addition,
they need to provide an internal climate that not
only allows but also motivates employees to work
to the best of their ability.
Innovative organizations have adapted an
increasingly organic structure that is more dynamic,
more flexible, and less centralized than the static
traditional hierarchical structure (Yourstone &
Smith, 2002). In these organically structured orga-
nizations, many decisions are made by the people
who will implement them, not by their bosses.
The organic network emphasizes increased flex-
ibility of the organizational structure (Fig. 5-3),
decentralized decision making, and autonomy for
working groups and teams. Rigid unit structures are
reorganized into autonomous teams that consist of
professionals from different departments and dis-
ciplines. Each team is given a specific task or func-
tion (e.g., intravenous team, a hospital infection
control team, a child protection team in a com-
munity agency). The teams are responsible for their
own self-correction and self-control, although
they may also have a designated leader. Together,
team members make decisions about work assign-
ments and how to deal with problems that arise.
In other words, the teams supervise and manage
themselves.
Supervisors, administrators, and support staff
have different functions in an organic network.
Instead of spending their time directing and con-
trolling other people’s work, they become planners
and resource people. They are responsible for pro-
viding the conditions required for the optimal
functioning of the teams, and they are expected to
ensure that the support, information, materials, and
funds needed to do the job well are available to the
teams. They also act as coordinators between the
teams so that the teams are cooperating rather than
blocking each other, working toward the same
goals, and not duplicating effort.
The structure of health-care organizations is
changing rapidly. For example, many formerly in-
dependent organizations are considering joining
together into accountable care organizations that
provide a continuum of care, from primary care to in-
patient care and long-term care for the people they
serve. The goal is to provide the best quality care
while keeping costs under control (Evans, 2013).
Processes
Organizations have formal processes for getting
things done and informal ways to get around the
formal processes (Perrow, 1969). The formal pro-
cesses are the written policies and procedures
present in all health-care organizations. The infor-
mal processes are not written and often not dis-
cussed. They exist in organizations as a kind of
“shadow” organization that is harder to see but
equally important to recognize and understand
(Purser & Cabana, 1999).
The informal route is often much simpler
and faster to use than the formal one. Because the
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chapter 5 ■ Organizations, Power, and Empowerment 77
Assistant
Administrator
for Clinical
Services
Director,
Environmental
Services
Maintenance
Supervisor
Maintenance
Technician
Payroll Clerk
Payroll Clerk
Accountant
Maintenance
Technician
Maintenance
Technician
Maintenance
Technician
Director,
Personnel
Records
Supervisor
Training
Supervisor
Recruiter
Payroll
Supervisor
Accounting
Supervisor
Social Work
Supervisor
Social Work
Supervisor
Social Worker
Community
Worker
Community
Worker
Clerk
Clerk
Consultant
Dietitian
Nursing
Supervisor
Nursing
Supervisor
Social Work
Supervisor
Nurse
Practitioner
Nurse
Practitioner
Nurse
Practitioner
Medical
Director
Director,
Accounting
and Payroll
Director,
Outreach
Program
Director,
Satellite
Clinic
Director,
Main
Clinic
Physician
Physician
LPN
LPN
LPN
LPN
LPN
LPN
Social Worker
Social Worker
Assistant
Administrator
for Managerial
Services
Social Worker
Community
Worker
Community
Worker
Social Worker
Social Worker
Nurse
Nurse
Records Clerk
Records Clerk
Trainer
Trainer
Nurse
Nurse
Nurse
Administrator/
Executive
Director
Figure 5.2 Table of organization of an ambulatory care center. Adapted from DelBueno, D.J. (1987). An organizational
checklist. Journal of Nursing Administration, 17(5), 30–33.
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78 unit 2 ■ Working Within an Organization
informal ways of getting things done are seldom
discussed (and certainly not a part of a new employ-
ee’s orientation), it may take some time for you to
figure out what they are and how to use them. Once
you know they exist, they may be easier for you to
identify. The following is an example:
Jocylene noticed that Harold seemed to get STAT
x-rays done on his patients faster than she did. At
lunch one day, Jocylene asked Harold why that hap-
pened. “That’s easy,” he said. “The people in x-ray
feel unappreciated. I always tell them how helpful
they are. Also, if you call and let them know that the
patients are coming, they will get to them faster.”
Harold has just explained an informal process to
Jocylene.
Here is another example. Community Hospital
recently installed a new EHR (electronic health
record) system. Both the labs and the emergency
department already had computerized record
systems, but these old systems did not interface with
the new hospital-wide system. Eventually, they
would transition to the new system as well, but in
the meantime they had to continue sharing infor-
mation across departments. To do this, they created
“workarounds,” going back to paper reports that had
to be sent to nursing units (Clancy, 2010). Although
Community Hospital was officially paperless, the
informal system had to develop a workaround
during the transition to a hospital-wide EHR.
Sometimes, people are unwilling to discuss the
informal processes. However, careful observation of
the most experienced “system-wise” individuals in
an organization will eventually reveal these pro-
cesses. This will help you do things as efficiently as
they do.
Power
There are times when one’s attempts to influence
others are overwhelmed by other forces or indi-
viduals. Where does this power come from? Who
has it? Who does not?
In the earlier section on hierarchy, it was noted
that although people at the top of the hierarchy
have most of the authority in the organization, they
do not have all of the power. In fact, the people at
the bottom of the hierarchy also have some sources
of power. This section explains how this can be true.
First, power is defined, and then the sources of
power available to people on the lower rungs of the
ladder are considered.
Definition
Power is the ability to influence other people despite
their resistance. Using power, one person or group
can impose its will on another person or group
(Haslam, 2001). The use of power can be positive,
as when the nurse manager gives a staff member an
extra day off in exchange for working an extra
weekend, or negative, as when a nurse administra-
tor transfers a “bothersome” staff nurse to another
unit after that staff nurse pointed out a physician
error (Talarico, 2004).
Sources
Isosaari (2011) calls organizations “systems of
power” (p. 385). There are numerous sources of
power. Many of them are readily available to nurses,
but some of them are not. The following is a list
derived primarily from the work of French, Raven,
and Etzioni (Barraclough & Stewart, 1992; Iso-
saari, 2011):
■ Authority. The power granted to an individual
or a group to control resources and decision
making by virtue of position within the
organizational hierarchy.
■ Reward. The promise of money, goods,
services, recognition, or other benefits.
■ Control of Information. The special
knowledge an individual is believed to possess.
Health and
Wellness
Care
Exercise and
Massage
Group
Relaxation
and
Meditation
Group
Nutrition
Group
Aromatherapy
and Imagery
Group
Figure 5.3 An organic organizational structure for a
nontraditional wellness center. Based on Morgan, A.
[1993]. Imaginization: The art of creative management. Newbury
Park, Calif.: Sage.
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chapter 5 ■ Organizations, Power, and Empowerment 79
As Sir Francis Bacon said, “Knowledge is
power” (Bacon, 1597, quoted in Fitton, 1997,
p. 150).
■ Coercion. The threat of pain or of some type
of harm, which may be physical, economic, or
psychological.
Power at Lower Levels of the Hierarchy
There is power at the bottom of the organizational
ladder as well as at the top. Patients also have
sources of power (Bradbury-Jones, Sambrook, &
Irvine, 2007). Various groups of people in a health-
care organization have different types of power
available to them:
■ Managers are able to reward people with
salary increases, promotions, and recognition.
They can also cause economic or psychological
pain for the people who work for them,
particularly through their authority to evaluate
and fire people but also through the way
they make assignments, grant days off, and
so on.
■ Patients. Considerable power over health-care
decisions is associated with health-care
professionals: their guidance is not often
questioned by patients (Fredericks et al., 2012).
The patient-centered care movement is
directed to redistributing this power, involving
patients and their families in decisions about
their health care. For the most part, patients
have not exerted the potential power that they
possess. If patients refused to use the services
of a particular organization, that organization
would eventually cease to exist. Patients can
reward health-care workers by praising them
to their supervisors. They can also cause
problems by complaining about them.
■ Assistants and technicians may also appear to be
relatively powerless because of their low
positions in the hierarchy. Imagine, however,
how the work of the organization (e.g.,
hospital, nursing home) would be impeded if
all the nursing aides failed to appear one
morning.
■ Registered nurses have expert power and
authority over licensed practical nurses,
aides, and other personnel by virtue of their
position in the hierarchy. They are critical
to the operation of most health-care
organizations and could cause considerable
trouble if they refused to work, another source
of nurse power.
Fralic (2000) offered a good example of the power
of information that nurses have always had: Flor-
ence Nightingale showed very graphically in the
1800s that far fewer wounded soldiers died when
her nurses were present, and many more died when
they were not. Think of the power of that informa-
tion. Immediately, people were saying, “What
would you like, Miss Nightingale? Would you like
more money? Would you like a school of nursing?
What else can we do for you?” She had solid data,
she knew how to collect it, and she knew how to
interpret and distribute it in terms of things that
people valued (p. 340).
Empowering Nurses
This final section looks at several ways in which
nurses, either individually or collectively, can maxi-
mize their power and increase their feelings of
empowerment.
Power is the actual or potential ability to “recog-
nize one’s will even against the resistance of others,”
according to Max Weber (quoted in Mondros &
Wilson, 1994, p. 5). Empowerment is a psychologi-
cal state, a feeling of competence, control, and
entitlement. Given these definitions, it is possible
to be powerful and yet not feel empowered. Power
refers to ability, and empowerment refers to feelings.
Both are of importance to nursing leaders and
managers.
Feeling empowered includes the following:
■ Self-determination. Feeling free to decide
how to do your work
■ Meaning. Caring about your work, enjoying it,
and taking it seriously
■ Competence. Confidence in your ability to do
your work well
■ Impact. Feeling that people listen to your
ideas, that you can make a difference (Spreitzer
& Quinn, 2001)
The following contribute to nurse empowerment:
■ Decision making. Control of nursing practice
within an organization
■ Autonomy. Ability to act on the basis of
one’s knowledge and experience (Manojlovich,
2007)
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80 unit 2 ■ Working Within an Organization
■ Manageable workload. Reasonable work
assignments
■ Reward and recognition. Appreciation, both
tangible (raises, bonuses) and intangible
(praise) received for a job well done
■ Fairness. Consistent, equitable treatment of all
staff (Spence & Laschinger, 2005)
The opposite of empowerment is disempower-
ment. Inability to control one’s own practice leads
to frustration and sometimes failure. Work overload
and lack of meaning, recognition, or reward produce
emotional exhaustion and burnout (Spence, Lasch-
inger, & Finegan, 2005). Nurses, like most people,
want to have some power and to feel empowered.
They want to be heard, to be recognized, to be
valued, and to be respected. They do not want to
feel unimportant or insignificant to society or to
the organization in which they work.
Participation in Decision Making
The amount of power available to or exercised by
a given group (e.g., nurses) within an organization
can vary considerably from one organization to the
next. Three sources of power are particularly impor-
tant in health-care organizations:
■ Resources. The money, materials, and human
help needed to accomplish the work
■ Support. Authority to take action without
having to obtain permission
■ Information. Patient care expertise and
knowledge about the organization’s goals and
activities of other departments
In addition, nurses also need access to opportuni-
ties: opportunities to be involved in decision making,
to be involved in vital functions of the organization,
to grow professionally, and to move up the organi-
zational ladder (Sabiston & Laschinger, 1995).
Without these, employees cannot be empowered
(Bradford & Cohen, 1998). Nurses who are part-
time, temporary, or contract employees are less
likely to feel empowered than full-time perma-
nent employees, who generally feel more secure
in their positions and connected to the organi-
zation (Kuokkanen & Katajisto, 2003). Mana-
gers and higher-level administrators can take
actions to empower nursing staff by providing these
opportunities.
Shared Governance
Nursing practice councils are an effective, although
not simple, way to share decision making (Brody,
Barnes, Ruble, & Sakowsk, 2012). Under shared
governance, staff nurses may be included in the
highest levels of decision making within the nursing
department through representation on various
councils that govern practice and management
issues. These councils may set standards for patient
safety, diversity, staffing, career ladders, evaluations,
promotion, and the like. In many cases, a change in
the organizational culture is necessary before shared
governance can work (Currie & Loftus-Hills, 2002;
Moore & Wells, 2010).
Genuine sharing of decision making is difficult
to accomplish, partly because managers are reluc-
tant to relinquish control or to trust their staff
members to make wise decisions. Yet genuine
empowerment of the nursing staff cannot occur
without this sharing. Having some control over
one’s work and the ability to influence decisions are
essential to empowerment (Manojlovich & Lasch-
inger, 2002). For example, if staff members cannot
control the budget for their unit, they cannot
implement a decision to replace aides with regis-
tered nurses without approval from higher-level
management. If they want increased autonomy in
decision making about the care of individual
patients, they cannot do so if opposition by another
group, such as physicians, is given greater credence
by the organization’s administration.
Return to the example of the staff of the critical
care department (Scenario 2). Why did the vice
president for nursing tell the nurse manager that
the plan would not be implemented?
Actually, the vice president for nursing thought
the plan had some merit. He believed that the
proposal to create a geriatric intensive care unit
could save money, provide a higher quality of
patient care, and result in increased nursing staff
satisfaction. However, the critical care department
was the centerpiece of the hospital’s agreement
with a nearby medical school. In this agreement,
the medical school provided the services of highly
skilled intensivists in return for the learning oppor-
tunities afforded their students. In its present form,
the nurses’ plan would not allow sufficient auton-
omy for the medical students, a situation that would
not be acceptable to the medical school. The vice
president knew that the board of trustees of the
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chapter 5 ■ Organizations, Power, and Empowerment 81
hospital believed their affiliation with the medical
school brought a great deal of prestige to the orga-
nization and that they would not allow anything to
interfere with this relationship.
“If shared governance were in place here, I think
we could implement this or a similar model of care,”
he told the nurse manager.
“How would that work?” she asked.
“If we had shared governance, the nursing prac-
tice council would review the plan and, if they
approved it, forward it to a similar medical practice
council. Then committees from both councils
would work together to figure out a way for this to
benefit everyone. It wouldn’t necessarily be easy to
do, but it could be done if we had real collegiality
between the professions. I have been working
toward this model but haven’t convinced the rest of
the administration to put it into practice yet.
Perhaps we could bring this up at the next nursing
executive meeting. I think it is time I shared my
ideas on this subject with the rest of the nursing
staff.”
In this case, the organizational goals and pro-
cesses existing at the time the nurses developed
their proposal did not support their idea. How-
ever, the vice president could see a way for it to
be accomplished in the future. Implementation of
genuine shared governance would make it possible
for the critical care nurses to accomplish their goal.
Professional Organizations
Although the purposes of the American Nurses
Association and other professional organizations
are discussed in Chapter 14, these organizations are
considered here specifically in terms of how they
can empower nurses.
A collective voice, expressed through these orga-
nizations, can be stronger and is more likely to be
heard than one individual voice. By joining together
in professional organizations, nurses make their
viewpoint known and their value recognized more
widely. The power base of nursing professional
organizations is derived from the number of
members and their expertise in health matters.
Why there is power in numbers may need some
explanation. Large numbers of active, informed
members of an organization represent large
numbers of potential voters to state and national
legislators, most of whom wish to be remembered
favorably in forthcoming elections. Large groups of
people also have a “louder” voice: they can write
more letters, speak to more friends and family
members, make more telephone calls, and generally
attract more attention than small groups can.
Professional organizations can empower nurses
in a number of ways:
■ Collegiality, the opportunity to work with
peers on issues of importance to the profession
■ Commitment to improving the health and
well-being of the people served by the
profession
■ Representation at the state or province and
national level when issues of importance to
nursing arise
■ Enhancement of nurses’ competence through
publications and continuing education
■ Recognition of achievement through
certification programs, awards, and the media
Collective Bargaining
Like professional organizations, collective bargain-
ing uses the power of numbers, in this case for
the purpose of equalizing the power of employees
and employer to improve working conditions,
gain respect, increase job security, and have greater
input into collective decisions (empowerment) and
pay increases (Tappen, 2001). It can provide nurses
with a stronger “voice,” providing sup port and
reducing fearfulness in speaking out about concerns
(Seago et al., 2011). It may reduce staff turnover
(Porter et al., 2010; Temple et al., 2011).
When people join for a common cause, they can
exert more power than when they attempt to bring
about change individually. Large numbers of people
have the potential to cause more psychological or
economic pain to an “opponent” (the employer in
the case of collective bargaining) than an individual
can. For example, the resignation of one nursing
assistant or one nurse may cause a temporary
problem, but it is usually resolved rather quickly by
hiring another individual. If 50 or 100 aides or
nurses call in “sick” or resign, however, the organiza-
tion can be paralyzed and will have much more
difficulty replacing these essential workers. Collec-
tive bargaining takes advantage of this power in
numbers.
An effective collective bargaining contract can
provide considerable protection to employees.
However, the downside of collective bargaining (as
with most uses of coercive power) is that it may
encourage conflict rather than cooperation between
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82 unit 2 ■ Working Within an Organization
employees and managers, an “us” against “them”
environment (Haslam, 2001). Many nurses are also
concerned about the effect that going out on strike
might have on their patients’ welfare and on their
own economic security. Most administrators and
managers prefer to operate within a union-free
environment (Hannigan, 1998). Others are able to
develop cooperative working relationships with
their collective bargaining units, finding ways to
work within the restrictions of a union contract and
work together toward shared goals. For example, a
Nursing Labor Management Partnership, part of a
hospital-wide labor management partnership, was
developed at Mt. Sinai Medical Center in New
York (Porter, Kolcaba, McNulty, & Fitzpatrick,
2010). The mission of this partnership was for
nurses and management to work together to achieve
“unprecedented excellence” in patient care and
create a positive work environment (p. 273). By
respecting each other’s differences and searching
for common ground, nursing management and
nursing union leaders worked together on shared
goals such as reduction of nosocomial (due to hos-
pitalization) pressure ulcers by 75% in 2 years.
Another example of collaboration is from Shands
Jacksonville Medical Center in Jacksonville, Florida.
Nursing management wanted to institute a clinical
ladder whereby nurses could achieve higher pay and
higher clinical levels by completing certain require-
ments such as obtaining a higher degree, conduct-
ing a research study, or working on implementing
an evidence-based change in practice. A traditional
clinical ladder would conflict with the union’s
efforts to achieve pay equity, so the achievements
were instead rewarded with bonuses for staff that
did not affect their annual salaries (Lawson et al.,
2011). It was a good way to achieve a win-win
outcome for all involved.
Enhancing Expertise
Most health-care professionals, including nurses,
are empowered to some extent by their professional
knowledge and competence. You can take steps to
enhance your competence, thereby increasing your
sense of empowerment (Fig. 5.4):
■ Participate in interdisciplinary team
conferences and patient-centered conferences
on your unit.
■ Participate in continuing education offerings
to enhance your expertise.
■ Attend local, regional, and national conferences
sponsored by relevant nursing and specialty
organizations.
■ Read journals and books in your specialty area.
■ Participate in nursing research projects related
to your clinical specialty area.
■ Discuss with colleagues in nursing and other
disciplines how to handle a difficult clinical
situation.
■ Observe the practice of experienced nurses.
■ Return to school to earn a bachelor’s degree
and higher degrees in nursing.
You can probably think of more, but this list at least
gives you some ideas. You can also share your
knowledge and experience with other people. This
means not only using your knowledge to improve
your own practice but also communicating what
you have learned to your colleagues in nursing and
other professions. It also means letting your super-
visors know that you have enhanced your profes-
sional competence. You can share your knowledge
with your patients, empowering them as well. You
may even reach the point at which you have learned
more about a particular subject than most nurses
have and want to write about it for publication.
Conclusion
Although most nurses are employed by health-care
organizations, too few have taken the time to
analyze the operation of their employing health-
care organization and the effect it has on their
practice. Understanding organizations and the
power relationships within them will increase the
effectiveness of your leadership.
Figure 5.4 How to increase your expert power.
Participate in interprofessional conferences
Attend continuing education offerings
Attend professional organization meetings
Read books and journals related to
your nursing practice
Problem-solve and brainstorm
with colleagues
Return to school to earn a higher degree
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chapter 5 ■ Organizations, Power, and Empowerment 83
Study Questions
1. Describe the organizational characteristics of a facility in which you currently have a clinical
assignment. Include the following: the type of organization, its organizational culture, its
structure, and its formal and informal goals and processes.
2. Define power, and describe how power affects the relationships between people of different
disciplines (e.g., nursing, medicine, physical therapy, housekeeping, administration, finance,
social work) in a health-care organization.
3. Discuss ways in which nurses can become more empowered. How can you use your leadership
skills to do this?
Case Study to Promote Critical Reasoning
Tanya Washington will finish her associate’s degree nursing program in 6 weeks. Her preferred
clinical area is pediatric oncology, and she hopes to become a pediatric nurse practitioner one day.
Tanya has received two job offers, both from urban hospitals with large pediatric units. Because
several of her friends are already employed by these facilities, she asked them for their thoughts.
“Central Hospital is a good place to work,” said one friend. “It is a dynamic, growing
institution, always on the cutting edge of change. Any new idea that seems promising, Central is
the first to try it. It’s an exciting place to work.”
“City Hospital is also a good place to work,” said her other friend. “It is a strong, stable
institution where traditions are valued. Any new idea must be carefully evaluated before it is
adapted. It’s been a pleasure to work there.”
1. How would the organizational culture of each hospital affect a new graduate?
2. Which organizational culture do you think would be best for a new graduate, Central’s or
City’s?
3. Would your answer differ if Tanya were an experienced nurse?
4. What do you need to know about Tanya before deciding which hospital would be best for her?
5. What else would you like to know about the two hospitals?
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84 unit 2 ■ Working Within an Organization
References
Aiken, L.H., Clarke, S.P., Sloane, D.M., Lake, C.T., et al.
(2008). Effects of hospital care environments on patient
mortality and nurse outcomes. Journal of Nursing
Administration, 38(5), 223–229.
Armstrong, K.J., & Laschinger, H. (2006). Structural
empowerment, magnet hospital characteristics, and
patient safety culture. Journal of Nursing Care Quality,
21(2), 124–132.
Barraclough, R.A., & Stewart, R.A. (1992). Power and
control: Social science perspectives. In Richmond, V.P., &
McCroskey, J.C. (eds.). Power in the classroom:
Communication, control and concern. Hillsdale, N.J.:
Lawrence Erlbaum.
Berkow, S., Workman, J., Arson, S., Stewart, J., Virkotis, K.,
& Kahn, M. (2012). Strengthening frontline nurse
investment in organizational goals. Journal of Nursing
Administration, 42(3), 165–169.
Bradbury-Jones, C., Sambrook, S., & Irvine, F. (2007).
Power and empowerment in nursing: A fourth theoretical
approach. Journal of Advanced Nursing, 62(2),
258–266.
Bradford, D.L., & Cohen, A.R. (1998). Power up:
Transforming organizations through shared leadership.
New York: John Wiley & Sons.
Brody, A., Barnes, K., Ruble, C., & Sakowksi, J. (2012).
Evidence-based practice councils: Potential path to staff
nurse empowerment and leadership growth. Journal of
Nursing Administration, 42(1), 28–33.
Cameron, K., & Quinn, R. (2006). Diagnosing and
changing organizational culture. San Francisco:
Jossey-Bass.
Clancey, T.R. (2010). Technology and complexity: Trouble
brewing? Journal of Nursing Administration, 40(6),
247–249.
Connaughton, M.J., & Hassinger, J. (2007). Leadership
character: Antidote to organizational fatigue. Journal of
Nursing Administration, 37(10), 464–470.
Currie, L., & Loftus-Hills, A. (2002). The nursing view
of clinical governance. Nursing Standard, 16(27),
40–44.
DelBueno, D.J. (1987). An organizational checklist. Journal
of Nursing Administration, 17(5), 30–33.
Evans, M. (2013). Redesigning healthcare: Accountable
care organization. Modern Healthcare, 43(12), 7.
Fitton, R.A. (1997). Leadership: Quotations from the world’s
greatest motivators. Boulder, Colo.: Westview Press.
Fralic, M.F. (2000). What is leadership? Journal of Nursing
Administration, 30(7/8), 340–341.
Fredericks, S., Lapeim, J., Schwind, J., Beanlands, H.,
Romaniuk, D., & McCay, E. (2012). Discussion of
patient-centered care in health care organizations.
Quality Management in Health Care, 21(3), 127–134.
Frusti, D.K., Niesen, K.M., & Campion, J.K. (2003).
Creating a culturally competent organization. Journal of
Nursing Administration, 33(1), 33–38.
Hannigan, T.A. (1998). Managing tomorrow’s high-
performance unions. Westport, Conn.: Greenwood
Publishing.
Haslam, S.A. (2001). Psychology in organizations.
Thousand Oaks, Calif.: Sage.
Hinshaw, A.S. (2008). Navigating the perfect storm:
Balancing a culture of safety with workforce. Nursing
Research, 57(1S), S4–10.
Isosaari, U. (2011). Power in health care organizations:
Contemplations from the first-line management
perspective. Journal of Health Organization and
Management, 25(4), 385–399.
Kuokkanen, L., & Katajisto, J. (2003). Promoting or
impeding empowerment? Journal of Nursing
Administration, 33(4), 209–215.
Laschinger, H.K.S., Wong, C., McMahon, L., & Kaufman,
C. (1999). Leader behavior impact on staff nurse
empowerment, job tension, and work effectiveness.
Journal of Nursing Administration, 29(5), 28–39.
Lawson, L., Miles, K., Vallish, R., & Jenkins, S. (2011).
Recognizing nursing professional growth and
development in a collective bargaining environment.
Journal of Nursing Administration, 41(5), 197–200.
Mackoff, B.L., & Triolo, P.K. (2008). Why do nurses,
managers stay? Building a model of engagement: Part
2: Cultures of engagement. Journal of Nursing
Administration, 38(4), 166–171.
Manojlovich, M. (2007). Power and empowerment in
nursing: Looking backward to inform the future. New
Hampshire Nursing News, 12(1), 14–16.
Manojlovich, M., & Laschinger, H.K. (2002). The
relationship of empowerment and selected personality
characteristics to nursing job satisfaction. Journal of
Nursing Administration, 32(11), 586–595.
Mondros, J.B., & Wilson, S.M. (1994). Organizing for
power and empowerment. New York: Columbia
University Press.
Moore, S.C., & Wells, N.J. (2010). Staff nurses lead
the way for improvement to shared governance
structure. Journal of Nursing Administration, 40(11),
477–482.
Morgan, A. (1997). Images of organization. Thousand
Oaks, Calif.: Sage.
Morgan, A. (1993). Imaginization: The art of creative
management. Newbury Park, Calif.: Sage.
Nelson, W. (2013). The imperative of a moral compass-
driven healthcare organization. Frontiers of a Health
Services Management, 30(1), 39–45
Perera, F. & Peiro, M. (2012). Strategic planning in
healthcare organizations. Revista Española de
Cardiología, 65(8), 749–754.
Perrow, C. (1969). The analysis of goals in complex
organizations. In Etzioni, A. (ed.). Readings on modern
organizations. Englewood Cliffs, N.J.: Prentice-Hall.
Porter, C., Kolcaba, K., McNulty, S.R., & Fitzpatrick, J.J.
(2010). A nursing labor management partnership model.
Journal of Nursing Administration, 40(6), 272–276.
Purser, R.E., & Cabana, S. (1999). The self-managing
organization. New York: Free Press (Simon & Schuster).
Redman, R.W. (2008). Symposium in tribute to a nursing
leader: Ada Sue Hinshaw. Nursing Research, 51(15),
S1–S3.
Roark, D.C. (2005). Managing the healthcare supply
chain. Nursing Management, 36(2), 36–40.
Rosen, R.H. (1996). Leading people: Transforming business
from the inside out. New York: Viking Penguin.
Sabiston, J.A., & Laschinger, H.K.S. (1995). Staff nurse
work empowerment and perceived autonomy. Journal of
Nursing Administration, 28(9), 42–49.
Schein, E.H. (2004). Organizational culture and leadership.
New York: Jossey-Bass.
Scott-Findley, S., & Golden-Biddle, K. (2005).
Understanding how organizational culture shapes
research use. Journal of Nursing Administration,
35(7/8), 359–365.
Seago, J., Spetz, J., Ash, M., Herrera, C., & Keane, D.
(2011). Hospital RN job satisfaction and nurse
3663_Chapter 5_0071-0086.indd 843663_Chapter 5_0071-0086.indd 84 9/15/2014 4:37:15 PM9/15/2014 4:37:15 PM
Process CyanProcess CyanProcess MagentaProcess MagentaProcess YellowProcess YellowProcess BlackProcess Black
chapter 5 ■ Organizations, Power, and Empowerment 85
unions. Journal of Nursing Administration, 41(3),
109–114.
Spence, H.K., & Laschinger, J.F. (2005). Using
empowerment to build trust and respect in the
workplace: A strategy for addressing the nursing
shortage. Nursing Economics, 23(1), 6–13.
Spreitzer, G.M., & Quinn, R.E. (2001). A company of
leaders. San Francisco: Jossey-Bass.
Talarico, K.M. (2004, April 27). A look at power in
nursing. Vital Signs, 6–7, 21.
Tappen, R.M. (2001). Nursing leadership and
management: Concepts and practice, 4th ed.
Philadelphia: F.A. Davis.
Temple, A., Dobbs, D., & Andel, R. (2011). Exploring
correlates of turnover among nursing assistants in the
hospital nursing home survey. Journal of Nursing
Administration, 41(7/8), S34–S44.
Trinh, H.Q., & O’Connor, S.J. (2002). Helpful or harmful?
The impact of strategic change on the performance of
U.S. urban hospitals. Health Services Research, 37(1),
145–171.
Vogus, T.J., & Sutcliffe, K.M. (2007). The safety organizing
scale: Development and validation of a behavioral
measure of safety culture in hospital nursing units.
Medical Care, 45(1), 46–54.
Weber, M. (1969). Bureaucratic organization. In A. Etzioni
(ed.). Readings on modern organizations. Englewood
Cliffs, N.J.: Prentice-Hall.
Weissman, J.S., Rothschild, J.M., Bendavid, E., Sprivulis, P.,
et al. (2007). Hospital workload and adverse events.
Medical Care, 45(5), 448–455.
Yourstone, S.A., & Smith, H.L. (2002). Managing system
errors and failures in health care organizations:
Suggestions for practice and research. Health Care
Management Review, 27(1), 50–61.
3663_Chapter 5_0071-0086.indd 853663_Chapter 5_0071-0086.indd 85 9/15/2014 4:37:16 PM9/15/2014 4:37:16 PM
Process CyanProcess CyanProcess MagentaProcess MagentaProcess YellowProcess YellowProcess BlackProcess Black
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chapter 6
Communicating With Others and Working
With the Interprofessional Team
OBJECTIVES
After reading this chapter, the student should be able to:
■ Explain the components necessary for effective interpersonal
communication.
■ Identify barriers to effective interpersonal communication.
■ Discuss the importance of interprofessional collaboration.
■ Apply components of interpersonal communication to
interprofessional collaboration.
■ Discuss strategies to promote interprofessional collaboration.
■ Describe effective strategies to build interprofessional teams.
OUTLINE
Communication
Assertiveness in Communication
Interpersonal Communication
Barriers to Communication Among Health-Care Providers
and Health-Care Recipients
Low Health Literacy
Cultural Diversity
Cultural Competence
Interprofessional Communication Education of Health-
Care Providers
Electronic Forms of Communication
Information Systems and E-Mail
Electronic Medical Records and Electronic Health
Records
E-Mail
Text Messaging
Reporting Patient Information
Hand-Off Communications
Communicating With the Health-Care Provider
ISBARR
Health-Care Provider Orders
Teams
Learning to Be a Team Player
Building a Working Team
Interprofessional Collaboration and the
Interprofessional Team
Interprofessional Collaboration
Interprofessional Communication
Building an Interprofessional Team
Conclusion
Claude has been working in a busy oncology center
for several years. The center uses an interprofessional
team approach to client care. Claude manages a
caseload of six to eight clients daily, and he believes
that he provides safe, competent care and collabo-
rates with other members of the interprofessional
team. While Claude was on his way to deliver che-
motherapy to a client recently diagnosed with osteo-
sarcoma, the team nutritionist, Sonja, called to him,
“Claude, come with me, please.”
Claude responded, “Wait one minute. I need to
hang the chemo on Mr. Juniper. I will come right
after that. Where will you be?”
Sonja responded, “I need you now. There have
been changes in Mrs. Alejandro’s home care and
medication regimen. I am trying to discuss how she
needs to change her diet due to the medication
changes. I can’t seem to explain this to her. She keeps
telling me she needs to eat ‘cold foods’ because she has
a ‘hot stomach.’ You seem to understand her better
than I do.” Claude stopped what he was doing and
went to speak with Sonja and Mrs. Alejandro.
While engaged in this conversation, the oncology
nurse practitioner re-evaluated Mr. Juniper’s lab
values and physical condition. The advanced prac-
tice nurse (APRN) determined that Mr. Juniper
should not receive his chemotherapy that day and
should be sent to the hospital for further evaluation.
The APRN wrote the order and went on to evaluate
other patients without communicating the change to
Claude. After Claude f inished with Sonja, he
returned to Mr. Juniper and proceeded to administer
the chemotherapy. That night Mr. Juniper was
admitted to the hospital with uncontrollable bleed-
ing and sepsis.
Health-care professionals need to communicate
clearly and effectively with each other. When they
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88 unit 2 ■ Working Within an Organization
fail to do so, patient safety is at risk. In this case,
the APRN failed to communicate a change in the
patient’s status. This resulted in a situation causing
the patient’s death.
Today’s health-care system requires nurses to
interact with more than physicians. Primary health-
care providers include APRNs and physician assis-
tants who work with physicians. Other disciplines
involved in direct patient care include pharma-
cists, physical and occupational therapists, speech-
language pathologists, and ancillary unlicensed
personnel. Effective communication among all
members of the health-care team is essential in the
provision of safe patient care. Based on the changes
in health care, the report from the Institute of
Medicine (IOM), and the move toward an inter-
professional model of providing health care, this
chapter focuses on communication skills needed
to work with members of the interprofessional
team and providing information in a multicultural
society.
Communication
People often assume that communication is simply
giving information to another person. In fact,
giving information is only a small part of commu-
nication. Communication models demonstrate
that communication occurs on several levels and
includes more than just giving information. Com-
munication involves the spoken word as well as
the nonverbal message, the emotional state of
people involved, outside distractions, and the cul-
tural background that affects their interpretation
of the message. Superficial listening often results
in misinterpretation of the message. An individu-
al’s attitude also influences what is heard and how
the message is interpreted. Active listening is nec-
essary to pick up all these levels of meaning in a
communication.
Assertiveness in Communication
Nurses are integral members of the health-care
team and often find themselves acting as “naviga-
tors” for patients as they guide them through the
system. For this reason nurses need to develop
assertive communication skills. Assertive behaviors
allow people to stand up for themselves and their
rights without violating the rights of others. Asser-
tiveness is different from aggressiveness. People use
aggressive behaviors to force their wishes or ideas
on others. In assertive communication, an indi-
vidual’s position is stated clearly and firmly, using
“I” statements. When working in an interprofes-
sional environment, assertiveness assumes a greater
importance as nurses need to act as patient advo-
cates to ensure that patients receive safe, effective,
and appropriate care. Using assertive communica-
tion helps in expressing your ideas and position;
however, it does not necessarily guarantee that you
will get what you want.
Interpersonal Communication
Communication is an integral part of our daily
lives. Most daily communication qualifies as imper-
sonal, such as interactions with salespeople or
service personnel. Interpersonal communication is
a process that gives people the opportunity to
reflect, construct personal knowledge, and develop
a sense of collective knowledge about others. Indi-
viduals use this form of communication to establish
relationships to promote their personal and profes-
sional growth. This type of communication remains
key to working effectively with others.
Interpersonal communication differs from
general communication in that it includes several
criteria. First, it is a selective process in that most
general communication occurs on a superficial
level. Interpersonal communication occurs on a
more intimate level. It is a systemic process as it
occurs within various systems and among the
members within those systems (Wood, 2010). The
work of the system influences how we communi-
cate, where we communicate, and the meaning of
the communication.
Interpersonal communication is also unique in
that the individuals engaged in the communication
are unique. Each person holds a specific role that
influences the form and process of the communica-
tion, thus impacting the outcome. Finally, interper-
sonal communication is a dynamic and ongoing
process. The communication changes based on the
need and the existing situation.
Transactional models of communication differ
from earlier linear models in that the transactional
models label all individuals as communicators and
not specifically as “senders” or “receivers.” They
highlight the dynamic process of interpersonal
communication and the many roles individuals
assume in these interactions. These models also
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chapter 6 ■ Communicating With Others and Working With the Interprofessional Team 89
allow for the fact that communication among and
between individuals occurs simultaneously as the
participants may be sending, receiving, and inter-
preting messages at the same time.
Transactional models acknowledge that noise,
which interrupts communication, occurs in all in-
teractions. Noise may assume many forms such
as background conversations within the workplace
or even spam or instant messages in the elec-
tronic milieu. Transactional models also include
the concept of time, as communication among
and between individuals changes over time and
acknowledges that communication occurs within
systems. These systems influence what people
communicate and how they relay and process
information.
Barriers to Communication Among
Health-Care Providers and
Health-Care Recipients
Successful interactions among health-care provid-
ers and between those providers and their patients
require effective communication. Many challenges
exist that impede this communication. These
include: (a) low health literacy; (b) cultural diver-
sity; (d) cultural competence of health-care provid-
ers; and (d) lack of interprofessional communication
education of providers (Schwartz, Lowe, & Sinclair,
2010).
Low Health Literacy
The IOM reports that approximately 90 million
Americans lack the health literacy needed to meet
their health-care needs (IOM, 2012). In the United
States the estimated cost of low health literacy
is between $106 and $236 billion (National Patient
Safety Foundation, 2012). Individuals who lack
the skills necessary to acquire and use health-care
information are less likely to manage their chron-
ic conditions and/or medication regimens effec-
tively. For this reason they utilize health-care
facilities more frequently and have higher mortality
rates.
Cultural Diversity
Nurses work in environments rich in cultural diver-
sity. This diversity exits among both professionals
and patients. Culture affects communication in
how the content is conveyed, emphasized, and
understood. These factors affect how the commu-
nicators process and act on the information.
Cultural Competence
Cultural competence affects the way health-care
providers interact with each other and with the
populations they service. Cultural competence
includes a set of similar behaviors, attitudes, and
policies that, when joined together, enable indi-
viduals or groups to work effectively in cross-
cultural situations (DHS, Office of Minority
Health, 2013). To practice cultural competence,
health-care professionals need to recognize and
relate to how culture is reflected in each other and
in the individuals with whom they interface.
Interprofessional Communication Education
of Health-Care Providers
Challenges exist when communicating with pro-
fessionals in other disciplines. Some difficulties
in interprofessional communication are related to
the use of concepts and terminology common to
one specific discipline but not well understood
by members of other professions. This interferes
with another professional’s understanding of the
meaning or value of the situation.
Effective and safe health-care delivery requires
nurses to be cognizant of these possible barriers to
communication with patients and among members
of the health-care team. When nurses and other
members of the health-care team lack effective
communication skills, patient safety is at risk. These
barriers are outlined in Table 6-1.
Electronic Forms of Communication
Information Systems and E-Mail
Electronic Medical Records and Electronic
Health Records
Communication through the use of computer tech-
nology is the norm today in nursing practice and
health-care institutions. Electronic medical records
(EMR) and documentation are used through-
out health care. The Health Information Technol-
ogy for Economic and Clinical Health (HITECH)
Act mandated the use of the electronic health
record (EHR) by the year 2015 (CMS, 2013). This
organization developed Medicare and Medicaid
incentive payment programs to help physicians and
health-care institutions transition from traditional
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90 unit 2 ■ Working Within an Organization
record-keeping to EHR. According to the Depart-
ment of Health and Human Services (DHHS),
“EHR adoption has tripled since 2010, increasing
to 44 percent in 2012 and computerized physician
order entry has more than doubled (increased 168
percent) since 2008” (CMS, 2013).
Although the terms electronic medical record
(EMR) and electronic health record (EHR) are used
interchangeably, they differ in the types of informa-
tion they contain. EMRs are the computerized
clinical records produced in the health-care institu-
tion and health-care provider offices. They are con-
sidered legal documents regarding patient care
within these settings. The EHR includes summa-
ries of the EMR. EMRs are digital versions of the
paper charts in the health-care provider’s office.
They contain the medical and treatment history of
the patients within that specific health-care pro-
vider’s practice. Some advantages of the EMR over
paper charts include the ability of the health-care
provider to:
■ Track data over time
■ Identify which patients need preventive
screenings or checkups
■ Monitor patients status regarding health
maintenance and prevention, such as blood
pressure readings or vaccinations
■ Evaluate and improve overall quality of care
within the specific practice
A disadvantage of the EMR is that it does not
easily move out of the specific practice. Often
the pati ent record needs to be printed and delivered
by mail to specialists and other members of the care
team.
EHR documents are shared among varying
institutions/individuals such as insurance compa-
nies, the government, and the patients themselves
(CMS, 2013). EHRs focus on the total health of a
patient extending beyond the data collected in the
health-care provider’s office. They provide a more
inclusive view of a patient’s care and are designed
to share information with other health-care provid-
ers, such as laboratories and specialists, so they
contain information from all the clinicians involved
in the patient’s care.
The use of electronic patient records allows
health-care providers to retrieve and distribute
patient information precisely and quickly. Deci-
sions regarding patient care can be made more effi-
ciently with less waiting time. Errors are reduced,
patient safety is increased, and quality is improved.
Information systems in many organizations also
provide opportunities to access current, high-
quality clinical and research data to support evi-
dence-based practice (Gartee & Beal, 2012).
Because security safeguards are in place, EHRs
also assist in maintaining patient confidentiality
when compared to traditional paper systems.
Health-care providers and institutions need to
enforce processes to protect patient information
through the use of passwords, limited accessibility,
and compliance with laws, regulations, and accept-
able standards. If a nurse attempts to obtain infor-
mation on a patient not under his or her care, the
institution may consider this a breach of security
and patient confidentiality. Many institutions have
strict policies in place that may result in a nurse
losing his or her position if an electronic record is
accessed when it is not necessary for the nurse’s job.
It is important to remember to always log off when
using a computerized system. This helps to prevent
security breaches.
The goal of computerized record-keeping is to
provide safe, quality care to patients. It allows for
tracking of quality controls. The use of BAR scan-
ning prior to administering medications or obtain-
table 6-1
Barriers to Effective Communication in Health Care
Low health literacy Lack of the skills needed to access and use health information
Cultural diversity Impedes the ability to access, understand, and utilize services and information.
Cultural competency of health-care
providers
Lack of the ability of health-care providers to identify and consider cultural practices
Communication skills of health-care
providers
Health-care providers lack the training needed for communicating with each other
(interprofessional communication)
Source: Adapted from Schwartz, Lowe, & Sinclair (2010). Communication in health care: Consideration and
strategies for successful consumer and team dialogue. Hypothesis, 8(1), 1–8.
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chapter 6 ■ Communicating With Others and Working With the Interprofessional Team 91
ing blood samples for laboratory testing maintains
quality and assists in ensuring patient safety.
Additional benefits of computerized systems for
health-care applications are listed in Box 6-1.
E-Mail
E-mail has become a communication standard.
Organizations use e-mail to communicate both
within (intranet) and outside (Internet) of their
systems. The same communication principles that
apply to traditional letter writing pertain to e-mail.
Using e-mail competently and effectively requires
good writing skills. Remember, when communicat-
ing by e-mail, you are not only making an impres-
sion but also leaving a written record (Shea, 2000).
The rules for using e-mail in the workplace are
somewhat different than for using e-mail among
friends. Much of the humor and wit found in per-
sonal e-mail is not appropriate for the work setting.
Emoticons are cute but not necessarily appropriate
in the work setting.
Professional e-mail may remain informal.
However, the message must be clear, concise, and
courteous. Avoid common text abbreviations such
as “LOL” or “BZ.” Think about what you need to
say before you write it. Then write it, read it, and
reread it. Once you are satisfied that the message is
appropriate, clear, and concise, send it.
Many executives read personal e-mail sent to
them, which means that it is often possible to
contact them directly. Many systems make it easy
to send e-mail to everyone at the health-care
institution. For this reason, it is important to
keep e-mail professional. Remember the “chain
of command”: always go through the proper
channels.
The fact that you have the capability to send
e-mail instantly to large groups of people does not
necessarily make sending it a good idea. Be careful
if you have access to an all-company mailing list. It
is easy to unintentionally send e-mail throughout
the system. Consider the following example:
A respiratory therapist and a department admin-
istrator at a large health-care institution were
engaged in a relationship. They started sending
each other personal notes through the company
e-mail system. One day, one of them acciden-
tally sent one of these notes to all the employees
at the health-care institution. Both employees
were terminated. The moral of this story is
simple: do not send anything by e-mail that you
would not want published on the front page of
a national newspaper or broadcasted on your
favorite radio station.
Although voice tone cannot be “heard” in e-mail,
the use of certain words and writing styles indicates
emotion. A rude tone in an e-mail message may
provoke extreme reactions. Follow the “rules of
netiquette” (Shea, 2000) when communicating
through e-mail. Some of these rules are listed in
Box 6-2.
Text Messaging
Text messaging has evolved as a non-voice cell
phone function among individuals. What started as
a simple informal method of communication has
evolved far beyond its initial intent. The average
number of texts sent and received daily per cell
phone user is growing rapidly. Texting as a brief,
informal method of electronic communication
between friends, close acquaintances, or automated
systems has become the rule more than the
exception.
• Increased hours for direct patient care
• Patient data accessible at bedside
• Improved accuracy and legibility of data
• Immediate availability of all data to all members of the
team
• Increased safety related to positive patient identification,
improved standardization, and improved quality
• Decreased medical errors
• Increased staff satisfaction
Adapted from Arnold, J., & Pearson, G. (eds.). (1992). Computer
applications in nursing education and practice. New York: National
League for Nursing.
box 6-1
Potential Benefits of Computer-
Based Patient Information Systems
1. If you were face-to-face, would you say this?
2. Follow the same rules of behavior online that you
follow when dealing with individuals personally.
3. Send information only to those individuals who need it.
4. Avoid flaming; that is, sending remarks intended to
cause a negative reaction.
5. Do not write in all capital letters; this suggests anger.
6. Respect other people’s privacy.
7. Do not abuse the power of your position.
8. Proofread your e-mail before sending it.
Adapted from Shea, V. (2000). Netiquette. San Rafael, CA: Albion.
box 6-2
Rules of Netiquette
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92 unit 2 ■ Working Within an Organization
Presently, there are not any texting “rules.” This
permits mobile phone users to express themselves
however they see fit. “Texters” frequently use short-
hand abbreviations during such exchanges to
replace longer, more commonly used phrases.
Although texting has evolved as a widely accepted,
even preferred, form of “talking,” messages may be
misinterpreted with the absence of voiced emotion
and body language.
Business consultants predict that texting will
evolve as an accepted form of electronic communi-
cation for certain occasions that require only simple
questions and answers. When texting colleagues or
departments, follow the same guidelines as you
would for e-mail (Ruggieri, 2012). Confidential
information should never be sent in a text message.
Reporting Patient Information
In today’s health-care system, delivery methods
involve multiple encounters and patient hand-offs
among numerous health-care practitioners who
have various levels of education and occupational
training. Patient information needs to be commu-
nicated effectively and efficiently to ensure that
critical information is relayed to each professional
responsible for care delivery (O’Daniel and Rosen-
stein, 2008). If health care professionals fail to com-
municate effectively, patient safety is at risk for
several reasons: (a) critical information may not be
given, (b) information may be misinterpreted,
(c) verbal or telephone orders may not be clear,
and (d) changes in status may be overlooked.
Medical errors easily occur given any one of these
situations.
Hand-Off Communications
The transmission of crucial information and the
accountability for care of the patient from one
health-care provider to another is a fundamental
component of communication in health care.
Nurses traditionally give one another a “report.”
The hand-off report, often referred to as the change
of shift report, has become the accepted method of
communicating patient care needs from one nurse
to another. However, with multiple providers
involved in patient care, other professionals in addi-
tion to nurses are included in the hand-off report.
In the report, pertinent information related
to events that occurred is given to the individu-
als responsible for providing continuity of care
(Box 6-3). Although historically the report has been
given face to face, there are newer ways to share
information. Many health-care institutions use au-
diotape and computer printouts as mechanisms for
sharing information. These mechanisms allow the
nurses and other providers from the previous shift
to complete their tasks and those assuming care to
make inquiries for clarification as necessary.
In 2009, the Joint Commission incorporated
“managing hand-off communications” in its
national patient safety goals (TJC, 2013). The
report should be organized, concise, and complete,
with relevant details. Not every unit uses the same
system for giving a hand-off report. The system is
easily modified according to the pattern of nursing
care delivery and the types of patients serviced. For
example, many intensive care units, because of their
small size and the more acute needs of their patients,
use walking rounds as a means for giving the report.
• Identify the patient, including the room and bed numbers.
• Include the patient diagnosis.
• Account for the presence of the patient on the unit. If the patient has left the unit for a diagnostic test, surgery, or just to
wander, it is important for the oncoming staff members to know the patient is off the unit.
• Provide the treatment plan that specifies the goals of treatment. Note the goals and the critical pathway steps either
achieved or in progress. Personalized approaches can be developed during this time and patient readiness for those
approaches evaluated. It is helpful to mention the patient’s primary care physician. Include new orders and medications
and treatments currently prescribed.
• Document patient responses to current treatments. Is the treatment plan working? Present evidence for or against this.
Include pertinent laboratory values as well as any negative reactions to medications or treatments. Note any comments
the patient has made regarding the hospitalization or treatment plan that the oncoming staff members need to address.
• Omit personal opinions and value judgments about patients as well as personal/confidential information not pertinent to
providing patient care. If you are using computerized information systems, make sure you know how to present the
material accurately and concisely.
box 6-3
Information for Change-of-Shift Report (Hand-Off)
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chapter 6 ■ Communicating With Others and Working With the Interprofessional Team 93
This system allows nurses and others involved in
patient care to discuss the current patient status and
to set goals for care for the next several hours.
Together, the nurses gather objective data as one
nurse ends a shift and another begins. This way,
there is no confusion as to the patient’s status at
shift change. This same system is often used in
emergency departments and labor and delivery
units. Larger patient care units may find the
“walking report” time-consuming and an ineffi-
cient use of resources.
It is helpful to take notes or create a worksheet
while listening to the report. Many institutions now
provide a computerized action plan to assist with
gathering accurate and concise information during
the hand-off report. A worksheet helps organize
the work for the day (Fig. 6.1). As specific tasks are
mentioned, the nurse assuming responsibility
makes a note of the activity in the appropriate time
slot. Patient status, medications, and treatments
should be documented. Any priority interventions
should also be identified at this time. Many institu-
tions are now using electronic tablets to assist
nurses and other health-care providers to organize
and track activities.
Any changes from the previous day are noted,
particularly when the nurse is familiar with the
patient. Recording changes counteracts the ten-
dency to remember what was done the day before
and repeat it, often without checking for new
orders. During the day, the worksheet acts as a
reminder of the tasks that have been completed and
of those that still need to be done.
Reporting skills improve with practice. When
presenting information in a hand-off report, certain
details must be included. Begin the report by iden-
tifying the patient, room number, age, gender, and
health-care provider. Also include the admitting as
well as current diagnoses. Address the expected
treatment plan and the patient’s responses to the
treatment. For example, if the patient has had mul-
tiple antibiotics and a reaction occurred, this infor-
mation must be relayed to the next nurse. Avoid
making value judgments and offering personal
opinions about the patient (Fig. 6.2).
Communicating With the
Health-Care Provider
The function of professional nurses in relation to
their patients’ health-care providers is to commu-
nicate changes in the patient’s condition, share
other pertinent information, discuss modifications
of the treatment plan, and clarify orders. This can
be stressful for a new graduate who still has some
role insecurity. Using good communication skills
and having the necessary information at hand are
helpful when discussing patient needs.
Before calling a health-care provider, make sure
that all the information needed is available. The
provider may want more clarification about the
situation. If calling to report a drop in a patient’s
blood pressure, be sure to have the list of the
patient’s medications, the last time the patient
received the medications, laboratory results, vital
signs, and blood pressure trends. Also be prepared
to provide a general assessment of the patient’s
present status.
There are times when a nurse calls a physician
or health-care provider and the health-care pro-
vider does not return the call. It is important to
document all health-care provider contacts in the
patient’s record. Many units keep calling logs. In
the log, enter the health-care provider’s name, the
date, the time, the reason for the call, and the time
the health-care provider returned the call. If the
provider does not return the call in a reasonable
amount of time, or patient safety is in jeopardy, the
nurse should follow chain of command to make
sure patient safety is maintained.
ISBARR
In response to the number of patients who die from
or confront a preventable adverse event during hos-
pitalization, health-care institutions have been
challenged to improve patient safety standards.
This challenge forced health-care institutions to
look at the causes of most sentinel events within
their environments. Originally known as SBAR
(Situation, Background, Assessment, and Recom-
mendation), the communication technique has
recently been updated to ISBARR or ISBAR.
ISBARR is an acronym for Introduction, Situation,
Background, Assessment, Recommendation, and
Read-back (Enlow, Shanks, Guhde, & Perkins,
2010; Haig, Sutton, & Whittingdon, 2006).
Whether referred to as SBAR or ISBARR, the
technique provides a framework for communi-
cating critical patient information in a systemized
and organized fashion. The ISBARR method
focuses on the immediate situation so that deci-
sions regarding patient care may be made quickly
and safely.
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94 unit 2 ■ Working Within an Organization
Name______________________ Room # ________ Allergies _____________________
0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800
Name______________________ Room # ________ Allergies _____________________
0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800
Name______________________ Room # ________ Allergies _____________________
0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800
Figure 6.1 Organization and time management schedule for patient care.
Although originally established by the U.S.
Navy as SBAR to accurately communicate critical
information, the technique was adapted by Kaiser-
Permanente as an “escalation tool” to be imple-
mented when a rapid change in patient status
occurs or is imminent. Both the Joint Commission
and the Institute for Health Care Improvement
have mandated that health-care institutions employ
a standardized reporting/hand-off system and
promote the use of the SBAR technique (Haig,
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chapter 6 ■ Communicating With Others and Working With the Interprofessional Team 95
Room # ________ Patient Name _______________ Diagnoses ___________________
Diet ___________ Activity _________________________________________________
1900 0100
2000 0200
2100 0300
2200 0400
2300 0500
2400 0600
Figure 6.2 Patient information report.
Sutton, & Whittingdon; www.rwjf.org, 2013; IHI,
2006; TJC, 2009). The use of the ISBARR format
helps to standardize a communication system to
effectively transmit needed information to provide
safe and effective patient care. Table 6-2 defines the
steps of the ISBARR communication model.
The implementation of ISBARR as a com-
munication technique has demonstrated success
in reducing adverse events and improving pati-
ent safety. It also allows nurses, health-care pro-
viders, and members of the interprofessional team
to communicate in a collegial and professional
manner.
Health-Care Provider Orders
Professional nurses are responsible for accepting,
transcribing, and implementing health-care pro-
vider orders. It is important to remember that
nurses may only receive orders from physicians,
dentists, podiatrists, and advanced practice regis-
tered nurses (APRNs) who are licensed and cre-
dentialed in the state in which they are working.
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96 unit 2 ■ Working Within an Organization
Orders written by medical students need to be
countersigned by a physician or APRN before
implementation.
The three main types of orders are written, tele-
phone, and faxed. Some health-care institutions are
looking into the possibility of receiving health-
care provider orders through e-mail. These orders
include the provider’s name, date, and time and
provide an electronic record of the order.
Written orders are dated and placed on the
appropriate institutional form. The health-care
provider gives telephone orders directly to the nurse
by telephone. Faxed orders come directly from the
health-care provider office and need to be initialed
by the provider. Telephone orders, e-mail orders,
and faxed orders also need to be signed when the
health-care provider comes to the nursing unit. It
is important to verify the institution’s policy on
telephone, e-mail, and faxed orders.
Many health-care institutions are moving to
maintaining the EMR and away from verbal orders
as the health-care provider is present and can enter
the order on the appropriate form in the patient’s
record. A telephone order needs to be written on
the appropriate institutional form, the time and
date noted, and the form signed as a telephone
order by the nurse.
When receiving a telephone order, repeat it back
to the physician for confirmation. If the health-care
provider is speaking too rapidly, ask him or her to
speak more slowly. Then repeat the information for
confirmation. If a faxed document is unclear, call
the health-care provider for clarification. Most
institutions require the health-care provider to
cosign the order within 24 hours.
Professionalism and a courteous attitude by all
parties are necessary to maintain collegial relation-
ships with physicians and other health-care profes-
sionals. One nurse explained their importance as
follows:
RN satisfaction simply is not about money. A major
factor is how well nurses feel supported in their
work. Do people listen to us—our managers, upper
management, human resources? Being able to com-
municate with each other—to be able to speak
directly with your peers, physicians, or managers in
a way that is nonconfrontational—is really impor-
tant to having good working relationships and to
providing good care. You need to have mutual
respect. (Quoted by Trossman, 2005, p. 1.)
This statement finds support in the IOM report
(2010) and research conducted by the American
Nurses Credentialing Center (ANCC), which
holds responsibility for MAGNET designation
(ANCC, 2012).
Teams
Teams and teamwork are everyday terms in today’s
organizations. Teams bring together the variety
of skills, perspectives, and talents that create an
table 6-2
ISBARR (Introduction, Situation, Background, Assessment, Recommendation,
Read-Back)
Elements Description Example
Introduction Identification of yourself, your role, and
location
Hello, my name is •••. I am the nurse at (location) for your
patient
Situation Brief description of the existing situation Critical laboratory value that needs to be addressed (critical
blood gas value, International Normalized Ratio [INR], etc.)
Background Medical, nursing, or family information
that is significant to the care and/or
patient condition
Patient admitted with a pulmonary embolus and on heparin
therapy, receiving oxygen at 4 L via nasal cannula; what
steps have been taken
Assessment Recent assessment data that indicate the
most current clinical state of the patient
Vital signs, results of laboratory values, lung sounds, mental
status, pulse oximetry results, electrocardiogram results
Recommendation Information for future interventions and/
or activities
Monitor patient
Change heparin dose
Repeat INR
Repeat computed tomography or ventilation- perfusion scan
Read-Back Repeat or re-state any new orders or
recommendations for clarity
Repeat the recommendations back to the HCP, or member of
the interprofessional health-care team Repeat the INR and
change the heparin dose to 1,500 units; repeat the VQ
scan and call with the results.
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chapter 6 ■ Communicating With Others and Working With the Interprofessional Team 97
effective work environment. Nursing is a “team
sport.” In other words, nurses bring a specific set of
skills and talents and need to work together with
other professionals to achieve a common goal. The
goal in this case is quality patient care. Health-care
providers understand that safe quality patient care
thrives in an environment that promotes interpro-
fessional teamwork and collaboration. Not all teams
are interprofessional teams, and it is important to
understand that a team does not necessarily infer
collaboration.
In 2004, the IOM revealed that issues surround-
ing nursing competency contributed in part to
ensuring patient safety. Some of the issues re-
volved around the lack of communication among
nurses and other members of the health-care team,
including medicine, pharmacy, and other support-
ive services. The Quality and Safety Education for
Nurses (QSEN) addressed these concerns and
looked at collaboration and teamwork as a way of
decreasing medical errors and promoting quality
care.
QSEN (2011) defined teamwork as the ability to
perform “effectively within nursing and interpro-
fessional teams, fostering open communication,
mutual respect, and shared decision-making to
achieve quality patient care” (http://qsen.org/
competencies/pre-licensure-ksas/#teamwork
_collaboration). Kalisch and Lee (2011) conducted
a study that looked at staffing, teamwork, and col-
laboration. The study supported the fact that team-
work contributes to safe quality care; however,
health-care institutions need to provide adequate
staffing to ensure collaboration and teamwork.
Health-care institutions that choose to apply for
MAGNET status must demonstrate how they
provide adequate staffing that promotes teamwork
and interprofessional collaboration.
Learning to Be a Team Player
When asking for assistance, nothing is more frus-
trating to hear than “Oh, he’s not my patient” or
“I have my own mess to deal with, I certainly
can’t help you.” A team player states, “I have not
seen that patient yet today, but let me help get
that information for you,” or “”How can I be of
assistance?”
Every team member brings value to the team
through personal strengths and specific skill sets.
To develop a strong team, members must treat each
other with dignity and respect. They also must
understand the role and scope of practice of each
discipline. It is important for each member to iden-
tify personal strengths, limitations, and competen-
cies in order to function as a contributing member
of the team.
Team players consistently treat other members
with courtesy and consideration. They demon-
strate commitment, understand the team’s goals,
and support other team members appropriately.
They care about the work and purpose of the team
and they contribute to its success. Team players
with commitment look beyond their own work-
load and provide support and assistance when and
where needed (Nelson & Economy, 2010). The
goal in the health-care setting is safe, quality patient
care.
Building a Working Team
Building a strong team takes time and talent.
Assuming that all the team members possess the
skills sets that are needed, how do you create an
efficient team? Brounstein (2002) identified 10
qualities of an effective team player (Box 6-4).
These qualities provide the foundation for a strong
professional team.
To build an effective team, first identify the team
players and focus on the strengths and weaknesses
of each. While building on the strengths, devise a
plan to assist team members in improving their
weaknesses. Second, make sure that the team
understands the goal and is committed to achieving
that outcome. In health care the primary goal is
safe, quality patient care. Third, act as a role model
and exhibit the expected behaviors. Fourth, reward
the team for accomplishments and achievements,
discuss setbacks, and together create an improve-
ment plan.
1. Demonstrates dependability
2. Communicates constructively
3. Engages in active listening
4. Actively participates
5. Shares information openly and willingly
6. Supports and offers assistance
7. Displays flexibility
8. Exhibits loyalty to the team
9. Acts as a problem solver
10. Treats others in a courteous and considerate manner
box 6-4
Ten Qualities of an Effective Team
Player
Adapted from Brounstein, M. (2002). Managing teams for dummies.
NY: John Wiley & Sons.
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98 unit 2 ■ Working Within an Organization
Interprofessional Collaboration
and the Interprofessional Team
Although building an interprofessional team seems
practical, it requires a commitment and collabora-
tion among members of all the disciplines (O’Daniel
& Rosenstein, 2008). The IOM (2010), the
National League for Nursing (NLN) (2012), the
American Association of Colleges of Nursing
(AACN) (2011), and the American Organization
of Nurse Executives (AONE) (2012) issued state-
ments supporting collaboration among all members
of the health-care team with the purpose of provid-
ing safe, effective care and achieving positive patient
outcomes. Research demonstrates that patient care
provided by integrated teams composed of health-
care professionals who understand each other’s
functions and goals results in better clinical out-
comes and greater patient satisfaction (Hale, 2011).
As simple as this concept seems, it takes an inte-
grated and dedicated approach to form a collabora-
tive interprofessional team.
Interprofessional Collaboration
The World Health Organization (WHO) (2010)
defines interprofessional collaboration as occurring
when “multiple health workers from different pro-
fessional backgrounds work together with patients,
families, caregivers, and communities to deliver the
highest quality care.” Collaboration differs from
cooperation. Cooperation means working with
someone in the sense of enabling: making them
more able to do something (typically by providing
information or resources they wouldn’t otherwise
have). Collaborating (from Latin laborare, to work)
requires working alongside someone to achieve
something (Martin, Ummenhofer, Manser, &
Spirig, 2010).
The fundamental difference between collabora-
tion and cooperation is the level of formality in
the relationships between agencies and/or stake-
holders. For many years members of other health-
care disciplines cooperated with each other. Nurses
and physicians cooperated with each other in
patient care delivery. However, inequalities existed
between the disciplines regarding shared expertise
and power (Robert Woods Johnson Foundation,
2013).
A true collaborative effort comprises the follow-
ing key components: sharing, partnership, interde-
pendency, and power (O’Brien, 2013). Collaboration
assumes that members share responsibility, values,
and resources. To engage in partnership, members
need to be honest and open with each other, dem-
onstrate mutual trust and respect, and value each
other’s contributions and perspectives. Members of
an interprofessional team are dependent on each
other and work with each other to achieve a
common goal. Finally, power is shared among the
members. The health professionals recognize their
own individual scope of practice and skill set, while
demonstrating an appreciation for the other
members’ capabilities and contributions. They also
share in the accountability for the delivery of
patient care. This shared effort among health-care
professionals helps to coordinate care and promote
patient safety.
Interprofessional Communication
Breakdowns in verbal and written communication
among health-care providers present a major
concern in the health-care delivery system. The
Joint Commission (www.tjc.org) attributes a high
percentage of sentinel events to poor communica-
tion among health-care providers (2009, 2013).
Communication is considered to be a core compe-
tency to promote interprofessional collaborative
practice. Using a common language among the pro-
fessions assists in understanding and overcoming
barriers to interprofessional communication.
The SBAR method was discussed earlier in the
chapter. A team-related method of communication,
Team STEPPS, developed by the Department of
Defense (DoD) and the Agency for Healthcare
Research and Quality (AHRQ), is another method.
The purpose of this teamwork system is to improve
collaboration and communication related to patient
safety (AHRQ, 2013). This method includes four
skills: leadership, situation monitoring, mutual
support, and communication. The program goals
focus on (a) creating highly effective medical teams
that optimize the use of information, people, and
resources to achieve the best clinical outcomes for
patients; (b) increasing team awareness and clarify-
ing team roles and responsibilities; (c) resolving
conflicts and improving information sharing; and
(d) eliminating barriers to quality and safety. The
program is composed of training modules available
to health-care institutions.
With the goal of collaboration among health-
care professionals, to promote continuity of care
and facilitate communication, many health-care
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chapter 6 ■ Communicating With Others and Working With the Interprofessional Team 99
institutions have created a position known as the
“nurse navigator.” The function of the navigator is
to coordinate patient care by guiding pati ents
through the diagnostic process, educating and sup-
porting them, integrating care with other members
of the interprofessional team, and assisting them
in making informed decisions (Brown, Cantril,
McMullen, Barkly, Dietz, Murphy, & Fabrey, 2012).
Nurses remain an integral part of the interpro-
fessional health-care team. Nurses usually have the
most contact with the patients and their families.
They often find themselves in the particularly
advantageous position to observe the patient’s
responses to treatments and report these back to
the interprofessional team. For example:
Mr. Richards, a 68-year-old man, was in a motor
vehicle accident and sustained a traumatic brain
injury. He had right-sided weakness and dysphagia.
The health-care provider requested evaluations and
treatment plans from speech pathology, physical
therapy, and social services. The speech pathologist
conducted a swallow study and determined that Mr.
Richards should receive pureed foods for the next 2
days. The RN assigned an LPN to feed Mr. Rich-
ards a pureed lunch. The LPN reported that although
Mr. Richards had done well the previous day, he
had diff iculty swallowing even pureed foods today.
The RN immediately notif ied the speech patholo-
gist, and a new treatment plan was developed.
Building an Interprofessional Team
Effective interprofessional teams include several
characteristics and focus on the needs of the patient
or client, not the individual contributions of the
team members. Each member understands the
characteristics of collaboration and demonstrates a
willingness to share, recognize the others’ expertise,
and participate in open communication. Members
of a team share information through verbal and
written communication in an interprofessional
team conference. The characteristics of an effec-
tive interprofessional health-care team are listed in
Box 6-5.
Interprofessional teams communicate by engag-
ing in conferences. The conference begins with the
presenter stating the patient’s name, age, and diag-
noses. Each team member then explains the goal of
his or her discipline, the interventions, and the
intended outcome. Effectiveness of treatment,
development of new interventions, and the setting
of new goals are discussed. All members contribute
and participate, demonstrating mutual respect and
valuing the expertise of the others. A method to
oversee the implementation of the plan is devised
in order to assess outcomes, and make adjustments
as needed. The nurse (or nurse navigator) is often
the individual who assumes the responsibility for
this oversight. The key to a successful interprofes-
sional conference is presenting information in a
clear, concise manner and ensuring input from
all disciplines and levels of care providers, from
nursing assistive personnel (NAP) to health-care
providers.
Conclusion
The responsibility for delivering and coordinating
patient care is an important part of the role of the
professional nurse. To accomplish this, nurses need
good communication skills. Being assertive without
being aggressive and interacting with others in a
professional manner enhance the relationships that
nurses develop with colleagues, health-care provid-
ers, and other members of the interprofessional
team.
A major focus of the national safety goals is
improved communication among health-care pro-
fessionals and the development of interprofes-
sional health-care teams. In an effort to improve
patient safety, health-care institutions have imple-
mented communication protocols referred to as
the SBAR method or Team STEPPS. SBAR sets
a specific procedure that reminds nurses how to
relay information quickly and effectively to the
patient’s health-care provider, which ultimately
leads to improved patient outcomes. Team STEPPS,
developed by the DoD, assists health-care institu-
1. Members provide care to a common group of
patients/clients.
2. Members develop common goals for patient/client
outcomes and work together to achieve the goals.
3. Members have roles and functions and understand
their roles and the roles of others.
4. The team develops a mechanism for sharing
information.
5. The team creates a system to supervise the
implementation of plans, evaluate outcomes, and make
adjustments based on the results.
box 6-5
Characteristics of Effective
Interprofessional Health-care Teams
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100 unit 2 ■ Working Within an Organization
tions in promoting patient safety through com-
munication and coordination of patient care.
Collaboration and teamwork encourage inter-
professional collegial relationships that promote
safe quality patient care. Key nursing organizations,
the IOM, QSEN, and MAGNET criteria address
the need for collaboration and teamwork. Nurses
act as the key players in ensuring interprofessional
communication and collaboration in patient care
delivery.
Finally, health-care institutions need to be com-
mitted to creating an environment that promotes
communication and team collaboration. This needs
to come from the top down and the bottom up to
create an organizational culture that promotes
patient safety. Nurses are in a unique position to act
as change agents within their organizations by
practicing safe, effective patient care, promoting
collegial communications, and committing them-
selves to interprofessional collaboration.
Study Questions
1. This is your first position as an RN, and you are working with an LPN who has been on the
unit for 20 years. On your first day she says to you, “The only difference between you and me is
the size of the paycheck.” Demonstrate how you would respond to this statement, using
assertive communication techniques.
2. A health-care provider orders “Potassium Chloride 20 milliequivalents IV over 20 minutes.”
You realize that this is a dangerous order. How would you approach the health-care provider?
3. A patient is admitted to the same-day surgical center for a breast biopsy. Her significant other,
who has just had an altercation with an admissions secretary about their insurance, accompanies
her. The patient is met by a nurse navigator who notes that the mammogram and blood work
are not in the electronic medical record. The patient’s significant other says, “What is wrong
with you people? Can’t you ever get anything straight? If you can’t get the insurance right, and
you can’t get the diagnostic tests right, how can we expect you to get the surgery right?” How
should the nurse navigator assist the patient and her significant other?
4. Your nurse manager asks you to develop an interprofessional team on the unit. This team is to
serve as a model for other nursing units. How would you start the process? What qualities
would you look for in the team members?
Case Study to Promote Critical Reasoning
Corel Jones is a new nursing assistive personnel (NAP) who has been assigned to your acute
rehabilitation unit. Corel is a hard worker; he comes in early and often stays late to finish his
work. However, Corel is gruff with the patients, especially with the male patients. If a patient is
reluctant to get out of bed, Corel often challenges him, saying, “Hey, let’s go. Don’t be such a
wimp. Move your big butt.” Today, you overheard Corel telling a female patient who said she did
not feel well, “You’re just a phony. You like being waited on, but that’s not why you’re here.” The
woman started to cry.
1. You are the newest staff nurse on this unit. How would you handle this situation? What would
happen if you ignored it?
2. If you decided to pursue the issue, with whom should you speak? What would you say?
3. What do you think is the reason Corel speaks to patients this way?
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chapter 6 ■ Communicating With Others and Working With the Interprofessional Team 101
References
Agency for Healthcare Research and Quality (AHRQ).
(2013). Team STEPPS. Retrieved September 25, 2013,
from http://teamstepps.ahrq.gov
American Association of Colleges of Nursing (AACN).
(2011). Core competencies for interprofessional
collaboration. Retrieved September 23, 2013, from
www.aacn.nche.edu/leading-initiatives/IPECReport
American Nurses Credentialing Center (ANCC). (2012).
MAGNET designated hospitals demonstrate lower
mortality rates. Retrieved from www.medscape.com/
viewarticle/773611
American Organization of Nurse Executives (AONE).
(2012). AONE guiding principles: AACN-AONE task
force on academic-practice partnerships. American
Organization of Nurse Executives.
Bello, J., Quinn, P., & Horrell, L. (2011). Maintaining
Patient Safety Through Innovation: An Electronic SBAR
Communication Tool. Computers Informatics and
Nursing, 29(9), 481–483.
Brounstein, M. (2002). Managing teams for dummies. NY:
John Wiley & Sons.
Brown, C.G., Cantril, C., McMullen, L., Barkely, D.L.,
Dietz, M., Murphy, C.M., & Fabrey, L.J. (2012).
Oncology nurse navigator role delineation study: An
oncology nursing society report. Clinical Journal of
Oncology Nursing, 16(6), 581–585.
Centers for Medicare and Medicaid Services (CMS).
(2013). Research, statistics data and systems. Retrieved
from www.cms.gov/Research-Statistics-Data-and
-Systems/Statistics-Trends-and-Reports/
MedicareMedicaidStatSupp/2010.html
Centers for Medicare and Medicaid Services (CMS).
(2013). Meaningful use. Retrieved from www.cms.gov/
apps/media/press/release.asp?Counter=4554&intNum
PerPage=10&checkDate=&checkKey=&srchType=1&num
Days=3500&sr.
Centers for Medicare and Medicaid Services (CMS).
(2013). EHR Incentive programs. Retrieved from
www.cms.gov/ cmsincentiveprograms
Department of Health and Human Services Office of
Minority Health. (2013). Retrieved from http://
minorityhealth.hhs.gov/templates/browse
.aspx?lvl=2&lvlID=11
Enlow, M., Shanks, L., Guhde, J., & Perkins, M. (2010).
Incorporating interprofessional communication Skills
(ISBARR) into an undergraduate nursing curriculum. Nurse
Educator, 35(4), 176–180.
Gabor, D. (1994). Speaking your mind in 101 difficult
situations. New York: Stonesong Press (Simon &
Schuster).
Gartee, R., & Beal, S. (2012). Electronic health records
and nursing. Boston, MA: Pearson.
Haig, K.M., Sutton, S., & Whittingdon, J. (2006). SBAR: A
shared mental model for improving communication
between clinicians. Journal on Quality and Patient
Safety, 32(3), 167–175.
Hale, J. F. (2011). The value and imperative for health
professions engaging in interprofessional learning.
Retrieved September 28, 2013, from www.umassmed
.edu/uploadedFiles/fmch/Community_Health/IPE%20
%20Update%20for%20Clerkship%20Booklet_hale2011
x
Institute for Healthcare Improvement. (2006). Using SBAR to
improve communication between caregivers. Retrieved
November 30, 2008, from www.ihi.org/IHI/
Programs/AudioAndWebPrograms/
WebACTIONUsingSBARtoImproveCommunication
.htm?TabId=7
Institute of Medicine (IOM), (2010). The future of nursing:
leading change, advancing health. Committee on the
Robert Wood Johnson Foundation Initiative on the Future
of Nursing at the Institute of Medicine; Institute of
Medicine. www.nap.edu/catalog/12956.html.
Institute of Medicine (IOM). (2012). Public health literacy.
Retrieved September 26, 2013, from www.iom.edu/~/
media/Files/Activity%20Files/PublicHealth/
HealthLiteracy/HealthLiteracyFactSheets_Feb6_2012
_Parker_JacobsonFinal1
Kalisch, B.J., & Lee, K.H. (2011). Nurse staffing levels and
teamwork: A cross-sectional study of seven patient care
units in acute care hospitals. Journal of Nursing
Scholarship, 43(1), 82–88.
Martin, J.S., Ummenhofer, W., Manser, T., & Spirig, R.
(2010). Interprofessional collaboration among nurses
and physicians: Making a difference in patient outcome.
Swiss Medical Weekly. May 4, 2010, 1–12. Retrieved
September 26, 2013, from www.snw.ch
National Patient Safety Foundation. (2012). Health literacy:
Statistics at a glance. Retrieved September 26, 2013,
from www.npsf.org/wpcontent/uploads/2011/12/
AskMe3_Stats_English
Nelson, B., & Economy, P. (2010). Managing for dummies
(3rd ed.). New York: John Wiley & Sons.
O’Brien, J. (2013). Interprofessional collaboration. AMN
Healthcare Education. Retrieved September 26, 2013,
from www.rn.com
O’Daniel, M., & Rosenstein, A. H. (2008). Professional
communication and team collaboration. In Hughes,
R.G., Patient Safety and Quality: An Evidence-Based
Handbook for Nurses. Retrieved September 26, 2013,
from www.ncbi.nlm.nih.gov/books/NBK2651
O’Malley, P.A. (2008). Profile of a professional. Nursing
Management, 39(6), 24–27.
Robert Woods Johnson Foundation. (2013). How to foster
interprofessional collaboration between physicians and
nurses? Robert Woods Johnson Foundation. January 9,
2013. Retrieved September 25, 2013, from www.sjcg
.net/departments/education/faq/aspx
Ruggieri, C. (2012). Is texting appropriate in business
communication? Washington University School of
Business. Retrieved February 28, 2013, from
managerialcommunication.wordpress.com
Schwartz, F., Lowe, M., & Sinclair, L. (2010).
Communication in health care: Consideration and
strategies for successful consumer and team dialogue.
Hypothesis, 8(1), 1–8.
Shea, V. (2000). Netiquette. San Rafael, CA: Albion.
The Joint Commission (TJC). (2013). Manual for Joint
Commission national quality measures (v2013A1).
Retrieved February 28, 2013, from https://manual
.jointcommission.org/releases/TJC2013A/
Trossman, S. (2005). Who you work with matters. American
Nurse, 37:4, 1, 8. American Nurses Association.
Wood, J.T. (2010). The interpersonal imperative. In
Interpersonal Communication: Everyday encounters (6th
ed.). Boston, MA: Cengage Learning.
World Health Organization (WHO). (2010). Framework for
Action on Interprofessional Education & Collaborative
Practice. Retrieved September 26, 2013, from http://
whqlibdoc.who.int/hq/2010/WHO_HRH_HPN_10.3
_eng
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103
chapter 7
Delegation and Prioritization of Client Care
OBJECTIVES
After reading this chapter, the student should be able to:
■ Define the term delegation.
■ Define the term prioritization.
■ Differentiate between delegation and prioritization.
■ Define the term nursing assistive personnel.
■ Discuss the legal implications of making assignments to
other health-care personnel.
■ Discuss barriers to successful delegation.
■ Make appropriate assignments to team members.
■ Apply priority setting guidelines to patient care.
OUTLINE
Introduction to Delegation
Definition of Delegation
Assignments and Delegation
Supervision
The Nursing Process and Delegation
The Need for Delegation
Safe Delegation
Criteria for Delegation
Task-Related Concerns
Abilities
Priorities
Efficiency
Appropriateness
Relationship-Oriented Concerns
Fairness
Learning Opportunities
Health
Compatibility
Staff Preferences
Barriers to Delegation
Experience Issues
Licensure Issues
Legal Issues and Delegation
Quality-of-Care Issues
Assigning Work to Others
Prioritization
Coordinating Assignments
Models of Care Delivery
Functional Nursing
Team Nursing
Total Patient Care
Primary Nursing
Conclusion
Ora, a new graduate, just completed her orientation.
She works from 7 p.m. to 7 a.m. on a busy, moni-
tored neuroscience unit. The client census is 48,
making this a full unit. Although there is an associ-
ate nurse manager for the shift, Ora acts as the
charge nurse. Her responsibilities include receiving
and confirming orders, contacting physicians with
any information or requests, accessing laboratory
reports from the computer, reviewing them and
giving them to the appropriate staff members, check-
ing any new medication orders and placing them in
the appropriate medication administration records,
relieving the monitor technician for dinner and
breaks, and assigning staff to dinner and breaks.
When Ora arrives to work, she discovers that one
registered nurse (RN) called in sick. Her staff
tonight consists of two RNs and three nursing assis-
tive personnel (NAP). To complicate matters, the
institution just rolled out a new computerized acu-
ity-based staff ing model last week, and she needs to
enter the complexity level of care for each client. She
panics and wants to refuse to take report. After a
discussion with the charge nurse from the previous
shift, she realizes that refusing to take report is not
an option. She sits down to evaluate the acuity of
the clients and the capabilities of her staff.
Introduction to Delegation
Delegation is not a new concept. In her Notes on
Nursing, Florence Nightingale (1859) clearly stated:
“Don’t imagine that if you, who are in charge,
don’t look to all these things yourself, those under
you will be more careful than you are . . . .” She
continued by directing, “But then again to look to
all these things yourself does not mean to do them
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104 unit 2 ■ Working Within an Organization
yourself. If you do it, it is by so much the better
certainly than if it were not done at all. But can you
not insure that it is done when not done by your-
self ? Can you insure that it is not undone when
your back is turned? This is what being in charge
means. And a very important meaning it is, too.
The former only implies that just what you can
do with your own hands is done. The latter that
what ought to be done is always done. Head in
charge must see to house hygiene, not do it herself ”
(p. 17).
Today, nurses find that there is more nursing
needed than nurses available to deliver the care.
Changes in demographics, improved life expec-
tancy, and newer, more complex therapies continue
to generate an increased demand for nursing care.
Changes in the health-care law compound this
need, requiring nurses to learn how to work effec-
tively with other members of the health-care deliv-
ery team, particularly nursing assistive personnel.
Knowing how and when to delegate are critical
skills for nurses entering the profession today and
in the future.
Definition of Delegation
In 2005, the American Nurses Association (ANA)
and the National Council of State Boards of
Nursing (NCSBN) approved papers regarding del-
egation in nursing practice (NCSBN, 2006). Previ-
ously the ANA (1996) defined delegation as the
reassigning of responsibility for the performance of
a job from one person to another. The NCSBN
describes delegation as the transferring of authority.
Both organizations agree that this means the reg-
istered nurse (RN) has the ability to request another
person to do something that this individual may
not usually be permitted to do. However, registered
nurses maintain accountability for supervising
those to whom tasks are delegated (ANA, 2005).
Nightingale referred to this delegation responsibil-
ity when she implied that the “head in charge” does
not necessarily carry out the task but still sees that
it is completed.
Assignments and Delegation
Making or giving an assignment is not the same as
delegation. In an assignment, power is not trans-
ferred (the directive to do something not necessar-
ily described as part of the job, does not occur).
Both the NCSBN and the ANA define an assign-
ment as the allocation of duties that each staff
member is responsible for during a specific work
period (2006). Assignments relate to situations
where an RN directs another individual to do
something that the person is already authorized to
do. For example, the RN assigns the NAP the
responsibility of taking vital signs on three patients.
The NAP is already authorized to take vital signs.
However, if the RN directed the NAP to check the
amount of drainage on a fresh postoperative
abdominal dressing, this would be considered del-
egation because the RN retains responsibility for
this action. Matching the skill set of the appropri-
ately educated health-care personnel with the needs
of the client and family defines the difference
between delegation and assignment (Weydt, 2010).
The individual state nurse practice acts define
the legal boundaries for professional nursing prac-
tice (www.ncsbn.org). Individual nursing organiza-
tions also set standards of practice for their
specialties that fall within the guidelines of the
nurse practice acts. Nurses need to understand the
guidelines and provisions of their state’s nurse prac-
tice acts regarding delegation of patient care
(Cipriano, 2010). However, according to the ANA,
specific overlying principles remain firm regarding
delegation. These include the following:
■ The nursing profession delineates the scope of
nursing practice.
■ The nursing profession identifies and
supervises the necessary education, training,
and use of ancillary roles concerned with the
delivery of direct client care.
■ The RN assumes responsibility and
accountability for the provision of nursing care
and expertise.
■ The RN directs care and determines the
appropriate utilization of any ancillary
personnel involved in providing direct client
care.
■ The RN accepts assistance from ancillary
nursing personnel in delivering nursing care
for the client (ANA, 2005, p. 6).
Nurse-related principles are also designated by the
ANA. These are important when considering what
tasks may be delegated and to whom. These prin-
ciples are:
■ The RN has the duty to be accountable for
personal actions related to the nursing process.
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chapter 7 ■ Delegation and Prioritization of Client Care 105
■ The RN considers the knowledge and skills of
any ancillary personnel to whom aspects of
care are delegated.
■ The decision to delegate or assign is based
on the RN’s judgment regarding the following:
the condition of the patient; the competence
of the members of the nursing team; and the
amount of supervision that will be required of
the RN if a task is delegated.
■ The RN uses critical thinking and professional
judgment when following the Five Rights of
Delegation delineated by the National Council
of State Boards of Nursing (NCSBN) (Box 7-1).
■ The RN recognizes that a relational aspect
exists between delegation and communication.
Communication needs to be culturally
appropriate, and the individual receiving the
communication should be treated with respect.
■ Chief nursing officers are responsible for
creating systems to assess, monitor, verify, and
communicate continuous competence
requirements in areas related to delegation.
■ RNs monitor organizational policies,
procedures, and job descriptions to ensure they
are in compliance with the nurse practice act,
consulting with the state board of nursing as
needed (ANA, 2005, p. 6).
Delegation may be direct or indirect. Direct del-
egation is usually “verbal direction by the RN del-
egator regarding an activity or task in a specific
nursing care situation” (ANA, 1996, p. 15). In this
case, the RN decides which staff member is capable
of performing the specific task or activity. Indirect
delegation is “an approved listing of activities or
tasks that have been established in policies and
procedures of the health care institution or facility”
(ANA, 1996, p. 15).
Permitted tasks vary from institution to institu-
tion. For example, a certified nursing assistant
(CNA) performs specific activities designated by
the job description approved by the particular
health-care institution. Although the institution
delineates tasks and activities, this does not mean
that the RN cannot decide to assign other person-
nel in specific situations. Take the following
example:
Ms. Ross was admitted to the neurological unit
from the neuroscience intensive care unit. She suf-
fered a right hemisphere intracerebral bleed 2 weeks
ago and has a left hemiplegia. She has diff iculty
with swallowing and receives tube feedings through
a percutaneous endoscopic gastrostomy (PEG) tube;
however, she has been advanced to a pureed diet. She
needs assistance with personal care, toileting, and
feeding. A physical therapist comes twice a day to get
her up for gait training; otherwise, the primary
health-care provider wants Ms. Ross in a chair as
much as possible.
Assessing this situation, the RN might consider
assigning a licensed practical nurse (LPN) to this
client. The swallowing problems place the client at
risk for aspiration, which means that feeding may
present a problem. Based on education and skill
level, the LPN is capable of managing the PEG
tube feeding. While assisting with bath ing, the
LPN can perform range-of-motion exercises to all
the client’s extremities and assess her skin for
breakdown. The LPN also knows the appro priate
way to assist the client in transferring from the
bed to the chair (Zimmerman and Schultz, 2013).
Supervision
The term supervisor implies that an individual
holds authority over others (National Labor Rela-
tions Act [NLRA], 1935). While nurses supervise
others on a daily basis, they do not necessarily hold
“authority” over those they supervise. Therefore, it
is important to differentiate between supervision
and delegation (Matthews, 2010). Supervision is
more direct and requires directly overseeing the
work or performance of others. Supervision includes
checking with individuals throughout the day to see
what activities they completed and what they may
still need to finish. When one RN works with
another, then supervision is not needed. This is a
collaborative relationship and includes consulting
and giving advice when needed.
The following gives an example of supervision:
A NAP has been assigned to take all the vital signs
on the unit and give the morning baths to eight
1. Right task
2. Right circumstances
3. Right person
4. Right direction/communication
5. Right supervision/evaluation
box 7-1
The Five Rights of Delegation
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106 unit 2 ■ Working Within an Organization
patients. Three hours into the morning, the NAP is
far behind in the assignment. At this point, it is
important that the RN discover the reason the NAP
has not been able to complete the assignment.
Perhaps one of the clients required more care than
expected, or the NAP needed to complete an errand
off the unit. Reevaluation of the assignment may be
necessary.
Individuals who supervise others also delegate
tasks and activities. Chief nursing officers often
delegate tasks to associate directors. This may
include record reviews, unit reports, or client acu-
ities. Certain administrative tasks, such as staff
scheduling, may be delegated to another staff
member, such as an associate manager. The delega-
tor remains accountable for ensuring the activities
are completed.
Supervision sometimes entails more direct
evaluation of performance, such as performance
evaluations and discussions regarding individual
interactions with clients and other staff members.
Regardless of where you work, you cannot
assume that only those in the higher levels of the
organization delegate work to other people. You,
too, will be responsible at times for delegating some
of your work to other nurses, to technical personnel,
or to other members of the interprofessional team.
Decisions associated with this responsibility often
cause some difficulty for new nurses. Knowing
each person’s capabilities and job description can
help you decide which personnel can assist with a
task.
The Nursing Process
and Delegation
Before deciding who should care for a particular
client, the nurse needs to assess each client’s care
requirements, set client-specific goals, and match
the skills of the person assigned with the tasks that
need to be accomplished (assessment). Thinking this
through before delegating helps prevent problems
later (plan). Next, the nurse assigns the tasks to the
appropriate person (implementation). The nurse
must then oversee the care and determine whe-
ther client care needs have been met (evaluation)
(Zimmerman and Schultz, 2013). It is also impor-
tant for the nurse to allow time for feedback during
the day. This enables all personnel to see what
has been accomplished and what still needs to be
done.
Often, the nurse must first coordinate care for
groups of clients before being able to delegate tasks
to other personnel. The nurse also needs to consider
his or her own responsibilities. This includes com-
municating clearly, assisting other staff members
with setting priorities, clarifying instructions, and
reassessing the situation.
The Need for Delegation
The 1990s brought rapid change to the health-care
environment. These changes, including shorter
hospital stays, increased patient acuity, and the
intensification of the nursing shortage, have con-
tinued into the 21st century, requiring institutions
to hire other personnel to assist nurses with client
care (McHugh, Kelly, Smith, Wu, Vanak, & Aiken,
2013).
Based on the studies by McHugh et al. (2013)
and the IOM (2001), it seems that registered nurses
need to provide all care needs to ensure safety and
quality in this complex and demanding health-care
environment. While a lofty idea, this system of
health-care delivery would be economically pro-
hibitive. For this reason, health-care institutions
often use nursing assistive personnel (NAP) to
perform certain patient care tasks.
As the nursing shortage becomes more critical,
there is a greater need for institutions to recruit
the services of NAPs (ANA, 2002). A survey
conducted by the American Hospital Associa-
tion (AHA) revealed that 97% of hospitals cur-
rently employ some type of NAP (Spetz, Donaldson,
Aydin, & Brown, 2008). Because a high percent-
age of institutions employ these personnel, many
nurses believe they know how to work with
and safely delegate tasks to them. This is not
the case. Therefore, many nursing organizations,
such as the American Association of Critical Care
Nurses (AACN) (2010), the Society of Gastro-
enterology Nurses (SGNA) (2009), and the Asso-
ciation for Women’s Health, Obstetrics and
Neonatal Nurses (AWHONN) (2010), have devel-
oped definitions for NAP and criteria regarding
their responsibilities. The ANA defines NAP as
follows:
Unlicensed assistive personnel/Nursing assistive
personnel are individuals who are trained to func-
tion in an assistive role to the registered nurse in the
provision of patient/client care activities as dele-
gated by and under the supervision of the registered
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chapter 7 ■ Delegation and Prioritization of Client Care 107
professional nurse. Although some of these people
may be certif ied (e.g., certif ied nursing assistant
[CNA]), it is important to remember that certif ica-
tion differs from licensure. When a task is delegated
to an unlicensed person, the professional nurse
remains personally responsible for the outcomes of
these activities (ANA, 2005).
As work on the unlicensed assistive personnel/
nursing assistive personnel (UAP/NAP) issue is
ongoing, the ANA updated its position statements
in 2012 to define direct and indirect patient care
activities that may be performed by UAP/NAP.
Included in these updates are specific definitions
regarding UAP/NAP and technicians and accept-
able tasks (www.nursingworld.org).
Use of the RN to provide all the care a client
needs may not be the most efficient or cost-
effective use of professional time. More hospitals
are moving away from hiring LPNs and utiliz-
ing all RN staffing with UAP/NAP. In these
facilities, the nursing focus is directed at diagnos-
ing client care needs and carrying out complex
interventions.
The ANA cautions against delegating nursing
activities that include the foundation of the nursing
process and that require specialized knowledge,
judgment, or skill (ANA, 1996, 2002, 2005). Non-
nursing functions, such as performing clerical or
receptionist duties, taking trips or doing errands off
the unit, cleaning floors, making beds, collecting
trays, and ordering supplies, should not be carried
out by the highest paid and most educated member
of the team. These tasks are easily delegated to
other personnel.
Safe Delegation
In 1990 the NCSBN adopted a definition of dele-
gation, stating that delegation is “transferring to a
competent individual the authority to perform a
selected nursing task in a selected situation” (p. 1).
In its publication Issues (1995), the NCSBN again
presented this definition. Likewise, the ANA Code
for Nurses (1985) stated, “The nurse exercises
informed judgment and uses individual compe-
tence and qualifications as criteria in seeking con-
sultation, accepting responsibilities, and delegating
nursing activities to others” (p. 1). In 2005, the
ANA defined delegation as “the transfer of respon-
sibility for the performance of an activity from one
individual to another while retaining accountability
for the outcome” (p. 4). To delegate tasks safely,
nurses must delegate appropriately and supervise
adequately.
In 1997 the NCSBN developed a Delegation
Decision-Making Grid (www.ncsbn.org). This grid
is a tool to help nurses delegate appropriately. It
provides a scoring instrument for seven categories
that the nurse should consider when making del-
egation decisions. The categories for the grid are
listed in Box 7-2.
Scoring the components helps the nurse evalu-
ate the situations, the client needs, and the health-
care personnel available to meet the needs. A low
score on the grid indicates that the activity may be
safely delegated to personnel other than the RN,
and a high score indicates that delegation may not
be advisable. Figure 7.1 shows the Delegation
Decision-Making Grid. The grid is also available
on the NCSBN Web site at ncsbn.com.
Nurses who delegate tasks to UAP/NAP should
evaluate the activities being considered for delega-
tion (Keeney, Hasson, McKenna, & Gillen, 2005).
The American Association of Critical Care Nurses
(AACN) (1990; 2010) recommended considering
five factors, which are listed in Box 7-3, in making
a decision to delegate.
1. Level of client acuity
2. Level of unlicensed assistive personnel capability
3. Level of licensed nurse capability
4. Possibility for injury
5. Number of times the skill has been performed by the
unlicensed assistive personnel
6. Level of decision making needed for the activity
7. Client’s ability for self-care
Adapted from the National Council of State Boards of Nursing.
Delegation Decision-Making Grid. National State Boards of Nursing,
Inc., 1997 (ncsbn.org).
box 7-2
Seven Components of the
Delegation Decision-Making Grid
1. Potential for harm to the patient
2. Complexity of the nursing activity
3. Extent of problem solving and innovation required
4. Predictability of outcome
5. Extent of interaction
Adapted from American Association of Critical Care Nurses (AACN).
(1990, 2010). Delegation of Nursing and Non-Nursing Activities in
Critical Care: A Framework for Decision-Making. Irvine, CA: AACN.
box 7-3
Five Factors for Determining
If Client Care Activity Should
Be Delegated
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108 unit 2 ■ Working Within an Organization
Elements for
Review
Client
A
Client
B
Client
C
Client
D
Activity/task
Level of Client
Stability
Level of
NAP
Competence
Level of
Licensed
Nurse
Competence
Potential for
Harm
Frequency
Level of
Decision
Making
Ability for
Self-Care
Describe activity/task:
Score the client’s level of stability:
0. Client condition is chronic/stable/predictable
1. Client condition has minimal potential for change
2. Client condition has moderate potential for change
3. Client condition is unstable/acute/strong potential for change
Score the NAP competence in completing delegated nursing
care activities in the defined client population:
0. NAP – expert in activities to be delegated, in defined population
1. NAP – experienced in activities to be delegated, in defined
population
2. NAP – experienced in activities, but not in defined population
3. NAP – novice in performing activities and in defined population
Score the licensed nurse’s competence in relation to both
knowledge of providing nursing care to a defined population
and competence in implementation of the delegation process:
0. Expert in the knowledge of nursing needs/activities of defined
client population and expert in the delegation process
1. Either expert in knowledge of needs/activities of defined client
population and competent in delegation or experienced in the
needs/activities of defined client population and expert in the
delegation process
2. Experienced in the knowledge of needs/activities of defined
client population and competent in the delegation process
3. Either experienced in the knowledge of needs/activities of
defined client population or competent in the delegation
process
4. Novice in knowledge of defined population and novice in
delegation
Score the potential level of risk the nursing care activity has
for the client (risk is probability of suffering harm):
0. None
1. Low
2. Medium
3. High
Score based on how often the NAP has performed the specific
nursing care activity:
0. Performed at least daily
1. Performed at least weekly
2. Performed at least monthly
3. Performed less than monthly
4. Never performed
Score the decision making needed, related to the specific
nursing care activity, client (both cognitive and physical
status), and client situation:
0. Does not require decision making
1. Minimal level of decision making
2. Moderate level of decision making
3. High level of decision making
Score the client’s level of assistance needed for self-care
activities:
0. No assistance
1. Limited assistance
2. Extensive assistance
3. Total care or constant attendance
Total Score
Figure 7.1 Delegation decision-making grid.
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chapter 7 ■ Delegation and Prioritization of Client Care 109
It is the responsibility of the RN to be well
acquainted with the state’s nurse practice act and
regulations issued by the state board of nursing
regarding UAP/NAP (ANA, 2005). State laws and
regulations supersede any publications or opinions
set forth by professional organizations. As stated
earlier, the NCSBN provides criteria to assist nurses
with delegation.
LPNs are trained to perform specific tasks,
such as basic medication administration, dressing
changes, and personal hygiene tasks. In some states,
the LPN, with additional training, may start and
monitor intravenous (IV) infusions and administer
certain medications.
Criteria for Delegation
The purpose of delegation is not to assign tasks to
others that you do not want to do yourself. When
you delegate to others effectively, the result is you
have more time to perform the tasks that only a
professional nurse is permitted to do.
In delegating, the nurse must consider both the
ability of the person to whom the task is delegated
and the fairness of the task to the individual and
the team (Whitehead, Weiss, & Tappen, 2010). In
other words, both the task aspects of delegation (Is
this a complex task? Is it a professional responsibil-
ity? Can this person do it safely?) and the inter-
personal aspects (Does the person have time to do
this? Is the work evenly distributed?) must be
considered.
The ANA (2005) has specified tasks that RNs
may not delegate because they are specific to the
discipline of professional nursing. These activities
include initial nursing and follow-up assessments if
nursing judgment is indicated (Zimmerman &
Schultz, 2013):
■ Decisions and judgments about client
outcomes
■ Determination and approval of a client plan of
care
■ Interventions that require professional nursing
knowledge, decisions, or skills
■ Decisions and judgments necessary for the
evaluation of client care
Task-Related Concerns
The primary task-related concern in delegating
work is whether the person assigned to do the task
has the ability to complete it. Team priorities and
efficiency are also important considerations.
Abilities
To make appropriate assignments, the nurse needs
to know the knowledge and skill level, legal defini-
tions, role expectations, and job description for each
member of the team. It is equally important to be
aware of the different skill levels of caregivers
within each discipline because ability differs with
each level of education. Additionally, individuals
within each level of skill possess their own strengths
and weaknesses. Prior assessment of the strengths
of each member of the team will assist in providing
safe and efficient care to clients. Figure 7.2 outlines
the skills of various health-care personnel.
People should not be assigned a task that they
do not have the skills or knowledge to perform,
regardless of their professional level. People are
LPN Skills
Vital signs
Some IV medication
(depending on state
Nurse Practice Act
and institution)
Physical care
Interprofessional
Personnel
Patient Care Needs
PT
OT
Nutrition
Speech
NAP
Feeding
Hygiene
Physical care
RN Skills
Assessment
IV medications
Blood administration
Planning care
Physician orders
Teaching
Figure 7.2 Diagram of delegation decision-making grid.
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110 unit 2 ■ Working Within an Organization
often reluctant to admit they cannot do something.
Instead of seeking help or saying they are not com-
fortable with a task, they may avoid doing it, delay
starting it, do only part of it, or even bluff their way
through it, a risky choice in health care.
Regardless of the length of time individuals have
been in a position, employees need orientation
when assigned a new task. Those who seek assis-
tance and advice are showing concern for the team
and the welfare of their clients. Requests for assis-
tance or additional explanations should not be
ignored, and the person should be praised, not criti-
cized, for seeking guidance (Whitehead, Weiss, &
Tappen, 2010).
Priorities
The work of a busy unit rarely ends up going as
expected. Dealing with sick people, their families,
physicians, and other team members all at the same
time is a difficult task. Setting priorities for the day
should be based on client needs, team needs, and
organizational and community demands. The
values of each may be very different, even opposed.
These differences should be discussed with team
members so that decisions can be made based on
team priorities.
One way to determine patient priorities is to
base decisions on Maslow’s hierarchy of needs.
Maslow’s hierarchy is frequently used in nursing to
provide a framework for prioritizing care to meet
client needs. The basic physiological needs come
first because they are necessary for survival. For
example, oxygen and medication administration, IV
fluids, and enteral feedings are included in this
group.
Identifying priorities and deciding the needs to
be met first help in organizing care and in deciding
which other team members can meet client needs.
For example, nursing assistants can meet many
hygiene needs, allowing licensed personnel to
administer medications and enteral feedings in a
timely manner.
Eff iciency
In an efficient work environment, all members of
the team know their jobs and responsibilities and
work together like gears in a well-built clock. They
mesh together and keep perfect time.
The current health-care delivery environment
demands efficient, cost-effective care. Delegat-
ing appropriately can increase efficiency and save
money. Likewise, incorrect delegation can decrease
efficiency and cost money. When delegating tasks
to individuals who cannot perform the job, the RN
must often go back to perform the task.
Although institutions often need to “float” staff
to other units, maintaining continuity, if at all pos-
sible, is important. Keeping the same staff members
on the unit all the time, for example, allows them
to develop familiarity with the physical setting and
routines of the unit as well as the types of clients
the unit services. Time is lost when staff mem-
bers are reassigned frequently to different units.
Although physical layouts may be the same, client
needs, unit routines, use of space, and availability of
supplies are often different. Time spent to orient
reassigned staff members takes time away from
delivery of client care. However, when staff mem-
bers are reassigned, it is important for them to
indicate their skill level and comfort in the new
setting. It is just as important for the staff mem-
bers who are familiar with the setting to identify
the strengths of the reassigned person and build
on them.
Appropriateness
Appropriateness is another task-related concern.
Nothing can be more counterproductive than, for
example, floating a coronary care nurse to labor and
delivery. More time will be spent teaching the nec-
essary skills than providing safe mother-baby care.
Assigning an educated, licensed staff member to
perform non-nursing functions to protect safety is
also poor use of personnel.
Relationship-Oriented Concerns
Relationship-oriented concerns include fairness,
learning opportunities, health concerns, compati-
bility, and staff preferences.
Fairness
Fairness requires the workload to be distributed
evenly in terms of both the physical requirements
and the emotional investment in providing health
care. The nurse who is caring for a dying client may
have less physical work to do than another team
member, but in terms of emotional care to the
client and family, he or she may be doing double
the work of another staff member.
Fairness also means considering equally all
requests for special consideration. The quickest way
to alienate members of a team is to be unfair. It is
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chapter 7 ■ Delegation and Prioritization of Client Care 111
important to discuss with team members any deci-
sions that have been made that may appear unfair
to any one of them. Allow the team members to
participate in making decisions regarding assign-
ments. Their participation will decrease resentment
and increase cooperation. In some health-care
institutions, team members make such decisions as
a group.
Learning Opportunities
Including assignments that stimulate motivation,
learning, and assisting team members to learn new
tasks and take on new challenges is part of the role
of the RN.
Health
Some aspects of caregiving jobs are more stressful
than others. Rotating team members through the
more difficult jobs may decrease stress and allow
empathy to increase among the members. Special
health needs, such as family emergencies or special
physical problems of team members, also need to
be addressed. If some team members have difficulty
accepting the needs of others, the situation should
be discussed with the team, bearing in mind the
employee’s right to privacy when discussing sensi-
tive issues.
Compatibility
No matter how hard you may strive to get your
team to work together, it just may not happen.
Some people work together better than others.
Helping people develop better working relation-
ships is part of team building. Creating opportuni-
ties for people to share and learn from each other
increases the overall effectiveness of the team.
As the leader, you may be forced to intervene in
team member disputes. Many individuals find it
difficult to work with others they do not like per-
sonally. It sometimes becomes necessary to explain
that liking another person is a plus but not a neces-
sity in the work setting and that personal problems
have no place in the work environment. For
example:
Laura had been a labor and delivery room supervi-
sor in a large metropolitan hospital for 5 years before
she moved to another city. Because a position similar
to the one she left was not available, she became a
staff nurse at a small local hospital. The hospital had
just opened its new birthing center. The f irst day on
the job went well. The other staff members seemed
cordial. As the weeks went by, however, Laura
began to have problems getting other staff to help
her. No one would offer to relieve her for meals or a
break. She noticed that certain groups of staff
members always went to lunch together but that she
was never invited to join them. She attempted to
speak to some of the more approachable coworkers,
but she did not get much information. Disturbed
by the situation, Laura went to the nurse manager.
The nurse manager listened quietly while Laura
related her experiences. She then asked Laura to
think about the last staff meeting. Laura realized
that she had alienated the staff during the meeting
because she had said repeatedly that in “her hospital”
things were done in a particular way. Laura also
realized that, instead of asking for help, she was in
the habit of demanding it. Laura and the nurse
manager discussed the diff iculties of her changing
positions, moving to a new place, and trying to
develop both professional and social ties. Together,
they came up with several solutions to Laura’s
problem.
Staff Preferences
Considering the preferences of individual team
members is important but should not supersede
other criteria for delegating responsibly. Allowing
team members to always select what they want to
do may cause the less assertive members’ needs to
be unmet.
It is important to explain the rationale for deci-
sions made regarding delegation so that all team
members may understand the needs of the unit or
organization. Box 7-4 outlines basic rights for
Professionals in the workplace are entitled to:
• Respect from other members of the interprofessional
health-care team
• A work assignment that matches skills and education
and does not exceed that of other members with the
same education and skills set
• Wages commensurate with the job
• Autonomy in setting work priorities
• Ability to speak out for self and others
• A healthy work environment
• Accountability for his/her own behaviors
• Act in the best interest of the client
• Be human
Adapted from ANA Resolutions: Workplace Abuse (2006).
box 7-4
Basic Entitlements of Nurses in
the Workplace
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112 unit 2 ■ Working Within an Organization
professional health-care team members. Although
written originally for women, the concepts are ap-
plicable to all professional health-care providers.
Barriers to Delegation
Many nurses, particularly new ones, have difficulty
delegating. The reasons for this include experience
issues, licensure issues, legal issues, and quality-of-
care issues.
Experience Issues
Many nurses working today graduated during the
1980s, when primary care was the major delivery
system. These nurses lacked the education and skill
needed for delegation. Nurses educated in the
1970s and before worked in settings with LPNs
and nursing assistants, where they routinely dele-
gated tasks. However, client acuity was lower and
the care less complex. More expert nurses have
considerable delegation experience and can be a
resource for younger nurses.
The added responsibility of delegation creates
some discomfort for nurses. Many believe they are
unprepared to assume this responsibility, especially
in deciding the competency of another person. To
decrease this discomfort, nurses need to participate
in establishing guidelines for NAP within their
institution. The ANA Position Statements on
Nursing Assistive Personnel/Unlicensed Assistive
Personnel address this. Table 7-1 lists the direct and
indirect client care activities that may be performed
by NAP.
Licensure Issues
Although the current health-care environment
requires nurses to delegate, many nurses voice
concerns about the personal risk regarding their
licensure if they delegate inappropriately. The
courts have usually ruled that nurses are not liable
for the negligence of other individuals, provided
that the nurse delegated appropriately. Delegation
is within the scope of nursing practice. The art and
skill of delegation are acquired with practice.
Legal Issues and Delegation
State nurse practice acts establish the legal bound-
aries for nursing practice. Professional nursing
organizations define practice standards, and the
policies of the health-care institution create job
descriptions and establish policies that guide appro-
priate delegation decisions for the organization.
Inherent in today’s health-care environment is
the safety of the client. The quality of client care
and the delivery of safe and effective care are central
to the concept of delegation. RNs are held account-
able when delegating care activities to others. This
means that they have an obligation to intervene
whenever they deem the care provided is unsafe or
unethical. It is also important to realize that a del-
egated task may not be “sub-delegated.” In other
words, if the RN delegated a task to the LPN, the
LPN cannot then delegate the task to the NAP,
even if the LPN has decided that it is within
the abilities of that particular NAP. There may be
legal implications if a client is injured as a result of
inappropriate delegation. Consider the following
case:
In Hicks v. New York State Department of Health,
a nurse was found guilty of patient neglect because
of her failure to appropriately train and supervise
the UAP working under her. In this particular situ-
ation, a security guard discovered an elderly nursing
home client in a totally dark room undressed and
covered with urine and fecal material. The client
table 7-1
Direct and Indirect Client Care Activities
Direct Client Care Activities Indirect Client Care Activities
Assisting with feeding and drinking Providing a clean environment
Assisting with ambulation Providing a safe environment
Assisting with grooming Providing companion care
Assisting with toileting Providing transportation for noncritical clients
Assisting with dressing Assisting with stocking nursing units
Assisting with socializing Providing messenger and delivery services
Source: Adapted from American Nurses Association. (2002). Position statement on utilization of unlicensed assistive
personnel/nursing assistive personnel. Washington, DC: American Nurses Association.
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chapter 7 ■ Delegation and Prioritization of Client Care 113
was partially in his bed and partially restrained in
an overturned wheelchair. The court found the nurse
guilty on the following: the nurse failed to assess
whether the UAP had delivered proper care to the
client, and this subsequently led to the inadequate
delivery of care (1991).
Quality-of-Care Issues
Nurses have expressed concern over the quality of
patient care when tasks and activities are delegated
to others. Activities typically delegated include
turning, ambulating, personal care, and blood
glucose monitoring. When these care activities are
missed, either delayed or omitted, the probability
of untoward and costly outcomes increases (Kalish,
Landstrom, & Hinshaw, 2009). Failure to carry out
these delegated activities appropriately also affects
patient safety (IOM, 2001). Remember Nightin-
gale’s words earlier in the chapter, “Don’t imagine
that if you, who are in charge, don’t look to all these
things yourself, those under you will be more careful
than you are.” She added that you do not need to
do everything yourself to see that it is done correctly.
When you delegate, you control the dele gation. You
decide to whom you will delegate the task.
Assigning Work to Others
Assigning work can be difficult for several reasons:
1. Some nurses think they must do everything
themselves.
2. Some nurses distrust subordinates to do things
correctly.
3. Some nurses think that if they delegate all the
technical tasks, they will not reinforce their
own learning.
4. Some nurses are more comfortable with the
technical aspects of patient care than with the
more complex issues of patient teaching and
discharge planning.
Families and clients do not always see profes-
sional activities. Rather, they see direct patient
care (Keeney, Hasson, McKenna, & Gillen, 2005).
Nurses believe that when they do not participate
directly in client care, they do not accomplish any-
thing for the client. The professional aspects of
nursing, such as planning care, teaching, and dis-
charge planning, help to promote positive outcomes
for clients and their families. When working with
LPNs, knowing their scope of practice helps in
making delegation decisions.
Prioritization
Nurses need to know how to effectively prioritize
care for their patients. Prioritizing requires making
a decision regarding the importance of choosing a
specific action or activity from several options.
Sometimes nurses base these choices on personal
values; other times nurses make decisions based on
imperatives (Lake, Moss, & Duke, 2009). Prioriti-
zation is defined as “deciding which needs or prob-
lems require immediate action and which ones
could be delayed until a later time because they are
not urgent” (Silvestri, 2008, p. 68). While it is
important to know what to do first, it is just as
imperative to understand the result of delaying an
action. If postponing the activity may result in an
unfavorable outcome, then this activity assumes a
level of priority.
Nurses focus care based on the intended outcome
of the care or intervention. Alfaro-Lefevre (2011)
provides three levels of priority setting:
■ Use the ABCs plus V (airway, breathing,
circulation, and vital signs). These are the most
critical.
■ Address mental status, pain, untreated medical
issues, and abnormal laboratory results.
■ Consider long-term health (chronic) problems,
health education, and coping.
Nurses need to evaluate and assess the situation
or need for completion of each task. Certain skills
such as assessment, planning, and evaluating
nursing care always remain within the purview of
the registered nurse. Understanding the process for
evaluating and setting patient care priorities is
essential when coordinating assignments and del-
egating care to others.
Coordinating Assignments
One of the most difficult tasks for new nurses to
master is coordinating daily activities. Often, you
have clients for whom you provide direct care while
at the same time you must supervise the work of
others, such as non-nurse caregivers (NAP), LPNs,
or licensed vocational nurses (LVNs). Although
critical (or clinical) pathways, concept maps, and
computer information sheets are available to help
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114 unit 2 ■ Working Within an Organization
identify patient needs, these items do not provide
a mechanism for coordinating the delivery of care.
Developing a personalized worksheet helps priori-
tize tasks to perform for each patient. Using the
worksheets assists the nurse to identify tasks that
require the knowledge and skill of an RN and those
that can be carried out by NAP.
On the worksheet, tasks are prioritized on the
basis of patient need, not nursing convenience. For
example, an order states that a patient receives con-
tinuous tube feedings. Although it may be conve-
nient for the nurse to fill the feeding container with
enough supplement to last 6 hours, it is not the
standard practice and may be unsafe for the patient.
Instead, the nurse should plan to check the tube
feeding every 2 hours.
As for Ora at the beginning of the chapter, a
worksheet will help her determine how to delegate.
First, she needs to decide which patients require the
skill sets of a registered nurse. These include receiv-
ing and transcribing orders; contacting physicians
with information or requests; accessing laboratory
reports from the computer, reviewing them, decid-
ing on an action, and giving them to the appropri-
ate staff members; and checking any new medication
orders and placing them in the medication admin-
istration records. Another RN may be able to
relieve the monitor technician for dinner and
breaks, and a second RN may be able to assign staff
to dinner and breaks. Next, Ora needs to look at
individual patient requirements on the unit and
prioritize them. She is now ready to effectively del-
egate to her staff.
Some activities must be done at a certain time,
and their timing may be out of the nurse’s control.
Examples include medication administration and
patients who need special preparation for a sched-
uled procedure. The following are some tips for
organizing work on personalized worksheets to
help establish client priorities (Whitehead, Weiss,
& Tappen, 2010):
■ Plan your time around activities that need to
occur at a specific time.
■ Do high-priority activities first.
■ Determine which activities are best done in a
cluster.
■ Remember that you are responsible for
activities delegated to others.
■ Consider your peak energy time when
scheduling optional activities.
This list acts as a guideline for coordinating client
care. The nurse needs to use critical thinking skills
in the decision-making process. Remember that
this is one of the ANA nurse-related principles of
delegation (ANA, 2005). For example, activities
that are usually clustered include bathing, changing
linen, and parts of the physical assessment. Some
patients may not be able to tolerate too much activ-
ity at one time. Take special situations into consid-
eration when coordinating patient care and deciding
who should carry out some of the activities.
Remember, however, that even when you delegate,
you remain accountable.
Figure 7.3 is an example of a personalized
worksheet.
Models of Care Delivery
Functional nursing, team nursing, total client care,
and primary nursing are models of care delivery
that developed in an attempt to balance the needs
of the client with the availability and skills of
nurses. Regardless of the method of assignment or
care delivery system, the majority of nursing care is
delivered within a group practice model where
coordination and continuity of care depend on
sharing common practice values and establishing
communication (Anthony & Vidal, 2010). Nurses
need to develop strong delegation and communica-
tion skills to successfully follow through with any
given model of care delivery.
Functional Nursing
Functional nursing or task nursing evolved during
the mid-1940s due to the loss of RNs who left home
to serve in the armed forces during the Second
World War. Prior to the war, RNs comprised the
majority of hospital staffing. Because of the lack of
nurses to provide care at home, hospitals used more
LPNs or LVNs and NAP to care for clients.
When implementing functional nursing, the
focus is on the task and not necessarily holistic
client care. The needs of the clients are categorized
by task, and then the tasks are assigned to the “best
person for the job.” This method takes into consid-
eration the skill set and licensure scope of practice
of each caregiver. For example, the RN would
perform and document all assessments and admin-
ister all IV medications; the LPN or LVN would
administer treatments and perform dressing
changes. NAP would be responsible for meeting
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chapter 7 ■ Delegation and Prioritization of Client Care 115
Nurse/Team_____________________________________________DNR 8607/Code 99
Patient Room # ______ Name _________________ Age________________________
Allergies_______________________________________________________________
Diagnosis______________________________________________________________
Diet _________Fluids: PO __________ IV__________ Type _____________________
Restrictions: BR _______ BRP ______OOB/Chair______ Ambulate with assist______
Activity ________________________________________________________________
Assessment____________________________________________________________
Treatments
1. ____________________________________________________________________
2. ____________________________________________________________________
3. ____________________________________________________________________
4. ____________________________________________________________________
5. ____________________________________________________________________
Monitor
1. Vital signs: Temp_____ Pulse_______AHR______ BP______Parameters ________
2. Cardiac Monitor: Rhythm_____________________ Rate ______________________
3. Neurologic Status _____________________________________________________
4. CMS: __________________________ Traction: _____________________________
Figure 7.3 Personalized patient worksheet.
hygiene needs of clients, obtaining and recording
vital signs, and assisting in feeding clients. This
method is efficient and effective; however, when
implemented, continuity in client care is lost. Many
times, reevaluation of client status and follow-up
does not occur, and a breakdown in communication
among staff occurs.
Team Nursing
Team nursing grew out of functional nursing;
nursing units often resort to this model when
appropriate staffing is unavailable. A group of
nursing personnel or a team provides care for a
cluster of clients. The manner in which clients are
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116 unit 2 ■ Working Within an Organization
divided varies and depends on several issues: the
layout of the unit, the types of clients on the unit,
and the number of clients on the unit. The organi-
zation of the team is based on the number of avail-
able staff and the skill mix within the group.
An RN assumes the role of the team leader. The
team may consist of another RN, an LPN, and
NAP. The team leader directs and supervises the
team, which provides client care. The team knows
the condition and needs of all the clients on the
team.
The team leader acts as a liaison between the
clients and the health-care provider/physician.
Responsibilities include formulating a client plan
of care, transcribing and communicating orders and
treatment changes to team members, and solving
problems of clients and/or team members. The
nurse manager confers with the team leaders,
supervises the client care teams and, in some insti-
tutions, conducts rounds with the health-care
providers.
For this method to be effective, the team leader
needs strong delegation and communication skills.
Communication among team members and the
nurse manager avoids duplication of efforts and
decreases competition for control of assignments
that may not be equal based on client acuity and
the skills sets of team members.
Total Patient Care
During the 1920s total patient care was the original
model of nursing care delivery. Much nursing
was in the form of private duty nursing. In this
model, nurses cared for patients in homes and in
hospitals. Hospital schools of nursing provided stu-
dents who staffed the nursing units and delivered
care under the watchful eyes of nursing supervisors
and directors. In this model, one RN assumes the
responsibility of caring for one client. This includes
acting as a direct liaison among the patient, family,
health-care provider, and other members of the
health-care team. Today, this model is seen in high-
acuity areas such as critical care units; postanesthe-
sia recovery units; and labor, delivery, and recovery
(LDR) units. This model requires RNs to engage
in non-nursing tasks that might be assumed by
NAP.
Primary Nursing
In the 1960s, nursing care delivery models started
to move away from team nursing and placed the
RN in the role of giving direct patient care. The
central principle of this model distributes nursing
decision making to the nurses who care for the
client. As the primary nurse, the RN devises, imple-
ments, and maintains responsibility for the nursing
care of the patient during the time the patient
remains on the nursing unit. The primary nurse,
along with associate nurses, gives direct care to the
client.
In its ideal form, primary nursing requires an
all-RN staff. Although this model provides conti-
nuity of care and nursing accountability, staffing is
difficult and expensive, especially in today’s health-
care environment. Some view it as ineffective as
other personnel could carry out many tasks that
consume the time of the registered nurse.
Conclusion
The concept of delegation is not new. In today’s
health-care environment and the need for cost con-
tainment, using full RN staffing is unrealistic.
Knowing the principles of delegation remains an
essential skill for registered nurses. Personal orga-
nizational skills and the ability to prioritize patient
care are prerequisites to delegation. Before the
nurse can delegate tasks to others, he or she needs
to identify individual patient needs. Using work-
sheets, the ABC plus V method, and Maslow’s
hierarchy helps the nurse understand these indi-
vidual patient needs, set priorities, and identify
which tasks can be delegated to others. Using the
Delegation Decision-Making Grid helps the nurse
delegate safely and appropriately.
Nurses need to be aware of the capabilities of
each staff member, the tasks that may be delegated,
and the tasks that the RN needs to perform. When
delegating, the RN uses critical thinking and pro-
fessional judgment in making decisions. Profes-
sional judgment is directed by state nurse practice
acts, evidence-based practice, and approved national
nursing standards. Institutions develop their own
job descriptions for NAP and other health-care
professionals, but institutional policies must remain
compliant with state nurse practice acts. Although
the nurse delegates the task or activity, he or she
remains accountable for the delegated decision.
Understanding the concept of delegation helps
the new nurse organize and prioritize client care.
Knowing the staff and their capabilities simplifies
delegation. Utilizing staff members’ capabilities
creates a pleasant and productive working environ-
ment for everyone involved.
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chapter 7 ■ Delegation and Prioritization of Client Care 117
Study Questions
1. What are the responsibilities of the professional nurse when delegating tasks to an LPN/LVN
or NAP?
2. What factors need to be considered when delegating tasks?
3. What is the difference between delegation and assignment?
4. What are the nurse manager’s legal responsibilities in supervising nursing assistive personnel?
5. Review the scenario on p. 111. If you were the nurse manager, how would you have handled
Laura’s situation?
6. Bring the patient diagnosis census from your assigned clinical unit to class. Using the
Delegation Decision-Making Grid, decide which patients you would assign to the personnel on
the unit. Give reasons for your decision.
7. What type of nursing delivery model is implemented on your assigned clinical unit? Give
examples of the roles of the personnel engaged in client care to support your answer.
Case Study to Promote Critical Reasoning
Julio works at a large teaching hospital in a major metropolitan area. This institution services the
entire geographical region, including indigent clients, and, because of its reputation, administers
care to international clients and individuals who reside in other states. Like all health-care
institutions, this one has been attempting to cut costs by using more NAP. Nurses are often
floated to other units. Lately, the number of indigent and foreign clients on Julio’s unit has
increased. The acuity of these clients has been quite high, requiring a great deal of time from the
nursing staff.
Julio arrived at work at 6:30 a.m., his usual time. He looked at the census board and discovered
that the unit was filled, and Bed Control was calling all night to have clients discharged or
transferred to make room for several clients who had been in the emergency department since the
previous evening. He also discovered that the other RN assigned to his team called in sick. His
team consists of himself, two NAP, and an LPN who is shared by two teams. He has eight
patients on his team:
• Two need to be readied for surgery, including preoperative and postoperative teaching, one of whom
is a 35-year-old woman scheduled for a modified radical mastectomy for the treatment of breast
cancer.
• Three are second-day postoperative clients, two of whom require extensive dressing changes, are
receiving IV antibiotics, and need to be ambulated.
• One postoperative client who is required to remain on total bedrest, has a nasogastric tube to
suction as well as a chest tube, is on total parenteral nutrition and lipids, needs a central venous
catheter line dressing change, has an IV, is taking multiple IV medications, and has a Foley
catheter.
• One client who is ready for discharge and needs discharge instruction.
• One client who needs to be transferred to a subacute unit, and a report must be given to the RN
of that unit.
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118 unit 2 ■ Working Within an Organization
Once the latter client is transferred and the other one is discharged, the emergency department
will be sending two clients to the unit for admission.
1. How should Julio organize his day? Set up an hourly schedule.
2. Make a priority list based on the ABC plus V method.
3. What type of client management approach should Julio consider in assigning staff
appropriately?
4. If you were Julio, which clients and/or tasks would you assign to your staff ? List all of them,
and explain your rationale.
5. Using the Delegation Decision-Making Grid, make staff and client assignments.
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chapter 7 ■ Delegation and Prioritization of Client Care 119
References
Alfaro-Lefevre, R. (2011). Critical thinking, clinical
reasoning, and clinical judgment: A practical approach
(5th ed.). St. Louis, MO. Mosby: Elsevier.
American Association of Critical Care Nurses (AACN).
(1990). Delegation of nursing and non-nursing activities
in critical care: A framework for decision making. Irvine,
CA: AACN.
American Association of Critical Care Nurses (AACN).
(2010). Delegation handbook. Irvine, CA: AACN.
American Nurses Association (ANA). (1985). Code for
nurses. Washington, DC: ANA.
American Nurses Association (ANA). (1996). Registered
professional nurses and unlicensed assistive personnel.
Washington, DC: ANA.
American Nurses Association (ANA). (2002). Position
statements on registered nurse utilization of unlicensed
assistive personnel. Washington, DC: ANA.
American Nurses Association (ANA). (2005). Principles for
delegation. Washington, DC: ANA.
American Nurses Association (ANA). (2012). ANA’s
principles for delegation: For registered nurses to
unlicensed assistive personnel (UAP). Bethesda, MD:
ANA.
Anthony, M.K., & Vidal, K. (2010). Mindful communication:
A novel approach to improving delegation and
increasing patient safety. The Online Journal of Issues in
Nursing, 15(2), 1–3. Retrieved September 22, 2013,
from www.nursingworld.org/MainMenuCategories/
ANAMarketplace/ANAPeriodicals/OJIN/JournalTopics/
Delegation-Dilemmas
Association for Women’s Health, Obstetrics and Neonatal
Nurses (AWHONN). (2010). Guidelines for
professional nurse staffing on perinatal units.
Washington, DC: AWHONN.
Cipriano, R.F. (2010). Overview and summary: Delegation
dilemmas: Standards and skills for practice. The Online
Journal of Issues in Nursing, 15(2), 1–3. Retrieved
September 22, 2013, from www.nursingworld.org/
MainMenuCategories/ANAMarketplace/
ANAPeriodicals/OJIN/JournalTopics/
Delegation-Dilemmas.
Hicks v. New York State Department of Health. (1991).
570 N.Y.S. 2d 395 (A.D. 3 Dept).
Institute of Medicine. (2001). Crossing the quality chasm:
A new health system for the 21st century. Washington,
DC: National Academy Press.
Kalisch, B.J., Landstrom, G.L., & Hinshaw, A.S. (2009).
Missed nursing care: A concept analysis. Journal of
advanced nursing, 65(7), 1509–1517.
Keeney, S., Hasson, F., McKenna, H., & Gillen, P. (2005).
Health care assistants: The view of managers of health
care agencies on training and employment. Journal of
Nursing Management, 13(1), 83–92.
Keeney, S., Hasson, F., & McKenna, H. (2005). Nurses’,
midwives’, and patients’ perceptions of trained health
care assistants. Journal of Advanced Nursing, 50(4),
345–355.
Lake, S., Moss, C., & Duke, J. (2009). Nursing
prioritization of the patient need for care: A tacit
knowledge embedded in the clinical decision-making
literature. International Journal of Nursing Practice, 15(5),
376–388.
Matthews, J. (2010). When does delegating make you
a supervisor? The Online Journal of Issues in Nursing,
15(2). Retrieved September 22, 2013, from
www.nursingworld.org/MainMenuCategories/
ANAMarketplace/ANAPeriodicals/OJIN/JournalTopics/
Delegation-Dilemmas
McHugh, M.D., Kelly, L.A., Smith, H.L. , Wu, E.S., Vanak,
J.M., & Aiken, L.H. (2013). Lower mortality in magnet
hospitals. Medical Care, 51(5), 382–388.
National Council of State Boards of Nursing. (1990).
Concept paper on delegation. Chicago: NCSBN.
National Council of State Boards of Nursing. (1995).
Delegation: Concepts and decision-making process.
Issues (December), 1–2.
National Council of State Boards of Nursing. (1997).
Delegation decision-making grid. Chicago: NCSBN.
Retrieved on from https://www.ncsbn.org/delegation
_grid_NEW
National Council of State Boards of Nursing. (2006). Joint
Statement on delegation. Retrieved September 20,
2013, from https://www.ncsbn.org/Delegation_joint
_statement_ NCSBN
National Council of State Boards of Nursing. (2007). The
five rights of delegation. Retrieved from www.ncsbn.
org/Joint_statement
National Labor Relations Act (NLRA). (1935). Retrieved
September 22, 2013, from www.dol.gov/olms/
regs/compliance/EmployeeRightsPoster11x17_Final
Nightingale, F. (1859). Notes on nursing: What it is and
what it is not. London: Harrison and Sons. (Reprint
1992. Philadelphia: JB Lippincott.)
Silvestri, L. (2008). Saunders comprehensive review for the
NCLEX-RN examination (4th ed.). St. Louis, MO:
Saunders.
Society of Gastroenterology Nureses and Associates, Inc.
(2009). Position statement: Role delineation of nursing
assistive personnel in gastroenterology.
Spetz, J., Donaldson, N., Aydin, C., & Brown D.S. (2008).
How many nurses per patient? Measurements of nurse
staffing in health services research. Health Services
Research, 43(5), 1674–1692.
Weydt, A. (2010). Developing delegation skills. The
Online Journal of Issues in Nursing, 15(2). Retrieved
September 22, 2013, from www.nursingworld.org/
MainMenuCategories/ANAMarketplace/
ANAPeriodicals/OJIN/JournalTopics/
Delegation-Dilemmas
Whitehead, D.K., Weiss, S.A., & Tappen, R. (2010).
Essentials of leadership and management. (5th ed.) .
Philadelphia: F.A. Davis.
Zimmerman, P.G., & Schultz, M.J. (2013). Delegating to
unlicensed assistive personnel. Gannet Education
Publishing.
3663_Chapter 7_0103-0120.indd 1193663_Chapter 7_0103-0120.indd 119 9/15/2014 4:37:24 PM9/15/2014 4:37:24 PM
Process CyanProcess CyanProcess MagentaProcess MagentaProcess YellowProcess YellowProcess BlackProcess Black
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121
chapter 8
Dealing With Problems and Conflicts
OBJECTIVES
After reading this chapter, the student should be able to:
■ Identify common sources of conflict in the workplace.
■ Guide an individual or small group through the process of
problem resolution.
■ Participate in informal negotiations.
■ Discuss the purposes of collective bargaining.
OUTLINE
Conflict
Many Sources of Conflict
Power Plays and Competition Between Groups
Increased Workload
Multiple Role Demands
Threats to Safety and Security
Scarce Resources
Cultural Differences
Ethical Conflicts
Invasion of Personal Space
When Conflict Occurs
Resolving Problems and Conflicts
Win, Lose, or Draw?
Other Conflict Resolution Myths
Problem Resolution
Identify the Problem or Issue
Generate Possible Solutions
Review Suggested Solutions and Choose the Best
Solution
Implement the Solution Chosen
Evaluate: Is the Problem Resolved?
Negotiating an Agreement Informally
Scope the Situation
Set the Stage
Conduct the Negotiation
Agree on a Resolution of the Conflict
Formal Negotiation: Collective Bargaining
The Pros and Cons of Collective Bargaining
Conclusion
The pressures and demands of the workplace often
generate conflicts among people that can seriously
interfere with their ability to work together. If the
various polls and surveys of nurses are correct, the
amount of hostility and unresolved conflict experi-
enced by nurses at work seems to be increasing
(Lazoritz & Carlson, 2008; Siu, Laschinger, &
Finegan, 2008). Conflicts with doctors, supervisors,
managers, and colleagues can be very stressful (Las-
chinger et al., 2013; Vivar, 2006). Consider Case 1,
which is the first of three that will be used to illus-
trate how to deal with problems and conflicts.
Conflict
There are no conflict-free work groups (Van de
Vliert & Janssen, 2001). Small or large, conflicts are
a daily occurrence in the life of nurses (McElhaney,
1996), and they can interfere with getting work
done, as shown in Case 1.
Serious conflicts can be very stressful. Stress
symptoms—such as difficulty concentrating, an xie-
ty, sleep disorders, and withdrawal—and other inter-
personal relationship problems can occur. Bitterness,
anger, and, in rare occurrences, violence can erupt
in the workplace if conflicts are not resolved.
Conflict also has a positive side, however. In the
process of learning how to manage conflict con-
structively, people can develop more open, coopera-
tive ways of working together (Tjosvold & Tjosvold,
1995). They can begin to see each other as people
with similar needs, concerns, and dreams instead of
as competitors or blocks in the way of progress.
Being involved in successful conflict resolution can
be an empowering experience (Horton-Deutsch &
Wellman, 2002).
The goal in dealing with conflict is to create an
environment in which conflicts are dealt with in as
cooperative and constructive a manner as possible,
rather than in a competitive and destructive manner.
Many Sources of Conflict
Why do conflicts occur? The workplace itself
can be a generator of conflict. Some conflicts are
focused on issues related to the work being done;
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122 unit 2 ■ Working Within an Organization
these are task-related conflicts. Others are primarily
related to personal and social issues; these are rela-
tionship conflicts ( Jordan & Troth, 2004).
Power Plays and Competition
between Groups
Differences in status and authority within the
health-care team may generate conflicts. Physi-
cians often feel that they have authority over other
members of the team, sometimes causing them to
disregard input from other team members (Sun,
2011) or refuse to engage in conflict reso lution. The
most common problem is disrespect or incivility,
but sarcasm, finger-pointing, throwing things, and
use of inappropriate language also occur (Lazoritz
& Carlson, 2008). In one study of new graduate
nurses, 12% reported daily workplace incivility
from coworkers, 4.87% reported incivility from
supervisors, and 7% reported daily incivility from
physicians (Laschinger et al., 2013). The amount of
incivility from fellow nurses is especially signifi-
cant since they are an important source of guid-
ance and support for new graduates.
Bullying involves behavior intended to exert
power over another person. It is more than being
overly demanding. Workplace bullies often single
out one individual as a target, adding a degree of
personal malice to their behavior. The effect on the
targeted individual can be devastating and the cost
to the organization is huge. A 2007 Gallup poll of
over a million workers found that having an over-
bearing boss was the most common reason given
for leaving a job (Wescott, 2012).
In some settings, nurses feel powerless, trapped
by the demands of tasks they must complete and
frustrated that they cannot provide quality care
(Ramos, 2006). Union-management conflicts occur
in some workplaces. Disagreements over profes-
sional “territory” can occur in any setting. Nurse
practitioners and physicians may disagree over the
scope of nurse practitioner practice, for example.
Gender-based issues, including equal pay for
women and sexual harassment, and diversity issues
such as speaking languages other than English
or feelings of being accepted by others may also
occur (Howard & Wellins, 2009; Osterberg &
Lorentsson, 2010).
Increased Workload
Emphasis on cost reduction has resulted in work
intensif ication, a situation in which employees are
required to do more in less time (Willis, Taffoli,
Case 1
Team A and Team B
Team A has stopped talking to Team B. If several members of Team A are out sick, no one on Team B will
help Team A with their work. Likewise, Team A members will not take telephone messages for anyone on
Team B. Instead, they ask the person to call back later. When members of the two teams pass each other
in the hall, they either glare at each other or turn away to avoid eye contact. Arguments erupt when members
of the two teams need the same computer terminal or another piece of equipment at the same time.
When a Team A nurse reached for a glucometer at the same moment as a Team B nurse did, the
second nurse said, “You’ve been using that all morning.”
“I’ve got a lot of patients to monitor,” was the response.
“Oh, you think you’re the only one with work to do?”
“We take good care of our patients.”
“Are you saying we don’t?”
The nurses fell silent when the nurse manager entered the room.
“Is something the matter?” she asked. Both nurses shook their heads and left quickly.
“I’m not sure what’s going on here,” the nurse manager thought to herself, “but something’s wrong,
and I need to find out what it is right away.”
We will return to this case later as we discuss workplace problems and conflicts, their
sources, and how to resolve them.
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chapter 8 ■ Dealing With Problems and Confl icts 123
Henderson, & Walter, 2008). Common responses
are skipping breaks, doing paperwork over lunch,
and working overtime without pay. This leaves
many health-care workers believing that their
employers are taking advantage of them and causes
even more conflict if they believe others are not
working as hard as they are.
Multiple Role Demands
Inappropriate task assignments (e.g., asking nurses
to clean patient rooms as well as nurse their
patients) are often the result of cost-control efforts.
Such assignments can lead to disagreements about
who does what task and who is responsible for the
outcome.
Threats to Safety and Security
When cost saving is emphasized and staff members
face layoffs, people’s economic security is threat-
ened. This can be a source of considerable stress
and tension.
Scarce Resources
Limited resources almost inevitably lead to compe-
tition to get one’s fair share (or more), often result-
ing in conflict between individuals and between
departments (Isosaari, 2011). Inadequate money
for pay raises, equipment, supplies, or additional
help can increase competition between or among
individuals and departments as they scramble to
grab their share of what little is available.
Cultural Differences
Language differences may make communication
challenging. Some cultures emphasize the impor-
tance of the individual while others emphasize the
importance of the group (Osterberg & Lorentsson,
2010). Different beliefs about how hard a person
should work, what constitutes productivity, and
even what it means to arrive at work “on time” can
lead to conflicts if they are not reconciled.
Ethical Conflicts
Moral distress occurs when a nurse encounters a
situation that violates his or her personal or profes-
sional ethics, especially when others ignore it or
pretend it is not a concern (Lachman, Murray,
Iseminger, & Ganske, 2012). Examples of such
conflicts are recording care that was not given or
failing to fully explain a procedure before obtaining
patient consent.
Invasion of Personal Space
Crowded conditions and the constant interactions
that occur at a busy nurses’ station can increase
interpersonal tension and lead to battles over scarce
work space (McElhaney, 1996).
When Conflict Occurs
Conflict can occur at any level and involve any
number of people. On the individual level, conflict
can occur between two people on a team, in differ-
ent departments, or between a staff member and a
patient or family member. On the group level, con-
flict can occur between two teams (as in Case 1),
two departments, or two different professional
groups (e.g., between nurses and social workers over
who is responsible for advance care planning). Con-
flict can also occur between two organizations (e.g.,
when two home health agencies compete for a con-
tract with a large hospital). The focus in this chapter
is primarily on the first two levels: among individu-
als and groups of people within a health-care
organization.
Health care–oriented workplaces have been
especially resistant to effective conflict manage-
ment in the past, but several forces are reducing this
resistance. The Institute of Medicine report To Err
is Human (IOM, 1999) exposed serious threats to
patient safety due to preventable errors and made
it clear that problems need to be resolved, not
buried. The Joint Commission added several stan-
dards that focus on better communication and
problem resolution (Feldman et al., 2011). Nurses
also find themselves in patient care situations where
an ethical response might cause some conflict about
which they cannot remain silent if this puts a
patient at risk. Developing competency in dealing
with conflict is an important leadership skill (Kritek,
2011). Box 8-1 lists situations in which conflict
resolution is needed.
Resolving Problems and Conflicts
Win, Lose, or Draw?
Some people think about problems and conflicts
that occur at work in the same way they think about
a basketball game or tennis match: someone has
to win and someone has to lose. There are some
problems with this sports comparison. First, the
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124 unit 2 ■ Working Within an Organization
aim of conflict resolution is to work together more
effectively, not to win. Second, if people really
do lose they are likely to feel bad about it. As a
result, they may spend their time gearing up to win
the next round rather than concentrating on their
work.
A win-win result in which both sides gain some
benefit is the best resolution (Haslan, 2001). Some-
times people cannot reach agreement (consensus)
but can recognize and accept their differences and
get on with their work (McDonald, 2008).
Other Conflict Resolution Myths
Many people think of what can be “won” as a fixed
amount: “I get half, and you get half.” This is the
f ixed pie myth of conflict resolution (Thompson &
Fox, 2001). Another erroneous assumption is called
the devaluation reaction: “If the other side is getting
what they want, then it has to be bad for us.” These
erroneous beliefs can be serious barriers to achieve-
ment of a mutually beneficial conflict resolution.
When disagreements first arise, problem solving
may be sufficient. If the situation has already devel-
oped into a full-blown conflict, however, negotia-
tion, either informal or formal, of a settlement may
be necessary.
Problem Resolution
The use of the problem-solving process in patient
care should be familiar. The same approach can be
used when staff problems occur. The goal is to find
a solution that satisfies everyone involved. The
process illustrated in Figure 8.1 includes iden-
tifying the issue, generating solutions, evaluating
the suggested solutions, choosing what appears to
be the best solution, implementing that solution,
evaluating the extent to which the problem has
been resolved, and, finally, concluding either that
the problem has been resolved or that it will be
necessary to repeat the process to find a better
solution.
Identify the Problem or Issue
First, ask participants in the conflict what they
want (Sportsman, 2005). If the issue is not highly
charged, they may be able to give a direct answer.
Other times, however, some discussion and explo-
ration of the issues will be necessary before the real
problem emerges. “It would be nice,” wrote Browne
and Keeley, “if what other people were really saying
was always obvious, if all their essential thoughts
were clearly labeled for us . . . and if all knowledge-
able people agreed about answers to important
questions” (Browne & Keeley, 1994, p. 5). Of course,
this is not what usually happens. People are often
vague about what their real concern is; sometimes
they are genuinely uncertain about what the real
problem is. Strong emotions may further cloud the
issue. All this needs to be sorted out so that the
problem is clearly identified and a solution can be
sought.
Generate Possible Solutions
Here, creativity is especially important. Try to dis-
courage people from using old solutions for new
problems. It is natural for people to try a solution
that has already worked well, but previously suc-
cessful solutions may not work in the future.
Problem
resolved
If yes, end
Begin
here
If not,
repeat
process
Implement
solution
chosen
Generate
possible
solutions
Choose
best
solution
Evaluate
suggested
solutions
Identify
the
problem
Figure 8.1 The process of resolving a problem.
• You feel very uncomfortable in a situation.
• Members of your team are having trouble working
together.
• Team members stop talking with each other.
• Team members begin “losing their cool,” attacking
each other verbally.
box 8-1
Signs That Conflict Resolution Is Needed
Adapted from Patterson, K., Grenny, J., McMillan, R., & Surtzler, A.
(18 March 2003). Crucial conversations: Making a difference
between being healed and being seriously hurt. Vital Signs, 13(5),
14–15.
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chapter 8 ■ Dealing With Problems and Confl icts 125
When an innovative solution is needed, suggest
that the group take some time to brainstorm. Ask
everyone to write down (or call out as you write on
a board, screen, or flip chart) as many solutions as
they can come up with (Rees, 2005). Then give
everyone a chance to consider each suggestion on
its own merits.
Review Suggested Solutions and Choose
the Best Solution
An open-minded evaluation of each suggestion is
needed, but accomplishing this is not always easy.
Some groups get “stuck in a rut,” unable to “think
outside the box.” Other times, groups find it diffi-
cult to separate the suggestion from its source. On
an interdisciplinary team, for example, the status of
the person who made the suggestion may influence
whether the suggestion is judged to be useful. Yet
the best suggestions often come from those closest
to the problem (McChrystal, 2012). This may be
the care assistants who spend the most time with
their patients. Whose solution is most likely to be
the best one, the physician’s or the unlicensed assis-
tant’s? A suggestion should be judged on its merits,
not its source. Which of the suggested solutions is
most likely to work? A combination of suggestions
is often the best solution.
Implement the Solution Chosen
The true test of any suggested solution is how well
it actually works. Once a solution has been imple-
mented, it is important to give it time to work.
Impatience sometimes leads to premature aban-
donment of a good solution.
Evaluate: Is the Problem Resolved?
Not every problem is resolved successfully on the
first attempt. If the problem has not been resolved,
then the process needs to be resumed with even
greater attention to what the real problem is and
how it can be resolved successfully.
Consider the following situation in which
problem-solving was helpful (Case 2)
The nurse manager asked Ms. Deloitte to meet
with her to discuss the problem. The following is a
summary of their problem-solving:
■ The Issue. Ms. Deloitte wanted to take her
vacation from the end of December through
early January. Making the assumption that she
was going to be permitted to go, she had
purchased nonrefundable tickets. The policy
forbids vacations from December 20 to January
5. The former nurse manager had not enforced
this policy with Ms. Deloitte, but the new
nurse manager thought it fair to enforce the
policy with everyone, including Ms. Deloitte.
■ Possible Solutions
1. Ms. Deloitte resigns.
2. Ms. Deloitte is fired.
3. Allow Ms. Deloitte to take her vacation as
planned.
Case 2
The Vacation
Francine Deloitte has been a unit secretary for 10 years. She is prompt, efficient, accurate, courteous,
flexible, and productive—everything a nurse manager could ask for in a unit secretary. When nursing staff
members are very busy, she distributes afternoon snacks or sits with a family for a few minutes until a
nurse is available. There is only one issue on which Ms. Deloitte is insistent and stubborn: taking her
2-week vacation over the Christmas and New Year holidays. This is forbidden by hospital policy, but every
nurse manager has allowed her to do this because it is the only special request she ever makes and
because it is the only time she visits her family during the year.
A recent reorganization of the administrative structure had eliminated several layers of nursing manag-
ers and supervisors. Each remaining nurse manager was given responsibility for two or three units. The
new nurse manager for Ms. Deloitte’s unit refused to grant her request for vacation time at the end of
December. “I can’t show favoritism,” she explained. “No one else is allowed to take vacation time at the end
of December.” Assuming that she could have the time off as usual, Francine had already purchased a
nonrefundable ticket for her visit home. When her request was denied, she threatened to quit. On hearing
this, one of the nurses on Francine’s unit confronted the new nurse manager saying, “You can’t do this. We
are going to lose the best unit secretary we’ve ever had if you do.”
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126 unit 2 ■ Working Within an Organization
4. Allow everyone to take vacations between
December 20 and January 5 as requested.
5. Allow no one to take a vacation between
December 20 and January 5.
■ Evaluate Suggested Solutions. Ms. Deloitte
preferred solutions 3 and 4. The new nurse
manager preferred 5. Neither wanted 1 or 2.
They could agree only that none of the
solutions satisfied both of them, so they
decided to try again.
■ Second List of Possible Solutions
1. Reimburse Ms. Deloitte for the cost of the
tickets.
2. Allow Ms. Deloitte to take one last vacation
between December 20 and January 5.
3. Allow Ms. Deloitte to take her vacation
during Thanksgiving instead.
4. Allow Ms. Deloitte to begin her vacation on
December 26 so that she would work on
Christmas Day but not on New Year’s Day.
5. Allow Ms. Deloitte to begin her vacation
earlier in December so that she could return
in time to work on New Year’s Day.
■ Choose the Best Solution. As they discussed
the alternatives, Ms. Deloitte said she could
change the day of her flight without a penalty.
The nurse manager said she would allow
solution 5 on the second list if Ms. Deloitte
understood that she could not take vacation
time between December 20 and January 5 in
the future. Ms. Deloitte agreed to this.
■ Implement the Solution. Ms. Deloitte
returned on December 30 and worked both
New Year’s Eve and New Year’s Day.
■ Evaluate the Solution. The rest of the staff
members had been watching the situation very
closely. Most believed that the solution had
been fair to them as well as to Ms. Deloitte.
Ms. Deloitte thought she had been treated
fairly. The nurse manager believed both parties
had found a solution that was fair to Ms.
Deloitte but still reinforced the manager’s
determination to enforce the vacation policy.
■ Resolved, or Resume Problem Solving? Ms.
Deloitte, staff members, and the nurse
manager all thought the problem had been
solved satisfactorily.
Negotiating an Agreement Informally
When a disagreement has become too big, too
complex, or too heated for problem resolution to be
successful, a more elaborate process may be required
to resolve it. On evaluating Case 1, the nurse
manager decided that the tensions between Team
A and Team B had become so great that negotia-
tion would be necessary.
The process of negotiation is a complex one that
requires much careful thought beforehand and con-
siderable skill in its implementation. Box 8-2 is an
outline of the most essential aspects of negotiation.
Case 1 is used to illustrate how it can be done.
Scope the Situation
For a strategy to be successful, it is important that
the entire situation be understood thoroughly.
Walker and Harris (1995) suggested asking three
questions:
1. What am I trying to achieve? The nurse manager
in Case 1 is very concerned about the tensions
between Team A and Team B. She wants the
members of these two teams to be able to work
together in a cooperative manner, which they
are not doing at the present time.
2. What is the environment in which I am
operating? The members of Teams A and B
were openly hostile to each other. The overall
climate of the organization, however, was
benign. The nurse manager knew that
teamwork was encouraged and that her actions
to resolve the conflict would be supported by
administration.
3. What problems am I likely to encounter? The
nurse manager knew that she had allowed the
problem to go on too long. Even physicians,
social workers, and visitors to the unit were
getting caught up in the conflict. Team
members were actively encouraging other staff
to take sides, making clear that “if you’re not
with us, you’re against us.” This made people
• Scope the situation. Ask yourself:
What am I trying to achieve?
What is the environment in which I am operating?
What problems am I likely to encounter?
What does the other side want?
• Set the stage.
• Conduct the negotiation.
• Set the ground rules.
• Clarify the problem.
• Make your opening move.
• Continue with offers and counteroffers.
• Agree on the resolution of the conflict.
box 8-2
The Informal Negotiation Process
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chapter 8 ■ Dealing With Problems and Confl icts 127
from other departments very uncomfortable
because they had to work with both teams. The
nurse manager knew that resolution of the
conflict would be a relief to many people.
It is important to ask one additional question in
preparation for negotiations.
4. What does the other side want? In this situation,
the nurse manager was not certain what either
team really wanted. She realized that she
needed this information before she could begin
to negotiate.
Set the Stage
When a conflict such as the one between Teams A
and B has gone on for some time, the opposing
sides are often unwilling to meet to discuss the
problem. This avoidance prevents an exchange of
information between the two groups (Sun, 2011).
If this occurs, it may be necessary to confront them
with direct statements designed to open communi-
cations between the two sides, challenging them to
seek resolution of the situation. At the same time,
it is important to avoid any suggestion of blame
because this provokes defensiveness.
To confront Teams A and B with their behavior
toward one another, the nurse manager called them
together at the end of the day shift. “I am very
concerned about what I have been observing,” she
told them. “It appears to me that instead of working
together, our two teams are working against each
other.” She continued with some examples of what
she had observed, taking care not to mention names
or blame anyone for the problem. She was also
prepared to take responsibility for having allowed
the situation to deteriorate before taking this
much-needed action.
Conduct the Negotiation
As indicated earlier, conducting a negotiation
requires a great deal of skill.
1. Manage the emotions. When people are very
emotional, they have trouble thinking clearly.
Acknowledging these emotions is essential to
negotiating effectively (Fiumano, 2005). When
faced with a highly charged situation, do not
respond with added emotion. Take time out if
you need to get your own feelings under
control. Then find out why emotions are high
(watch both verbal and nonverbal cues
carefully) and refocus the discussion on the
issues. Allow disagreements to be expressed.
Those who are willing to voice their differences
play an important role in helping the group
move toward resolution of the problem. The
leader’s role is to encourage group members to
listen to and consider these differences, the first
step in moving toward resolution of the conflict
(Sarkar, 2009). Without effective leadership to
prevent disagreements, emotional outbursts,
and personal attacks, a mishandled negotiation
can worsen a situation. With effective
leadership, the conflict may be resolved
(Box 8-3).
2. Set ground rules. Members of Teams A and B
began throwing accusations at each other as
soon as the nurse manager made her statement.
The nurse manager stopped this quickly and
said, “First, we need to set some ground rules
for this discussion. Everyone will get a chance
to speak but not all at once. Please speak for
yourself, not for others. And please do not
make personal remarks or criticize your
coworkers. We are here to resolve this problem,
not to make it worse.” She had to remind the
group of these ground rules several times
during the meeting.
3. Clarification of the problem. The nurse
manager wrote a list of problems raised
by team members on a chalkboard. As the list
grew longer, she asked the group, “What do
you see here? What is the real problem?” The
group remained silent. Finally, someone said,
• Create a climate of comfort.
• Let others know the purpose is to resolve a problem or
conflict.
• Freely admit your own contribution to the problem.
• Begin with the presentation of facts.
• Recognize your own emotional response to the
situation.
• Set ground rules.
• Do not make personal remarks.
• Avoid placing blame.
• Allow each person an opportunity to speak.
• Do speak for yourself but not for others.
• Focus on solutions.
• Keep an open mind.
box 8-3
Tips for Leading the Discussion
Adapted from Patterson, K., Grenny, J., McMillan, R., & Surtzler, A.
(18 March 2003). Crucial conversations: Making a difference
between being healed and being seriously hurt. Vital Signs, 13(5),
14–15.
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128 unit 2 ■ Working Within an Organization
“We don’t have enough people, equipment, or
supplies to get the work done.” The rest of the
group nodded in agreement.
4. Opening move. Once the problem is clarified,
it is time to obtain everyone’s agreement to
seek a way to resolve the conflict. In a more
formal negotiation, you may make a statement
about what you wish to achieve. This first
statement sets the stage for the rest of the
negotiation (Suddath, 2012). For example, if
you are negotiating a salary increase, you might
begin by saying, “I am requesting a 10%
increase for the following reasons: . . .” Of
course, your employer will probably make a
counteroffer, such as, “The best I can do is 3%.”
These are the opening moves of a negotiation.
5. Continue the negotiations. The discussion
should continue in an open, nonhostile manner.
Each side’s concerns may be further explained
and elaborated. Additional offers and
counteroffers are common. As the discussion
continues, it is helpful to emphasize areas of
agreement as well as disagreement so that both
parties are encouraged to continue the
negotiations (Tappen, 2001).
Agree on a Resolution of the Conflict
After much testing for agreement, elaborating each
side’s positions and concerns, and making offers
and counteroffers, the people involved should
finally reach an agreement.
The nurse manager of Teams A and B led them
through a discussion of their concerns related to
working with severely limited resources. The teams
soon realized that they had a common concern and
that they might be able to help each other rather
than compete with each other. The nurse manager
agreed to become more proactive in seeking
resources for the unit. “We can simultaneously seek
new resources and develop creative ways to use the
resources we already have,” she told the teams.
Relationships between members of Team A and
Team B improved remarkably after this meeting.
They learned that they could accomplish more
by working together than they had ever achieved
separately.
Formal Negotiation: Collective Bargaining
There are many varieties of formal negotiations,
from real estate transactions to international peace
treaty negotiations. A formal negotiation process of
special interest to nurses is collective bargaining,
which is highly formalized because it is governed
by laws and contracts called collective bargaining
agreements.
Collective bargaining involves a formal proce-
dure governed by labor laws, such as the National
Labor Relations Act in the United States. Non-
profit health-care organizations were added to the
organizations covered by these laws in 1974. Once
a union or professional organization has been
designated as the official bargaining agent for
a group of nurses, a contract defining such impor-
tant matters as salary increases, benefits, time off,
unfair treatment, safety issues, and promotion of
pro fessional practice is drawn up. This contract
governs employee-management relations within
the organization.
A collective bargaining contract is a legal docu-
ment that governs the relationship between man-
agement and staff, who are represented by the
union (for nurses, it may be the nurses’ association
or another health-care workers’ union). The con-
tract may cover some or all of the following:
■ Economic issues: Salaries, shift differentials,
length of the workday, overtime, holidays, sick
leave, breaks, health insurance, pensions,
severance pay
■ Management issues: Promotions, layoffs,
transfers, reprimands, grievance procedures,
hiring and firing procedures
■ Practice issues: Adequate staffing, standards
of care, code of ethics, safe working
environment, other quality-of-care issues, staff
development opportunities
Better patient-nurse staffing ratios, more reason-
able workloads, opportunities for professional
development, and better relationships with man-
agement are among the most important issues for
practicing nurses (Budd, Warino, & Patton, 2004).
Case 3 is an example of how collective bargain-
ing agreements can influence the outcome of a
conflict between management and staff in a health-
care organization.
The Pros and Cons of Collective Bargaining
Some nurses believe it is unprofessional to belong
to a union. Others point out that physicians and
teachers are union members and that the protec-
tions offered by a union outweigh the downside.
There is no easy answer to this question.
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chapter 8 ■ Dealing With Problems and Confl icts 129
Probably the greatest advantages of collective
bargaining are protection of the right to fair treat-
ment and the availability of a written grievance
procedure that specifies both the employee’s and
the employer’s rights and responsibilities if an issue
arises that cannot be settled informally (Forman &
Merrick, 2003). Another advantage is salary: nurses
working under a collective bargaining agreement
can earn as much as 28% more than those who do
not (Pittman, 2007).
The greatest disadvantage of using collective
bargaining as a way to deal with conflict is that it
clearly separates management from staff, often cre-
ating an adversarial relationship. Any nurses who
make staffing decisions may be classified as super-
visors and, therefore, may be ineligible to join
the union, separating them from the rest of their
colleagues (Martin, 2001). The result is that man-
agement and staff are treated as opposing parties
rather than as people who are trying to work
together to provide essential services to their
patients. The collective bargaining contract also
adds another layer of rules and regulations between
staff members and their supervisors. Because man-
agement of such employee-related rules and regula-
tions can take almost a quarter of a manager’s time
(Drucker, 2002), this can become a drain on a nurse
manager’s time and energy.
Conclusion
Conflict is inevitable within any large, diverse group
of people who are trying to work together over
an extended period. However, conflict does not
have to be destructive, nor does it have to be an
entirely negative experience. If it is handled skill-
fully, conflict can stimulate people to learn more
about each other and how to work together in
more effective ways. Resolving a conflict, when
done well, can lead to improved working relation-
ships, more creative methods of operation, and
higher productivity.
Case 3
Collective Bargaining
The chief executive officer (CEO) of a large home health agency in a southwestern resort area called a
general staff meeting. She reported that the agency had grown rapidly and was now the largest in the area.
“Much of our success is due to the professionalism and commitment of our staff members,” she said. “With
growth come some problems, however. The most serious problem is the fluctuation in patient census. Our
census peaks in the winter months when seasonal residents are here and troughs in the summer. In the past,
when we were a small agency, we all took our vacations during the slow season. This made it possible to
continue to pay everyone his or her full salary all year. However, given pressures to reduce costs and the
large number of staff members we now have, we cannot continue to do this. We are very concerned about
maintaining the high quality of patient care currently provided, but we have calculated that we need to reduce
staff by 30 percent over the summer in order to survive financially.”
The CEO then invited comments from the staff members. The majority of the nurses said they wanted
and needed to work full-time all year. Most supported families and had to have a steady income all year. “My
rent does not go down in the summer,” said one. “Neither does my mortgage payment or the grocery bill,” said
another. A small number said that they would be happy to work part-time in the summer if they could be
guaranteed full-time employment from October through May. “We have friends who would love this work
schedule,” they added.
“That’s not fair,” protested the nurses who needed to work full-time all year. “You can’t replace us with
part-time staff.” The discussion grew louder and the participants more agitated. The meeting ended without
a solution to the problem. Although the CEO promised to consider all points of view before making a
decision, the nurses left the meeting feeling very confused and concerned about the security of their future
income. Some grumbled that they probably should begin looking for new positions “before the ax falls.”
The next day the CEO received a telephone call from the nurses’ union representative. “If what I heard about
the meeting yesterday is correct,” said the representative, “your plan is in violation of our collective bargaining
contract.” The CEO reviewed the contract and found that the representative was correct. A new solution to the
financial problems caused by the seasonal fluctuations in patient census would have to be found.
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130 unit 2 ■ Working Within an Organization
Study Questions
1. Debate the question of whether conflict is constructive or destructive. How can good leadership
affect the outcome of a conflict?
2. Give an example of how each of the seven sources of conflict listed in this chapter can lead to a
serious problem. Then discuss ways to prevent the occurrence of conflict from each of the seven
sources.
3. What is the difference between problem resolution and negotiation? Under what circumstances
would you use one or the other?
4. Identify a conflict (actual or potential) in your clinical area, and explain how either problem
resolution or negotiation could be used to resolve it.
5. In what ways does collective bargaining increase conflict? How does it help resolve conflicts?
Case Study to Promote Critical Reasoning
A not-for-profit hospice center in a small community received a generous gift from the grateful
family of a patient who had died recently. The family asked only that the money be “put to the
best use possible.”
Everyone in this small facility had an opinion about the “best” use for the money. The
administrator wanted to renovate the old, rundown headquarters. The financial officer wanted to
put the money in the bank “for a rainy day.” The chaplain wanted to add a small chapel to the
building. The nurses wanted to create a food bank to help the poorest of their clients. The social
workers wanted to buy a van to transport clients to health-care provider offices. The staff agreed
that all the ideas had merit, that all of the needs identified were important ones. Unfortunately,
there was enough money to meet only one of them.
The more the staff members discussed how to use this gift, the more insistent each group
became that their idea was best. At their last meeting, it was evident that some were becoming
frustrated and that others were becoming angry. It was rumored that a shouting match between
the administrator and the financial officer had occurred.
1. In your analysis of this situation, identify the sources of the conflict that are developing in this
facility.
2. What kind of leadership actions are needed to prevent the escalation of this conflict?
3. If the conflict does escalate, how could it be resolved?
4. Which idea do you think has the most merit? Why did you select the one you did?
5. Try role-playing a negotiation among the administrator, the financial officer, the chaplain, a
representative of the nursing staff, and a representative of the social work staff. Can you suggest
a creative solution?
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chapter 8 ■ Dealing With Problems and Confl icts 131
References
Browne, M.N., & Keeley, S.M. (1994). Asking the right
questions: A guide to critical thinking. Englewood Cliffs,
NJ: Prentice-Hall.
Budd, K., Warino, L., & Patton, M. (2004). Traditional and
non-traditional collective bargaining: Strategies to
improve the patient care environment. The Online Journal
of Nursing. Retrieved on December 4, 2013, from
www.nursingworld.org/MainMenuCategories/
ANAMarketplace/ANAPeriodicals/OJIN/
TableofContents/Volume92004/No1Jan04/
CollectiveBargainingStrategies.aspx
Drucker, P.F. (2002). They’re not employees, they’re people.
Harvard Business Review, 80(2), 70–77, 128.
Feldman, H.R., & Greenberg, M.J. (Eds.). (2011). Nursing
leadership: A concise encyclopedia. New York, NY:
Springer Publishing Company.
Fiumano, J. (2005). Navigate through conflict, not around
it. Nursing Management, 36(8), 14, 18.
Forman, H., & Merrick, F. (2003). Grievances and
complaints: Valuable tools for management and for staff.
Journal of Nursing Administration, 33(3), 136–138.
Haslan, S.A. (2001). Psychology in organizations.
Thousand Oaks, CA: Sage.
Horton-Deutsch, S.L., & Wellman, D.S. (2002). Christman’s
principles for effective management. Journal of Nursing
Administration, 32, 596–601.
Howard, A., & Wellins, R. (2009). Holding women back:
Troubling discoveries—and best practices for helping
female leaders succeed. A special report from
Development Dimensions International’s Global
Leadership Forecast.
Institute of Medicine. (1999). To err is human: Building a
safer health care system. Washington, DC: National
Academies Press.
Isosaari, V. (2011). Power in health care organizations.
Journal of Health Organization and Management,
25(4), 385–399.
Jordan, P., & Troth, A.C. (2004). Managing emotions
during team problem solving: Emotional intelligence and
conflict resolution. Human Performance, 17(2),
195–218.
Kritek, P.B. (2011). Conflict management in nursing
leadership: A concise encyclopedia (2nd ed.). New
York: Springer Publishing Company.
Lachman, V.D., Murray, J.S., Iseminger, K., & Ganske, K.M.
(2012). Doing the right thing: Pathways to moral
courage. American Nurse Today, 7(5), 24–29.
Laschinger, H., Wong, C., Regan, S., Young-Ritchie, C., &
Bushell, P. (2013). Workplace incivility and new
gradate nurses’ mental health: The protective role of
incivility. The Journal of Nursing Administration, 43(7/8),
415–421.
Lazoritz, S., & Carlson, P.J. (2008). Descriptive physician
behavior. American Nurse Today, 3(3), 20–22.
Martin, R.H. (June 2001). Ruling may limit ability to
unionize. Advance for Nurses, 9.
McChrystal, S. (2012). (Quoted by R. Safian). Secrets of
the flux leader. Fast Company, 170, 105.
McDonald, D. (2008). Revisiting a theory of negotiation:
The utility of Markiewicz (2005) proposed six principles.
Evaluation and Program Planning, 31(3), 259–265.
McElhaney, R. (1996). Conflict management in nursing
administration. Nursing Management, 27(3), 49–50.
Osterberg, C., & Lorentsson, T. (2010). Organizational
conflict and socialization processes in healthcare.
(Thesis). University of Gothenburg, Göteborg, Sweden.
Patterson, K., Grenny, J., McMillan, R., & Surtzler, A. (18
March 2003). Crucial conversations: Making a
difference between being healed and being seriously
hurt. Vital Signs, 13(5), 14–15.
Pittman, J. (2007). Registered nurse job satisfaction and
collective bargaining unit membership status. Journal of
Nursing Administration, 37(10), 471–476.
Ramos, M.C. (2006). Eliminate destructive behaviors
through example and evidence. Nursing Management,
37(9), 34–41.
Rees, F. (2005). 25 Activities for developing team leaders.
San Francisco: Pfeiffer.
Sarkar, S. (2009). The dance of dissent: Managing conflict
in healthcare organizations. Psychoanalytic
Psychotherapy. 23(2), 121–135.
Siu, H., Laschinger, H.R.S., & Finegan, J. (2008). Nursing
professional practice environments: Setting the stage for
constructive conflict resolution and work effectiveness.
Journal of Nursing Administration, 38(5), 250–257.
Sportsman, S. (2005). Build a framework for conflict
assessment. Nursing Management, 36(4), 32–40.
Suddath, C. (2012). The art of haggling: When fighting for
a new salary, it’s all about the first number on the table.
Bloomberg Businessweek, November 26–December
2012. Retrieved December 4, 2013, from http://
www.businessweek.com/articles/2012-11-21/
the-art-of-haggling
Sun, K. (2011). Inter-unit conflict, conflict resolution methods,
and post-merger, organizational integration in healthcare
organizations. (Dissertation.) University of Minnesota,
Minneapolis.
Tappen, R.M. (2001). Nursing leadership and
management: Concept and practice. Philadelphia: F.A.
Davis.
Thompson, L., & Fox, C.R. (2001). Negotiation within and
between groups in organizations: Levels of analysis. In
Turner, M.E. (ed.), Groups at Work, 221–266.
Mahwah, NJ: Laurence Erlbaum.
Tjosvold, D., & Tjosvold, M.M. (1995). Psychology for
leaders: Using motivation, conflict, and power to
manage more effectively. New York: John Wiley & Sons.
Van de Vliert, E., & Janssen, O. (2001). Description,
explanation, and prescription of intragroup conflict
behaviors. Groups at work: Theory and research,
267–297.
Vivar, C.G. (2006). Putting conflict management into
practice: A nursing case study. Journal of Nursing
Management, 14, 201–206.
Walker, M.A., & Harris, G.L. (1995). Negotiations: Six
steps to success. Upper Saddle River, NJ: Prentice-Hall.
Wescott, D. (2012). Field guide to office bullies.
Bloomberg Businessweek. Retrieved from http://images.
businessweek.com/slideshows/2012-11-21/
field-guide-to-office-bullies
Willis, E., Taffoli, L., Henderson, J., & Walter, B. (2008).
Enterprise bargaining: A case study in the
de-intensification of nursing work in Australia. Nursing
Inquiry, 15(2), 148–157.
3663_Chapter 8_0121-0132.indd 1313663_Chapter 8_0121-0132.indd 131 9/15/2014 4:37:28 PM9/15/2014 4:37:28 PM
Process CyanProcess CyanProcess MagentaProcess MagentaProcess YellowProcess YellowProcess BlackProcess Black
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133
chapter 9
People and the Process of Change
OBJECTIVES
After reading this chapter, the student should be able to:
■ Describe the process of change.
■ Recognize resistance to change and identify its sources.
■ Suggest strategies to reduce resistance to change.
■ Assume a leadership role in implementing change.
OUTLINE
Change
A Natural Phenomenon
Macro and Micro Change
Change and the Comfort Zone
Resistance to Change
Receptivity to Change
Preference for Certainty
Speaking to People’s Feelings
Sources of Resistance
Technical Concerns
Personal Needs
Position and Power
Recognizing Resistance
Lowering Resistance
Sharing Information
Disconfirming Currently Held Beliefs
Providing Psychological Safety
Dictating Change
Leading Change
Designing the Change
Planning
Implementing the Change
Integrating the Change
Personal Change
Conclusion
When asked the theme of a nursing management
conference, a top nursing executive answered,
“Change, change, and more change.” Whether it is
called innovation, turbulence, or change, change is
constant in the workplace today. Mismanaging
change is common. In fact, as many as three out of
four major change efforts fail (Cameron & Quinn,
2006; Hempel, 2005; Shirey, 2012), often because
of resistant staff or a resistant organizational culture.
This chapter discusses how people respond to
change, how you can lead change, and how you can
help people cope with change when it becomes
difficult.
Change
A Natural Phenomenon
“Being scared by change doesn’t help” (Carter
quoted by Safian, 2012, p. 97). Change is a part of
everyone’s lives. People have new experiences, meet
new people, and learn something new. People grow
up, leave home, graduate from college, begin a
career, and perhaps start a family. Some of these
changes are milestones, ones for which people have
prepared and have anticipated for some time. Many
are exciting, leading to new opportunities and chal-
lenges. Some are entirely unexpected, sometimes
welcome and sometimes not. When change occurs
too rapidly or demands too much, it can make
people uncomfortable, even anxious or stressed.
Macro and Micro Change
The “ever-whirling wheel of change” (Dent, 1995,
p. 287) in health care seems to spin faster every year.
Medicare and Medicaid cuts, large numbers of
people who are uninsured or underinsured, restruc-
turing, downsizing, and staff shortages are major
concerns. Increasingly diverse patient populations,
rapid advances in technology, and new research
findings necessitate frequent changes in nursing
practice (Boyer, 2013; Cornell et al., 2010; Rodts,
2011). When first introduced, managed care had a
tremendous impact on the provision of health care,
and the recent Patient Protection and Affordable
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134 unit 2 ■ Working Within an Organization
Care Act may revolutionize health-care delivery yet
again (Leonard, 2012; Webb & Marshall, 2010).
Such changes sweep through the health-care
system, affecting patients and caregivers alike. They
are the macro-level (large-scale) changes that affect
virtually every health-care facility.
A change may be local (confined to one nursing
care unit, for example) or organization-wide. The
change may be small, affecting just one care prac-
tice or one aspect of system operation, or sweeping,
revolutionizing the structure and operation of the
entire organization. Finally, the change may be
implemented gradually or happen swiftly (Chreim,
& Williams, 2012).
A series of small-scale changes to improve
care on a pediatric care unit are described by
MacDavitt (2011). They used a two-phase approach,
designing the change in Phase I and implementing
it in Phase II. One of the changes was initiation of
bedside rounding including family members if they
were available. Most of the pediatricians were
enthusiastic supporters. However, the pulmonolo-
gists were more resistant, agreeing to test it first
with only one patient, increasing the number by
one each day. This had to begin all over again the
next week when there was a new attending pulmo-
nologist. The team persisted, patiently working
through each new rotation of attending pulmon-
ologists. Families were enthusiastic about the
bedside rounds and complained if they didn’t
happen. This was critical to successful implementa-
tion of bedside rounds including families for all
patients on this unit.
Change anywhere in a system creates ripples
across the system (Parker & Gadbois, 2000). Every
change that occurs at the system (organization or
macro) level filters down to the micro level, to
nursing units, teams, and individuals. Nurses, col-
leagues in other disciplines, and patients are par-
ticipants in these changes. The micro level of
change is the primary focus of this chapter.
New graduates may find themselves given
responsibility for helping to bring about change.
The following change-related activities are exam-
ples of the kinds of changes in which they might
be asked to participate:
■ Introducing a new technical procedure
■ Implementing evidence-based practice
guidelines
■ Providing new policies for staff evaluation and
promotion
■ Participating in quality improvement and
patient safety initiatives
■ Preparing for surveys and safety inspections
Change and the Comfort Zone
The basic stages of the change process originally
described by Kurt Lewin in 1951 are unfreezing,
change, and refreezing (Lewin, 1951; Schein, 2004).
■ Unfreezing involves actions that create
readiness to change.
■ Change is the implementation phase, the
actions needed to put the change into effect.
■ Refreezing is the restabilizing phase during
which the change that was made becomes a
regular part of everyday functions.
Imagine a work situation that is basically stable.
People are generally accustomed to each other, have
a routine for doing their work, know what to expect,
and know how to deal with whatever problems
come up. They are operating within their “comfort
zone” (Farrell & Broude, 1987; Lapp, 2002). A
change of any magnitude is likely to move people
out of this comfort zone into discomfort. This
move out of the comfort zone is called unfreezing
(Fig. 9.1). For example:
Many health-care institutions offer nurses the choice
of weekday or weekend work. Given these choices,
Unfreezing Change Refreezing
Comfort
Zone
New Comfort
Zone
Discomfort
Zone
Figure 9.1 The change process. Based on Farrell, K., & Broude, C. (1987]). Winning the Change Game: How to Implement
Information Systems With Fewer Headaches and Bigger Paybacks. Los Angeles: Breakthrough Enterprises; and Lewin, K. (1951). Field
Theory in Social Science: Selected Theoretical Papers. New York: Harper & Row.
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chapter 9 ■ People and the Process of Change 135
nurses with school-age children are likely to f ind
their comfort zone on weekday shifts. Imagine the
discomfort they would experience if they were trans-
ferred to weekends. Such a change would rapidly
unfreeze their usual routine and move them into the
discomfort zone. They might have to f ind a new
babysitter or begin a search for a new child-care
center that is open on weekends. An alternative
would be to establish a child-care center where they
work. Yet another alternative would be to f ind a
position that offers more suitable working hours.
Whatever alternative they chose, the nurses were
being challenged to f ind a solution that enabled
them to move into a new comfort zone. To accom-
plish this, they would have to f ind a consistent,
dependable source of child care suited to their new
schedule and to the needs of their children and then
refreeze their situation. If they did not f ind a
satisfactory alternative, they could remain in an
unsettled state, in a discomfort zone, caught in a
conflict between their personal and professional
responsibilities.
As this example illustrates, what seems to be a small
change can greatly disturb the people involved in
it. The next section considers the many reasons why
change can be unsettling and why change provokes
resistance.
Resistance to Change
People resist change for a variety of reasons that
vary from person to person and situation to situa-
tion. You might find that one patient-care techni-
cian is delighted with an increase in responsibility,
whereas another is upset about it. Some people are
eager to make changes; others prefer the status quo
(Hansten & Washburn, 1999). Managers may find
that one change in routine provokes a storm of
protest and that another is hardly noticed. Why
does this happen? We will first consider why people
may be ready for change and why they may resist
change.
Receptivity to Change
Preference for Certainty
An interesting research study on nurses’ preferred
information processing styles suggests that nurse
managers were more receptive to change than were
their staff members (Kalisch, 2007). Nurse manag-
ers were found to be innovative and decisive,
whereas staff nurses preferred “proven” approaches
and were resistant to change. Nursing assistants,
unit secretaries, and licensed practical nurses were
also unreceptive to change, adding layers of people
who formed a “solid wall of resistance” to change.
Kalisch suggests that helping teams recognize their
preference for certainty (as opposed to change) will
increase their receptivity to necessary changes in
the workplace.
Speaking to People’s Feelings
Although both thinking and feeling responses to
change are important, Kotter (1999) says that the
heart of responses to change lies in the emotions
surrounding it. He suggests that a compelling story
will increase receptivity to a change more than a
carefully crafted analysis of the need for change. It
is more likely to create that sense of urgency needed
to stimulate change (Braungardt & Fought, 2008;
Shirey, 2011). How is this done? The following are
some examples of appeals to feelings.
■ Instead of presenting statistics about the
number of people who are re-admitted due
to poor discharge preparation, providing a
story may be more persuasive. For example,
you can tell the staff about a patient who
collapsed at home the evening after discharge
because he had not been able to control his
diabetes post-surgery. Trying to break his fall,
he fractured both wrists and needed surgical
repair. With broken wrists, he is now unable to
return home or take care of himself.
■ Even better, videotape an interview with this
man, letting him tell his story and describe the
repercussions of poor preparation for discharge.
■ Drama may also be achieved through visual
display. A culture plate of pathogens grown
from swabs of ventilator equipment and
patient room furniture is more attention-
getting than an infection control report. A
display of disposables with price tags attached
for just one patient is more memorable than
an accounting sheet listing the costs.
The purpose of these activities is to present a com-
pelling image that will affect people emotionally,
increasing their receptivity to change and moving
them into a state of readiness to change (Kotter,
1999).
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136 unit 2 ■ Working Within an Organization
Sources of Resistance
Resistance to change comes from three major
sources: technical concerns, relation to personal
needs, and threats to a person’s position and power
(Araujo Group).
Technical Concerns
The change itself may have design flaws. Resistance
may be based on concerns about whether the pro-
posed change is a good idea.
The Professional Practice Committee of a small hos-
pital suggested replacing a commercial mouthwash
with a mixture of hydrogen peroxide and water in
order to save money. A staff nurse objected to this
proposed change, saying that she had read a research
study several years ago that found peroxide solutions
to be an irritant to the oral mucosa (Tombes &
Gallucci, 1993). A later review of the research noted
that this depended on the concentration used (Hos-
sainian, Slot, Afennich, & Van der Weijden, 2011).
Fortunately, the chairperson of the committee recog-
nized that this objection was based on technical
concerns and requested a thorough study of the evi-
dence before instituting the change. “It’s important
to investigate the evidence supporting a proposed
change thoroughly before recommending it,” she said.
A change may provoke resistance for practical
reasons. For example, if the bar codes on patients’
armbands are difficult to scan, nurses may develop
a way to work around this safety feature by taping
a duplicate armband to the bed or to a clipboard,
defeating the electronically monitored medication
system (Englebright & Franklin, 2005).
Personal Needs
Change often creates anxiety, much of it related to
what people fear they might lose (Berman-Rubera,
2008; Johnston, 2008). Human beings have a hier-
archy of needs, from the basic physiological needs
to the higher-order needs for belonging, self-
esteem, and self-actualization (Fig. 9.2). Maslow
(1970) observed that the more basic needs (those
lower on the hierarchy) must be at least partially
met before a person is motivated to seek fulfillment
of the higher-order needs.
Change may make it more difficult for a person
to meet any or all of his or her needs. It may
threaten safety and security needs. For example, if
a massive downsizing occurs and a person’s job is
eliminated, needs ranging from having enough
money to pay for food and shelter to opportunities
to fulfill one’s career potential are likely to be
threatened.
In other cases, the threat is subtler and may be
harder to anticipate. For example, an institution-
wide reevaluation of the effectiveness of the ad-
vanced practice role would be a great concern to a
staff nurse who is working toward accomplishing a
lifelong dream of becoming an advanced practice
nurse in oncology. Staff reorganization that moves
some staff members to different units could chal-
lenge the belonging needs of those who have close
friends on the unit but few friends outside of work.
Position and Power
Once gained within an organization, status, power,
and influence are hard to relinquish. This applies
to people anywhere in the organization, not just
those at the top. For example:
A clerk in the surgical suite had been preparing the
operating room schedule for many years. Although
his supervisor was expected to review the schedule
Highest Level
Lowest Level
Self-actualization
Growth, development,
fulfill potential
Esteem
Self-esteem, respect,
recognition
Love and belonging
Acceptance, approval,
inclusion, friendship
Safety and security
Physical safety, trust,
stability, assistance
Physiological needs
Air, water, food, sleep,
shelter, sex, stimulation
Figure 9.2 Maslow’s hierarchy of needs. Based on
Maslow, A.H. (1970). Motivation and Personality. New York:
Harper & Row.
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chapter 9 ■ People and the Process of Change 137
before it was posted, she rarely did so because the
clerk was skillful in balancing the needs of various
parties, including some very demanding surgeons.
When the supervisor was transferred to another
facility, her replacement decided that she had to
review the schedules before they were posted because
they were ultimately her responsibility. The clerk
became defensive. He tried to avoid the new super-
visor and posted the schedules without her approval.
This surprised her. She knew the clerk did this well
and did not think that her review of them would be
threatening.
Why did this happen? The supervisor had not real-
ized the importance of this task to the clerk. The
opportunity to tell others when and where they
could perform surgery gave the clerk a feeling of
power and importance. The supervisor’s insistence
on reviewing his work reduced the importance of
his position. What seemed to the new supervisor
to be a very small change in routine had provoked
surprisingly strong resistance because it threatened
the clerk’s sense of importance and power.
Recognizing Resistance
Resistance may be active or passive (Heller, 1998).
It is easy to recognize resistance to a change when
it is expressed directly. When a person says to you,
“That’s not a very good idea,” “I’ll quit if you sched-
ule me for the night shift,” or “There’s no way I’m
going to do that,” there is no doubt you are encoun-
tering resistance. Active resistance can take the
form of outright refusal to comply, writing memos
that destroy the idea, quoting existing rules that
make the change difficult to implement, or encour-
aging others to resist.
When resistance is less direct, however, it can be
difficult to recognize unless you know what to look
for. Passive approaches usually involve avoidance:
canceling appointments to discuss implementation
of the change, being “too busy” to make the change,
refusing to commit to changing, agreeing to it but
doing nothing to change, and simply ignoring the
entire process as much as possible (Table 9-1).
Once resistance has been recognized, action can be
taken to lower or even eliminate it.
Lowering Resistance
A great deal can be done to lower people’s resis-
tance to change. Strategies fall into four categories:
sharing information, disconfirming currently held
beliefs, providing psychological safety, and dictating
(forcing) change (Tappen, 2001).
Sharing Information
Much resistance is simply the result of misunder-
standing a proposed change. Sharing information
about the proposed change can be done on a one-
to-one basis, in group meetings, or through written
materials distributed to everyone involved via print
or electronic means.
Disconf irming Currently Held Beliefs
Disconfirming current beliefs is a primary force for
change (Schein, 2004). Providing evidence that
what people are currently doing is inadequate,
incorrect, inefficient, or unsafe can increase people’s
willingness to change. For example, Lindberg and
Clancy (2010) note a widespread belief in the inevi-
tability of health-care associated infections, that
they are unfortunate but unavoidable. To imple-
ment a successful campaign to reduce infection
rates, this myth would have to be dispelled. The
dramatic presentations described in the section on
receptivity help to disconfirm current beliefs and
practices. The following is a less dramatic example
but still persuasive:
Jolene was a little nervous when her turn came to
present information to the Clinical Practice Com-
mittee on a new enteral feeding procedure. Commit-
tee members were very demanding: they wanted
clear, evidence-based information presented in a
concise manner. Opinions and generalities were not
acceptable. Jolene had prepared thoroughly and had
practiced her presentation at home until she could
speak without referring to her notes. The presenta-
tion went well. Committee members commented on
how thorough she was and on the quality of the
information presented. To her disappointment,
however, no action was taken on her proposal.
table 9-1
Resistance to Change
Active Passive
Attacking the idea Avoiding discussion
Refusing to change Ignoring the change
Arguing against the change Refusing to commit to the
change
Organizing resistance of other
people
Agreeing but not acting
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138 unit 2 ■ Working Within an Organization
Returning to her unit, she shared her disappoint-
ment with the nurse manager. Together, they used
the unfreezing-change-refreezing process as a guide
to review the presentation. The nurse manager
agreed that Jolene had thoroughly reviewed the
information on enteral feeding. The problem, she
explained, was that Jolene had not attended to the
need to unfreeze the situation. Jolene realized that
she had not put any emphasis on the high risk of
contamination and resulting gastrointestinal dis-
turbances of the procedure currently in use. She had
left members of the committee still comfortable with
current practice because she had not emphasized the
risk involved in failing to change it.
At the next meeting, Jolene presented addi-
tional information on the risks associated with
the current enteral feeding procedures. This discon-
firming evidence was persuasive. The committee
accepted her proposal to adopt the new, lower-risk
procedure.
Without the addition of the disconfirming evi-
dence, it is likely that Jolene’s proposed change
would never have been implemented. The inertia
(tendency to remain in the same state rather than
to move toward change) exhibited by the Clinical
Practice Committee is not unusual (Pearcey &
Draper, 1996).
Providing Psychological Safety
As indicated earlier, a proposed change can threaten
people’s basic needs. Resistance can be lowered by
reducing that threat, leaving people feeling more
comfortable with the change. Each situation poses
different kinds of threats and, therefore, requires
different actions to reduce the levels of threat; the
following is a list of useful strategies to increase
psychological safety:
■ Express approval of people’s interest in
providing the best care possible.
■ Recognize the competence and skill of the
people involved.
■ Provide assurance (if possible) that no one will
lose his or her position because of the change.
■ Suggest ways in which the change can
provide new opportunities and challenges
(new ways to increase self-esteem and
self-actualization).
■ Involve as many people as possible in the
design or plan to implement change.
■ Provide opportunities for people to express
their feelings and ask questions about the
proposed change.
■ Allow time for practice and learning of any
new procedures before a change is
implemented.
Dictating Change
This is an entirely different approach to change.
People in authority in an organization can simply
require people to make a change in what they are
doing or can reassign people to new positions
(Porter-O’Grady, 1996). This may not work well if
there are ways for people to resist, however, such as
in the following situations:
■ When passive resistance can undermine the
change
■ When high motivational levels are necessary to
make the change successful
■ When people can refuse to obey the order
without negative consequences
The following is an example of an unsuccessful
attempt to dictate change:
A new, insecure nurse manager believed that her
staff members were taking advantage of her inex-
perience by taking more than the two 15-minute
coffee breaks allowed during an 8-hour shift. She
decided that staff members would have to sign in
and out for their coffee breaks and their 30-minute
meal break. Staff members were outraged by this
new policy. Most had been taking fewer than 15
minutes for coffee breaks or 30 minutes for lunch
because of the heavy care demands of the unit. They
refused to sign the coffee break sheet. When asked
why they had not signed it, they replied, “I forgot,”
“I couldn’t f ind it,” or “I was called away before I
had a chance.” This organized passive resistance was
suff icient to overcome the nurse manager’s author-
ity. The nurse manager decided that the coffee break
sheet had been a mistake, removed it from the bul-
letin board, and never mentioned it again.
For people in authority, dictating a change often
seems to be the easiest way to institute change: just
tell people what to do, and do not listen to any
arguments. There is risk in this approach, however.
Even when staff members do not resist authority-
based change, overuse of dictates can lead to a
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chapter 9 ■ People and the Process of Change 139
passive, dependent, unmotivated, and unempow-
ered staff. Providing high-quality patient care
requires staff members who are active, motivated,
and highly committed to their work.
Leading Change
Now that you understand how change can affect
people and have learned some ways to lower their
resistance to change, consider what is involved in
taking a leadership role in successful implementa-
tion of change.
The entire process of bringing about change can
be divided into four phases: designing the change,
deciding how to implement the change, carrying
out the actual implementation, and following
through to ensure the change has been integrated
into the regular operation of the facility (Fig. 9.3).
Designing the Change
This is the starting point. The first step in bringing
about change is to craft the change carefully. Not
every change is for the better: some fail because
they are poorly conceived in the first place.
Ask yourself the following questions:
■ What are we trying to accomplish?
■ Is the change necessary?
■ Is the change technically correct?
■ Will it work?
■ Is this change a better way to do things?
Encourage people to talk about the changes
planned, to express their doubts, and to provide
their input (Fullan, 2001). Those who do are usually
enthusiastic supporters later in the process.
Planning
All the information presented previously about
sources of resistance and ways to overcome that
resistance should be taken into consideration when
deciding how to implement a change.
For large-scale change, it is often helpful to ap-
point a champion, even a co-champion, to lead the
innovation, helping staff prepare for the change and
monitoring progress (Staren, Braun, & Denny, 2010).
The environment in which the change will take
place is another factor to consider when assessing
resistance to change. This includes the amount of
change occurring at the same time and past history
of change in the organization. Is there goodwill
toward change because it has gone well in the past?
Or have other changes gone badly? Bad experiences
with previous changes can generate ill will and
resistance to additional change (Maurer, 2008).
There may be external pressure to change because
of the competitive nature of the health-care market.
In other situations, government regulations either
may make it difficult to bring about a desired
change or may force a change.
Almost everything you have learned about effec-
tive leadership is useful in planning the implemen-
tation of change: communicating the vision,
motivating people, involving people in decisions
that affect them, dealing with conflict, eliciting
cooperation, providing coordination, and fostering
teamwork. Consider all of these when formulating
a plan to implement a change. Remember that
people have to be moved out of their comfort zone
to get them ready to change.
Implementing the Change
You are finally ready to embark on a journey of
change and innovation that has been carefully
planned. Consider the following factors:
■ Magnitude: Is it a major change that affects
almost everything people do, or is it a minor
one?
■ Complexity: Is this a difficult change to make?
Does it require much new knowledge and skill?
How much time will it take to acquire them?
■ Pace: How urgent is this change? Can it be
done gradually, or must it be implemented
immediately?
■ Stress: Is this the only change that is taking
place, or is it just one of many? How stressful
Design the Change
Plan the Implementation
Implement the Change
Integrate the Change
Figure 9.3 Four phases of planned change.
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140 unit 2 ■ Working Within an Organization
are these changes? How can you help people
keep their stress at tolerable levels?
A simple change, such as introducing a new type
of thermometer, may be planned, implemented, and
integrated easily into everyone’s work routine. A
complex change, such as introducing a new medica-
tion administration system, may require testing the
new system, evaluating what works and what does
not, and adapting the system before it works well
in your facility.
Some discomfort is likely to occur with almost
any change, and it is important to keep it within
tolerable limits. You can exert some pressure to
make people pay attention to the change process,
but not so much pressure that they are overstressed.
In other words, you want to raise the heat enough
to get them moving but not so much that they boil
over (Heifetz & Linsky, 2002).
Integrating the Change
This is the refreezing phase of change. After the
change has been made, make sure that everyone has
moved into a new comfort zone. Ask yourself:
■ Is the change well integrated into everyday
operations and routines?
■ Is it working well?
■ Are people comfortable with it?
■ Is it well accepted? Is there any residual
resistance that could still undermine it?
It may take some time before a change is fully
integrated into everyday routines. As Kotter noted,
change “sticks” when, instead of being the new way
to do something, it has become “the way we always
do things around here” (1999, p. 18).
Personal Change
The focus of this chapter is on leading others
through the process of change. However, if you are
leading change, you “have to be willing to change
yourself ” (Olivier quoted by Suddath, 2012, p. 85).
Choosing to change may be an important part of
your development as a leader.
Hart and Waisman (2005) used the story of the
caterpillar and the butterfly to illustrate personal
change:
Caterpillars cannot fly. They have to crawl or climb
to f ind their food. Butterflies, on the other hand, can
soar above an obstacle. They also have a different
perspective on their world because they can fly. It is
not easy to change from a caterpillar to a butterfly.
Indeed, the transition (metamorphosis) may be quite
uncomfortable and involves some risk. Are you ready
to become a butterfly?
The process of personal change is similar to the
process described throughout this chapter: first rec-
ognize the need for change, then learn how to do
things differently, and then become comfortable
with the “new you” (Guthrie & King, 2004). A
more detailed step-by-step process is given in Table
9-2. You might, for example, decide that you need
to stop interrupting people when they speak with
you. Or you might want to change your leadership
style from laissez-faire to participative.
Is a small change easier to accomplish than a
radical change? Perhaps not. Deutschman (2005a)
reports research that suggests radical change might
be easier to accomplish because the benefits are
evident much more quickly.
An extreme example: on the individual level,
many people could avoid a second coronary bypass
or angioplasty by changing their lifestyle, yet 90%
do not do so. Deutschman compares the typical
advice (exercise, stop smoking, eat healthier meals)
with Ornish’s radical vegetarian diet (only 10% of
calories from fat). After 3 years, 77% of the patients
who went through this extreme change had contin-
ued these lifestyle changes. Why? Ornish suggests
several reasons: (1) after several weeks, people felt
a change—they could walk or have sex without
pain; (2) information alone is not enough—the
emotional aspect is dealt with in support groups
and through meditation, relaxation, yoga, and
aerobic exercise; and (3) the motivation to pursue
this change is redefined—instead of focusing on
fear of death, which many find too frightening,
Ornish focuses on the joy of living, feeling better,
and being active without pain.
A large-scale, revolutionary change from frag-
mented, provider-centered care to fully integrated
patient-centered primary care is described by
Chreim and colleagues (2012). A family practice
with eight physicians saw 9,000 patients a year.
Some of the care they provided (well baby care, for
example) overlapped with (duplicated) the public
health nurses’ care. To integrate care would require
radical changes in the system including electronic
sharing of patient records, paying physicians per
patient per year (called capitation) instead of per
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chapter 9 ■ People and the Process of Change 141
visit and moving physicians, nurses, and others to
shared locations. After 4 years, patient satisfaction
was higher and more received preventive services
such as Pap smears or blood pressure checks. Col-
laboration and teamwork among providers
increased. Chreim and colleagues noted that there
had been considerable motivation to change and
the provincial government supported the change.
“What is best for the patient” (p. 227) became a
shared value and motivation. There were many dif-
ficulties to overcome, including frustration with
developing and learning how to use the electronic
information system, deciding how to share tasks
such as diabetes education, and limited physical
space to co-locate care providers. Perseverance
when encountering barriers and setbacks and ability
to tolerate uncertainty were essential in implement-
ing this large-scale change successfully.
The traditional approach to change is turned
on its head: a major change appears easier to
accomplish than a minor change, and people are
not stressed but feel better making the change.
Deutschman’s list of five commonly accepted
myths about change that have been refuted by new
insights from research summarize this approach
(Table 9-3).
It remains to be seen whether these new insights
on changing behavior are useful outside of these
special situations.
Conclusion
Change is an inevitable part of living and working.
How people respond to change, the amount
of stress it causes, and the amount of resistance it
provokes can be influenced by good leadership.
Handled well, most changes can become opportu-
nities for professional growth and development
rather than just additional stressors with which
nurses and their clients have to cope.
table 9-2
Which Stage of Change Are You In?
While studying how smokers quit the habit, Dr. James Prochaska, a psychologist at the University of Rhode Island,
developed a widely influential model of the “stages of change.” What stage are you in? See if any of the following
statements sound familiar.
Typical Statement Stage Risks
“As far as I’m concerned, I don’t have any
problems that need changing.”
1
Precontemplation
You are in denial. You probably feel coerced by other
people who are trying to make you change. But they
are not going to shame you into it—their meddling will
backfire.
“I guess I have faults, but there’s nothing that
I really need to change.”
(“Never”)
“I’ve been thinking that I wanted to change
something about myself.”
2
Contemplation
Feeling righteous because of your good intentions, you
could stay in this stage for years. But you might respond
to the emotional persuasion of a compelling leader.
“I wish I had more ideas on how to solve
my problems.”
(“Someday”)
“I have decided to make changes in the
next 2 weeks.”
3
Preparation
This “rehearsal” can become your reality. Some 85% of
people who need to change their behavior for health
reasons never reach this stage or progress beyond it.
“I am committed to join a fitness club by the
end of the month.”
(“Soon”)
“Anyone can talk about changing. I’m
actually doing something about it.”
4
Action
It is an emotional struggle. It is important to change
quickly enough to feel the short-term benefits that give a
psychic lift and make it easier to stick with the change.
“I am doing okay, but I wish I was more
consistent.”
(“Now”)
“I may need a boost right now to help me
maintain the changes I’ve already made.”
5
Maintenance
Relapse. Even though you have created a new mental
pathway, the old pathway is still there in your brain,
and when you are under a lot of stress, you might fall
back on it.
“This has become part of my day, and I feel
it when I don’t follow through.”
(“Forever”)
Source: Adapted from Deutschman’s which stage of change are you in? “Typical statements” adapted from stages of
change: theory and practice by Michael Samuelson, executive director of the National Center for Health
Promotion.
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142 unit 2 ■ Working Within an Organization
table 9-3
Five Myths About Changing Behavior: An Alternative Perspective
Myth Reality
1. Crisis is a powerful impetus for
change.
Ninety percent of patients who have had coronary bypasses do not sustain
changes in their unhealthy lifestyles, which worsens their heart disease and
threatens their lives.
2. Change is motivated by fear. It is too easy for people to deny the bad things that might happen to them.
Compelling positive visions of the future are a stronger inspiration for change.
3. The facts will set us free. Our thinking is guided by narratives, not facts. When a fact does not fit people’s
conceptual “frames”—the metaphors used to make sense of the world—people
reject the fact. Change is best inspired by emotional appeals rather than factual
statements.
4. Small, gradual changes are easier
to make and sustain.
Radical changes may be easier because they yield benefits quickly.
5. People cannot change because the
brain becomes “hardwired” early in
life.
Brains have extraordinary “plasticity,” meaning that people can continue learning
throughout life—assuming they remain active and engaged.
Source: Adapted from Deutschman’s Fact Take: Five Myths About Changing Behavior. Deutschman, A. (2005/May).
Change or die. Fast Company, 94, 52–62.
Study Questions
1. Why is change inevitable? What would happen if no change at all occurred in health care?
2. Why do people resist change? Why do nursing staff seem particularly resistant to change?
3. How can leaders overcome resistance to change?
4. Describe the process of implementing a change from beginning to end. Use an example from
your clinical experience to illustrate this process.
Case Study to Promote Critical Reasoning
A large health-care corporation recently purchased a small, 50-bed rural nursing home. A new
director of nursing was brought in to replace the former one, who had retired after 30 years. The
new director addressed the staff members at the reception held to welcome him. “My philosophy
is that you cannot manage anything that you haven’t measured. Everyone tells me that you have all
been doing an excellent job here. With my measurement approach, we will be able to analyze
everything you do and become more efficient than ever.” The nursing staff members soon found
out what the new director meant by his measurement approach. Every bath, medication, dressing
change, episode of incontinence care, feeding of a resident, or trip off the unit had to be counted,
and the amount of time each activity required had to be recorded. Nurse managers were required
to review these data with staff members every week, questioning any time that was not accounted
for. Time spent talking with families or consulting with other staff members was considered
time wasted unless the staff member could justify the “interruption” in his or her work. No one
complained openly about the change, but absenteeism rates increased. Personal day and vacation
time requests soared. Staff members nearing retirement crowded the tiny personnel office,
overwhelming the sole staff member with their requests to “tell me how soon I can retire with full
benefits.” The director of nursing found that shortage of staff was becoming a serious problem and
that no new applications were coming in, despite the fact that this rural area offered few good job
opportunities.
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chapter 9 ■ People and the Process of Change 143
1. What evidence of resistance to change can you find in this case study?
2. What kind of resistance to change did the staff members exhibit?
3. Why did staff members resist this change?
4. If you were a staff nurse at this facility, how do you think you would have reacted to this
change in administration?
5. How do you think the director of nursing handled this change? What could the nurse
managers and staff nurses do to improve the situation?
6. How could the new administrator have made this change more acceptable to the staff ?
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144 unit 2 ■ Working Within an Organization
References
Araujo Group. A compilation of opinions of experts in the
field of the management of change. Unpublished report.
Berman-Rubera, S. (2008, August 10). Leading and
embracing change. Business/Change-Management.
Retrieved from http://ezinearticles.
com/?Leading-And-Embracing-Change&id=1180585
Boyer, D. (2013). Paradigm shift: How ICD-10 will change
healthcare. Health Management Technology, 34(9),
24.
Braungardt, T., & Fought, S.G. (2008). Leading change
during an inpatient critical care unit expansion. Journal
of Nursing Administration, 38(11), 461–467.
Cameron, K.S., & Quinn, Q.E. (2006). Diagnosing
and changing organizational culture. New York:
Jossey-Bass.
Chreim, S., & Williams, B.E. (2012). Radical change in
healthcare organization: Mapping transition between
templates, enabling factors, and implementation
processes. Journal of Health Organization and
Management, 26(2), 215–236.
Cornell, P., Riordan, M., & Herrin-Griffith, D. (2010).
Transforming nursing workflow, part 2: The impact of
technology on nurse activities. Journal of Nursing
Administration, 40(10), 432–439.
Dent, H.S. (1995). Job Shock: Four new principles
transforming our work and business. New York: St.
Martin’s Press.
Deutschman, A. (2005a). Change or die. Fast Company,
94, 52–62.
Deutschman, A. (2005b). What state of change are you
in? Retrieved from www.fastcompany.com/52596/
which-stage-change-are-you
Englebright, J.D., & Franklin, M. (2005). Managing a new
medication administrative process. Journal of Nursing
Administration, 35(9), 410–413.
Farrell, K., & Broude, C. (1987). Winning the change
game: How to implement information systems with fewer
headaches and bigger paybacks. Los Angeles:
Breakthrough Enterprises.
Fullan, M. (2001). Leading in a culture of change. San
Francisco: Jossey-Bass.
Guthrie, V.A., & King, S.N. (2004). Feedback-intensive
programs. In McCauley, C.D., & Van Velson, E. (eds.),
The center for creative leadership handbook of
leadership development. San Francisco: Jossey-Bass.
Hansten, R.I., & Washburn, M.J. (1999). Individual and
organizational accountability for development of critical
thinking. Journal of Nursing Administration, 29(11),
39–45.
Hart, L.B., & Waisman, C.S. (2005). The leadership
training activity book. N.Y.: AMACOM.
Heifetz, R.A., & Linsky, M. (June 2002). A survival guide for
leaders. Harvard Business Review, 65–74.
Heller, R. (1998). Managing change. New York: DK
Publishing.
Hempel, J. (2005). Why the boss really had to say
goodbye. Business Week, July 4, p. 10.
Hossainian, N., Slot, D.E., Afennich, F., & Van der
Weijden, G.A. (2011). The effects of hydrogen
peroxide mouthwashes on the prevention of plaque and
gingival inflammation: A systematic review. International
Journal of Dental Hygiene, 9, 171–181.
Johnston, G. (2008, March 8). Change management—
Why the high failure rate. Business/Change-
Management. Retrieved from http://ezinearticles.
com/?Change-Management—Why-the-High-Failure
-Rate?&id=1028294
Kalisch, B.J. (2007). Don’t like change? Blame it on your
strategic style. Reflections on Nursing Leadership,
33(3). Retrieved from http://nursingsociety.org/
RNL/3Q_2007/features/feature5.html
Kotter, J.P. (1999). Leading change: The eight steps to
transformation. In Conger, J.A., Spreitzer, G.M., &
Lawler, E.E. (eds.), The Leader’s Change Handbook: An
Essential Guide to Setting Direction and Taking Action.
San Francisco: Jossey-Bass.
Lapp, J. (May 2002). Thriving on change. Caring
Magazine, 40–43.
Leonard, D. (2012/October 15). Obamacare is not an
epithet. Bloomberg Business Week, 98–100.
Lewin, K. (1951). Field theory in social science: Selected
theoretical papers. New York: Harper & Row.
Lindberg, C., & Clancy, T.R. (2010). Positive deviance: An
elegant solution to a complex problem. Journal of
Nursing Administration, 40(4), 150–153.
MacDavitt, K. (2011). Implementing small tests of change to
improve patient satisfaction. The Journal of Nursing
Administration, 41(1), 5–9.
Maslow, A.H. (1970). Motivation and personality. New
York: Harper & Row.
Maurer, R. (2008, August 13). The 4 reasons why people
resist change. Business/Change-Management. Retrieved
from http://ezinearticles.com/?The-7-Reasons-Why
-People-Resist-Change&id=1053595
Parker, M., & Gadbois, S. (2000). Building community in
healthcare workplace. Part 3: Belonging and satisfaction
at work. Journal of Nursing Administration, 30,
466–473.
Pearcey, P., & Draper, P. (1996). Using the diffusion of
innovation model to influence practice: A case study.
Journal of Advanced Nursing, 23, 724–726.
Porter-O’Grady, T. (1996). The seven basic rules for
successful redesign. Journal of Nursing Administration,
26(1), 46–53.
Rodts, M.F. (2011). Technology changes healthcare.
Orthopedic Nursing, 30(5), 292
Safian, R. (2012/November). Secrets of the flux leader.
Fast Company, 170, 96–106, 136.
Schein, E.H. (2004, August 1). Kurt Lewin’s change theory
in the field and in the classroom: Notes toward a
model of managed learning. Retrieved from www.
a2zpsychology.com/articles/kurt_lewin’s_change_theory.
htm
Shirey, M.R. (2011). Establishing a sense of urgency for
leading transformational change. Journal of Nursing
Administration, 41(4), 145–148.
Shirey, M.R. (2012). Stakeholder analysis and mapping as
targeted communication strategy. Journal of Nursing
Administration, 42(9), 399–403.
Staren, E.D., Braun, D.P., & Denny, D.S. (2010/March-
April). Optimizing innovation in health care organization.
Physicians Executive Journal, 54–62.
Suddath, C. (2012/December 3-9). Business by the bard.
Bloomberg Business Week, 83–85.
Tappen, R.M. (2001). Nursing leadership and management:
concepts and practice. Philadelphia: F.A. Davis.
Tombes, M.B., & Gallucci, B. (1993). The effects of
hydrogen peroxide rinses on the normal oral mucosa.
Nursing Research, 42, 332–337.
Webb, J.A.K., & Marshall, D.R. (2010). Healthcare reform
and nursing. Journal of Nursing Administration, 49(9),
345–349.
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unit 3
Career Considerations
chapter 10 Issues of Quality and Safety
chapter 11 Promoting a Healthy Work Environment
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147
chapter 10
Issues of Quality and Safety
OBJECTIVES
After reading this chapter, the student should be able to:
■ Discuss the history of quality and safety within the U.S.
health-care system.
■ Analyze historical, social, political, and economic trends
affecting the nursing profession and the health-care delivery
system.
■ Explain the importance of quality improvement (QI) for the
nurse, patient, organization, and health-care delivery system.
■ Discuss the role of the nurse in continuous quality
improvement (CQI) and risk management.
■ Examine factors contributing to medical errors and
evidence-based methods for the prevention of medical errors.
■ Explain the use of technology to enhance and promote safe
patient care, educate patients and consumers, evaluate
health-care delivery, and enhance the nurse’s knowledge base.
■ Describe the effects of communication on patient-centered
care, interprofessional collaboration, and safety.
■ Promote the role of the nurse in the delivery of safe,
effective quality care in today’s health-care environment.
OUTLINE
Overview
Historical Trends and Issues
The Institute of Medicine and the Committee on the
Quality of Health Care in America
Quality in the Health-Care System
Quality Improvement (QI)
Using CQI to Monitor and Evaluate Quality of Care
QI at the Organizational and Unit Levels
Strategic Planning
Structured Care Methodologies
Critical Pathways
Aspects of Health Care to Evaluate
Structure
Process
Outcome
Risk Management
The Nursing Shortage and Patient Safety
Factors Contributing to the Nursing Shortage
Safety in the U.S. Health-Care System
Types of Errors
Error Identification and Reporting
Developing a Culture of Safety
Organizations, Agencies, and Initiatives Supporting
Quality and Safety in the Health-Care System
Government Agencies
Health-Care Provider Professional Organizations
Nonprofit Organizations and Foundations
Quality Organizations
Integrating Initiatives and Evidenced-Based Practices
Into Patient Care
Influence of Nursing
Conclusion
Overview
You are entering professional nursing at a time
when issues pertaining to quality and safety of the
U.S. health-care system have come to the forefront
in the delivery of health care. Considering the com-
plexity of the decisions nurses make every day in
managing patient care at the bedside, it may seem
natural that these decisions would be based on safe
and effective care. However, often this is not the
case. As a professional registered nurse (RN), you
will participate daily in activities necessary to
support quality and safety initiatives at the bedside,
within your organization, and as part of the health-
care system. Patients place their lives in nurses’
hands and trust them to be knowledgeable and to
use good judgment when making decisions about
care. As nurses we need to understand that we work
within a system, and whenever there is a breakdown
somewhere within the system, the risk for error
increases. This chapter discusses quality and safety
in health care, presents reasons for errors, and offers
ways nurses can help to create a culture of safety.
Historical Trends and Issues
Many forces drive the rapidly changing health-care
delivery system (Baldwin, Conger, Maycock, &
Abegglen, 2002; Davis, 2001; Elwood, 2007; Ervin,
Bickes, & Schim, 2006; Menix, 2000; Milton,
2011). In this time of global health-care reform,
regulation at the global, national, state, and local
levels has taken on a new significance (Milton,
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148 unit 3 ■ Career Considerations
2011). The impetus to decrease costs and improve
outcomes influences the current movement toward
improved quality and safety. These forces include
economics, societal demographics and diversity,
regulation and legislation, technology, health-
care delivery and practice, and environment and
globalization.
Economics. Many economic trends and issues
affect the U.S health-care delivery system. Busi-
nesses, government, and the media criticize the
cost of health care within the United States when
compared with that of other developed nations
( Jackson, 2006; Kersbergen, 2000; Milton, 2011).
The costs of research and the costs to develop new
treatments and technology continue to rise. Edu-
cated consumers expect safe, quality care with asso-
ciated satisfaction and positive health outcomes.
Nurses need to be prepared to support consumers
with a thorough knowledge of quality, account-
ability, and cost-effectiveness (AACN, 2008, 2012).
This means that they must have the knowledge to
educate patients regarding the technology used in
their treatments and explain the rationale behind
the treatment selection. While initial expenses
may increase, improvements in quality and safety
will reduce costs in the long term (Aiken et. al.,
2012; Cronenwett et al, 2007; Institute of Medi-
cine [IOM], 2003a; Weiss, Yakusheva, & Bobay,
2011).
Societal demographics and diversity. Increased
numbers of racial and ethnic groups influence
health-care delivery (Billings & Halsted, 2011;
Davis, 2010; Elwood 2007; Health and Human
Services [HHS], 2011; Heller, Oros, & Durney-
Crowley, 2000; World Health Organization, 2009).
Increased numbers of the elderly, longer life expec-
tancy, and improvements in technology result in an
emphasis on specialized geriatric care. Both the
elderly and ethnic minorities are at-risk popula-
tions who suffer disadvantages in access to care,
payment for care, and quality of care (Affordable
Care Act, 2010; Anderson, Scrimshaw, Fullilove,
Fielding, & Normand, 2003). It is hoped that the
passage of the Affordable Care Act (ACA) will
minimize these disparities as more of these indi-
viduals will have access to health-care services
(Davis, 2010).
Regulation and legislation. The diverse interests
of consumers, insurance companies, government,
and regulation affect health-care legislation. For
health-care leaders and providers of care, unprec-
edented challenges continue despite the attention
that quality and safety have received during the
evolution of the existing health-care system. The
ACA now provides health care to individuals who
previously lacked coverage. This access to care will
increase the numbers of individuals who will need
providers as well as force changes in regulation and
cost management.
Technology. The use of technology and the incor-
poration of the electronic health record are pro-
jected to decrease costs and improve clinical
outcomes, quality, and safety (IOM, 2003a; Poon
et al., 2010). Nursing practice must adjust to these
health-care delivery trends with the inclusion of
concepts in interprofessional collaboration, patient-
focused systems, and information literacy (Booth,
2006; Sargeant, Loney, & Murphy, 2008). Addi-
tionally, nurses must utilize technology and infor-
matics to incorporate evidenced-based practices for
improved quality and safety in the health-care
delivery system (Hunter, 2011).
Technology also produces advancements in
disease treatments, especially in the areas of genet-
ics and genomics, and all professionals must inte-
grate these advancements into practice (Calzone,
Cashion, Feetham, Jenkins, Prows, Williams, &
Wung, 2010; Lea, Skirton, Read, & Williams,
2011). The current advances in genetics and genom-
ics continue to allow the redesign of treatments for
a variety of genetic disorders, quality improvement
(QI), and outcomes in clinical practice often related
to pharmacotherapeutics (Trossman, 2006; Lea,
Skirton, Read, & Williams, 2011).
Health-care delivery and practice. Health-care
professionals should be prepared to provide safe,
quality care in all settings, including acute care and
community settings. Nurses and other health-care
professionals need the knowledge, skills, attitudes,
and competencies to function in a variety of set-
tings and the ability to support the needs of the
increasingly diverse population (Anderson et al.,
2003; Ervin, Bickes, & Schim, 2006; Heller, Oros,
& Durney-Crowley, 2000).
The integration of evidenced-based practice
serves to improve quality and safety for patients,
and improves collaboration and interprofessional
teamwork (IOM, 2003a; O’Neill, 1998). Both the
IOM (2003a) and the Pew Health Professions
Commission (PEW, 1998) identified the need for
the health-care delivery system and its profession-
als to improve collaboration and to work in an
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chapter 10 ■ Issues of Quality and Safety 149
interprofessional team to improve quality and
safety.
Environment and globalization. The emergence
of a global economy, the ease of travel, and advances
in communication technology affect the move-
ment of people, money, and disease (Heller, Oros,
& Durney-Crowley, 2000; Kirk, 2002). Global
warming and climate change have been linked to
the emergence of new drug-resistant organisms and
an increase in vector-borne and waterborne disease
as warmer temperatures promote changes in organ-
ism structure and increase the growth rate of bac-
teria. Increased ease of travel allows for migration
of affected populations. Safe, quality health care
will need to confront the challenges of increasing
multiculturalism, potential for pandemic, and the
effect of climate change and pollution on health.
In addition, many health-care professionals,
government agencies, and supporting organizations
have contributed to the evolution of quality and
safety within the health-care system. The Histori-
cal Timeline (Table 10-1) highlights significant
organizations and initiatives of importance to
quality and safety.
table 10-1
Historical Timeline
1896 Nurses Associated Alumnae of the United States and Canada formed, later called the American Nurses
Association (ANA)
1906 Food and Drug Act signed, which began the regulation of food and drugs to protect consumers
1918 American College of Surgeons founded, which initiated minimum standards for hospitals and on-site hospital
inspections for adherence to standards
1930s Employers began offering health benefits, and the first commercial insurance companies arose
1945 Quality management principles developed by Edward Deming were applied successfully to industries such as
manufacturing, government, and health care
1951 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) founded; currently referred to as The Joint
Commission (JC)
1955 Social Security Act passed; hospitals that had volunteered for accreditation by JCAHO were approved for
participation in Medicare and Medicaid
1966 Quality of health-care services defined in the literature
1970 IOM established as a nonprofit adviser to the nation to improve health in the national academies
1979 National Committee on Quality Assurance (NCQA) established
1986 National Center of Nursing Research founded at the National Institutes of Health (NIH)
1989 Agency for Healthcare Research and Quality (AHRQ) established
1990 NCQA began accrediting managed care organizations by using data from Health Plan Employer Data and
Information Set (HEDIS)
1990 Institute of Healthcare Improvement (IHI) founded
1991 Nursing’s Agenda for Health Care Reform published by the ANA
1996 National Patient Safety Foundation (NPSF) founded; JC established Sentinel Event Policies
1996 IOM launched three-part initiative to study health-care system quality
1998 IOM National Roundtable on Health Care Quality released Consensus Statement
1999 IOM published To Err is Human: Building a Safer Health System
2001 IOM published Crossing the Quality Chasm: A New Health System for the 21st Century
2001 IOM published Envisioning the National Health Care Quality Report
2001 ANA’s National Database for Nursing Quality Indicators (NDNQI) demonstrated the positive impact of the
appropriate mix of nursing staff on patient outcomes
2001 JC mandated hospital-wide patient safety standards
2003 IOM published Priority Areas for National Action: Transforming Health Care Quality, which established priority
areas for national action to improve quality of care and outcomes (Box 10-1)
2003 JC established first set of National Patient Safety Goals (NPSG)
2003 IOM published Health Professions Education: A Bridge to Quality
2004 IOM published Keeping Patients Safe: Transforming the Work Environment of Nurses
2004 IOM published Patient Safety: Achieving a New Standard of Care
2005 ANA updated its Health Care Agenda, urging system reform
2006 IOM published Preventing Medication Errors: Quality Chasm Series
2014 JC updated National Patient Safety Goals
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150 unit 3 ■ Career Considerations
and strategy for health system reform (Box 10-2).
Two in particular, To Err is Human: Building a Safer
Health System (IOM, 2000) and Crossing the Quality
Chasm: A New Health System for the 21st Century
(IOM, 2001), provide a framework upon which the
21st-century health-care system is being built. In
2011 the IOM released a report on The Future of
Nursing: Leading Change, Advancing Health (IOM,
2011). This report describes the changes needed
in nursing practice and nursing education to
promote nursing’s role in the new era of health-care
delivery.
To Err is Human, discussed later in this chapter,
quantified unnecessary death in the U.S. health-
care system and placed emphasis on system failures
as the foundation for errors and mistakes. Accord-
ing to the report, it is the flawed systems in patient
care that often leave the door open for human error.
The report made a series of eight recommendations
in four areas (Box 10-3) that aimed to decrease
errors by at least 50% over 5 years. The goal of the
• Crossing the Quality Chasm: The IOM Quality Health
Care Initiative (1996)
• To Err Is Human: Building a Safer Health System
(2000)
• Crossing the Quality Chasm: A New Health System for
the 21st Century (2001)
• Envisioning the National Health Care Quality Report
(2001)
• Priority Areas for National Action: Transforming Health
Care Quality (2003b)
• Leadership by Example: Governmental Roles (2003)
• Health Professions Education: A Bridge to Quality
(2003a)
• Patient Safety: Achieving a New Standard of Care
(2003)
• Keeping Patients Safe: Transforming the Work
Environment for Nurses (2004)
• Academic Health Centers: Leading Change in the 21st
Century (2004)
• Preventing Medication Errors: Quality Chasm Series
(2006)
box 10-2
IOM Quality Reports (IOM, 2006)
• Enhance knowledge and leadership regarding safety.
• Identify and learn from errors.
• Set performance standards and expectations for safety.
• Implement safety systems within health-care
organizations.
box 10-3
Focus Areas of To Err is Human
Recommendations (IOM, 2000)
• Asthma • Ischemic heart disease
• Cancer screening • Major depression
• Care coordination • Nosocomial infections
• Children with • Obesity
special care needs • Pain control in advanced
• Diabetes cancer
• End-of-life issues • Pregnancy and childbirth
• Frail elderly • Self-management
• Health literacy • Severe, persistent mental illness
• Hypertension • Stroke
• Immunizations • Tobacco dependence in adults
box 10-1
Institute of Medicine Priority Areas (IOM,
2003b)
The Institute of Medicine and the
Committee on the Quality of Health Care
in America
The Institute of Medicine (IOM) is a private, non-
profit organization chartered in 1970 by the U.S
government. The IOM’s role is to provide unbiased,
expert health and scientific advice for the purpose
of improving health. The result of the IOM’s work
supports government policy making, the health-
care system, health-care professionals, and consum-
ers (Box 10-1).
In 1998 the IOM National Roundtable on
Health Care Quality released Statement on Quality
of Care (Donaldson, 1998), which urged health-
care leaders to make urgent changes in the U.S.
health-care system. The Roundtable reached con-
sensus in four areas regarding the U.S. health-care
system:
1. Quality can be defined and measured;
2. Quality problems are serious and extensive;
3. Current approaches to quality improvement
(QI) are inadequate; and
4. There is an urgent need for rapid change.
This IOM statement launched today’s movement
to improve quality and safety for the 21st century
U.S. health-care system.
In 1998 the IOM charged the Committee on
the Quality of Health Care in America to develop
a strategy to improve health-care quality in the
coming decade (IOM, 2000). The Committee
completed a systematic review and critique of lit-
erature that highlighted and quantified severe
shortcomings in the heath-care system. Its work led
to the series of reports that serves as the foundation
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chapter 10 ■ Issues of Quality and Safety 151
recommendations was “for the external environ-
ment to create sufficient pressure to make errors
costly to health-care organizations and providers,
so they are compelled to take action to improve
safety” (IOM, 2000, p. 4). The recommendations
sparked public interest in health-care quality and
safety and caused prompt responses by the govern-
ment and national quality organizations.
Crossing the Quality Chasm addressed broad
quality issues in the U.S. health-care system. The
report indicated that the health-care system is fun-
damentally flawed with “gaps,” and it proposed a
system-wide strategy and action plans to redesign
the health-care system. The report stated that the
gaps between actual care and high-quality care
could be attributed to four key inter-related areas
in the health-care system: the growing complexity
of science and technology, an increase in chronic
conditions, a poorly organized delivery system of
care, and constraints on exploiting the revolution in
information technology. With the overarching goal
of improving the health-care system by closing
identifiable gaps, the report made 13 recommenda-
tions, some of which are in Box 10-4. Additionally,
the report addressed the importance of aligning
and designing health-care payer systems, profes-
sional education, and the health-care environment
for quality enhancements, improved outcomes in
care, and use of best practices.
The Future of Nursing: Leading Change, Advanc-
ing Health discusses the role of nursing in the 21st
century. This document recognizes that the nursing
profession confronts many challenges in the chang-
ing health-care system. It identifies recommenda-
tions for an “action-oriented blueprint for the
future of nursing” (RWJF, 2008, p. s-2).
As a professional nurse, you have a responsibility
to acknowledge the complexity and deficits of the
health-care system. In managing patient care, you
must continually consider the impact of the system
on the care you provide and participate in the
quality and safety initiatives at the bedside, in your
unit, and within your organization to promote
quality and safety within the system.
Quality in the Health-Care System
The IOM defines quality as “the degree to which
health services for individuals and populations
increase the likelihood of desired health outcomes
and are consistent with current and professional
knowledge” (IOM, 2001, p. 232). This definition is
used by U.S. organizations and many international
health-care organizations, and it is the basis for
nursing management of patient care. Box 10-5
elaborates on this definition by outlining six primary
aims of health care.
Quality Improvement (QI)
QI activities have been part of nursing care since
Florence Nightingale evaluated the care of soldiers
during the Crimean War (Nightingale & Barnum,
1992). To achieve quality health care, QI activities
use evidence-based methods for gathering data and
achieving desired results.
Before the 1980s, health-care institutions
focused on quality assurance (QA) rather than QI.
QA outlined an inspection process to guarantee
that hospitals continued to follow minimum
1. Care is based on a continuous healing relationship.
2. Care is provided based on patient needs and values.
3. Patient is source of control of care.
4. Knowledge is shared and free-flowing.
5. Decisions are evidence-based.
6. Safety is a system property.
7. Transparency is necessary; secrecy is harmful.
8. Anticipate patient needs.
9. Waste is continually decreased.
10. Cooperation is needed between health-care providers.
box 10-4
Ten Rules to Govern Health-Care Reform
for the 21st Century (IOM, 2001, p. 61)
Health care should be:
1. Safe: Avoiding injuries to patients from the care that is
intended to help them
2. Effective: Providing services based on scientific
knowledge to all who could benefit and refraining from
providing services to those not likely to benefit
(avoiding underuse and overuse)
3. Patient-centered: Providing care that is respectful of and
responsive to individual patient preferences, needs,
and values and ensuring that patient values guide all
clinical decisions
4. Timely: Reducing waits and sometimes harmful delays
for those who receive and those who give care
5. Effi cient: Avoiding waste, in particular that of
equipment, supplies, ideas, and energy
6. Equitable: Providing care that does not vary in quality
because of characteristics such as gender, ethnicity,
geographic location, and socioeconomic status
box 10-5
Six Aims for Improving Quality in Health
Care (IOM, 2001, p. 39).
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152 unit 3 ■ Career Considerations
standards of patient care quality. This approach
used retrospective chart audits and fixed errors after
problems were found. QA places very little empha-
sis on change or assuming a proactive approach. In
contrast, QI infers a system-wide approach to
maintaining quality. The Joint Commission (2010)
vision identifies the core of quality improvement as
“All people should always experience the safest,
highest quality, best value health care across all set-
tings” (para. 1).
QI usually involves the following common char-
acteristics (McLaughlin & Kaluzny, 2006, p. 3):
■ A link to key elements of the organization’s
strategic plan
■ A quality council consisting of the institution’s
top leadership
■ Training programs for all levels of personnel
■ Mechanisms for selecting improvement
opportunities
■ Formation of process improvement teams
■ Staff support for process analysis and redesign
■ Personnel policies that motivate and support
staff participation in process improvement
Several terms, such as QI, total quality manage-
ment (TQM), Six Sigma, and Continuous Quality
Improvement (CQI), are used to describe quality
improvement. QI may be accomplished through a
variety of approaches and models such as the Focus,
Analyze, Develop, and Execute Model (FADE)
(http://patientsafetyed.duhs.duke.edu/module_a/
methods/fade.html) or the Plan Do Study Act
cycle (PDSA). Regardless of the term used, QI
provides a structured organizational process for
involving the health-care team in planning and
executing a continuous flow of improvements to
provide quality care that meets or exceeds expecta-
tions (McLaughlin & Kaluzny, 2006, p. 3). The
following sections focus on CQI.
Using CQI to Monitor and Evaluate Quality
of Care
Continuous quality improvement (CQI) is a
process. It includes: (a) identifying areas of concern
(indicators), (b) continuously collecting data on
these indicators, (c) analyzing and evaluating the
data, and (d) implementing needed changes. When
one indicator is no longer a concern, another indi-
cator is selected. Common indicators include the
number of falls, frequency of medication errors, and
infection rates. Indicators can be identified by the
accrediting agency or by the facility itself. The
purpose of CQI is to continuously improve the
capability of everyone involved in providing care,
including the organization itself. CQI aims to act
proactively and avoid a blaming environment. The
process attempts to provide a means to improve the
entire system.
CQI relies on collecting information and ana-
lyzing it. The time frame used in a CQI program
can be retrospective (evaluating past performance,
often called quality assurance), concurrent (evaluat-
ing current performance), or prospective (future-
oriented, collecting data as they come in). The
procedures used to collect data depend on the
purpose of the program. Data may be obtained by
observation, performance appraisals, patient satis-
faction surveys, statistical analyses of length-of-stay
and costs, surveys, peer reviews, and chart audits
(Ajjawi & Higgs, 2008; Lantham & Maxson-
Cooper, 2003).
In the CQI framework, data collection is every-
one’s responsibility. Collecting comprehensive,
accurate, and representative data is the first step in
the CQI process. You may be asked to brainstorm
your ideas with other nurses or members of the
interprofessional team, complete surveys or check-
lists, or keep a log of your daily activities. How do
you administer medications to groups of patients?
What steps are involved? Are the medications
always available at the right time and in the right
dose, or do you have to wait for the pharmacy to
bring them to the floor? Is the pharmacy technician
delayed by emergency orders that must be pro-
cessed? Looking at the entire process and mapping
it out on paper in the form of a flowchart may be
part of the CQI process for your organization
(Fig. 10.1).
QI at the Organizational and Unit Levels
Strategic Planning
Leaders and managers are so often preoccupied
with immediate issues that they lose sight of their
ultimate objectives. To stay on track, an organiza-
tion needs a strategic plan. A strategic plan is a
short, visionary, conceptual document that:
■ Serves as a framework for decisions or for
securing support/approval
■ Provides a basis for more detailed planning
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chapter 10 ■ Issues of Quality and Safety 153
■ Explains the business to others in order to
inform, motivate, and involve
■ Assists benchmarking and performance
monitoring
■ Stimulates change and becomes the building
block for the next plan (http://www.planware
.org/strategicplan.htm).
During the strategic planning process, the organi-
zation develops or reviews its vision, mission state-
ment, and corporate values. A group develops
business objectives and key strategies to meet these
objectives. In order to do this, a SWOT analysis is
done—a review of the organization’s Strengths,
Weaknesses, Opportunities, and Threats. Key strat-
egies are identified, and action plans are developed.
The organization’s mission, goals, and strategic plan
ultimately drive the outcomes and QI plan for that
organization. Be proactive, and ask your nurse
manager if there are opportunities for the staff to
participate in the planning process.
Issues related to QI may also come out of the
strategic planning process. Quality issues are not
often apparent to senior managers. Staff members
at the unit level can often identify quality issues
because they are the ones who can feel the impact
when quality is lacking. Once a process needing
improvement is identified, an interprofessional
team is organized consisting of members who have
knowledge of the identified process. The team
members meet to identify and analyze problems,
discuss solutions, and evaluate changes. The team
clarifies the current knowledge of the process; it
identifies causes for variations in the process and
works to unify the process. Box 10-6 identifies
questions that team members should ask as they
work on the QI plan.
Structured Care Methodologies
Most agencies have tools for tracking outcomes.
These tools are called structured care methodologies
(SCMs). SCMs are interprofessional tools to
Assign Responsibilities
Identify Vital Areas
Define Scope of Care
Evaluate Performance and Outcomes
Recommend and Implement Actions
Evaluate Degree of Improvement
Analyze Area in Terms of:
Aspects
Standards
Indicators
Criteria
Measure Actual Performance
and
Measure Patient Outcomes
Figure 10.1 Unit level QI process. Adapted from Hunt,
D.V. (1992). Quality in America: How to implement a competitive
quality program. Homewood, IL: Business One Irwin; and
Duquette, A.M. (1991]). Approaches to monitoring practice:
Getting started. In Schroeder, P. [ed.]. Monitoring and Evaluation
in Nursing. Gaithersburg, MD: Aspen. 1. Who are our customers, stakeholders, markets?
2. What do they expect from us?
3. What are we trying to accomplish?
4. What changes do we think will make an
improvement?
5. How and when will we pilot-test our predicted
improvement?
6. What do we expect to learn from the pilot test?
7. What will we do with negative results? Positive
results?
8. How will we implement the change?
9. How will we measure success?
10. What did we learn as a team from this experience?
11. What changes would we make for the future?
box 10-6
Questions the Team Needs to Ask
Adapted from McLaughlin, C., & Kaluzny, A. (2006). Continuous
Quality Improvement in Health Care: Theory, Implementations, and
Applications. 3rd ed. Massachusetts: Jones & Bartlett.
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154 unit 3 ■ Career Considerations
“identify best practices, facilitate standardization of
care, and provide a mechanism for variance
tracking, quality enhancement, outcomes measure-
ment, and outcomes research” (Cole & Houston,
1999, p. 53). SCMs include guidelines, protocols,
algorithms, standards of care, and critical pathways.
In line with this idea is the development of a
Nursing Care Performance Framework (NCPF)
that identifies core aspects of nursing performance.
The framework incorporates many of these other
tools and offers decision-makers a conceptual
instrument that acts to define performance, create
a shared and stable set of performance indicators
for a given segment of nursing care, and develop
benchmarks to measure the outcomes (Dubois,
D’Amour, Pomey, Girard, & Brault, 2013).
■ Guidelines. Guidelines first appeared in the
1980s as statements to assist health-care
providers and patients in making appropriate
health-care decisions. Guidelines are based on
current research strategies and are often
developed by experts in the field. The use of
guidelines is seen as a way to decrease
variations in practice.
■ Protocols. Protocols are specific, formal
documents that outline how a procedure or
intervention should be conducted. Protocols
have been used for many years in research and
specialty areas but have been introduced into
general health care as a way to standardize
approaches to achieve desired outcomes. An
example in use in many facilities is a chest
pain protocol.
■ Algorithms. Algorithms are systematic
procedures that follow a logical progression
based on additional information or patient
responses to treatment. They were originally
developed in mathematics and are frequently
seen in emergency medical services. Advanced
cardiac life support algorithms are now widely
used in health-care agencies.
■ Standards of care. Standards of care are often
discipline-related and help to operationalize
patient care processes and provide a baseline
for quality care. Lawyers often refer to a
discipline’s standards of care in evaluating
whether a patient has received appropriate
services.
■ Critical (or clinical) pathways. A critical
pathway outlines the expected course of
treatment for patients who have similar
diagnoses. The critical pathway should orient
the nurse easily to the patient’s outcomes for
the day. In some institutions, nursing diagnoses
with specific time frames are incorporated into
the critical pathway, which describes the course
of events that lead to successful patient
outcome within the diagnosis-related group
(DRG)–defined time frame. For the patient
with an uncomplicated myocardial infarction
(MI), a proposed course of events leading to a
successful patient outcome within the 4-day
DRG-defined time frame might be as follows
(Doenges, Moorhouse, & Murr, 2009): (1)
Patient states that chest pain is relieved; (2)
ST- and T-wave changes resolve and pulse
oximeter reading is greater than 90%; patient
has clear breath sounds; (3) Patient ambulates
in hall without experiencing extreme fatigue or
chest pain; (4) Patient verbalizes feelings about
having an MI and future fears; (5) Patient
identifies effective coping strategies; (6)
Ventricular dysfunction, dysrhythmia, or
crackles resolved.
Different types of SCMs may be used alone or
together. A patient who is admitted for an MI may
have care planned using a critical pathway for an
acute MI, a heparin protocol, and a dysrhythmia
algorithm. In addition, the nurses may refer to the
standards of care in developing a traditional nursing
care plan.
The use of SCMs can improve physiological,
psychological, and financial outcomes. Services and
interventions are sequenced to provide safe and
effective outcomes at designated times and with
the most effective use of resources. They also give
an interprofessional perspective that is not found in
the traditional nursing care plan. Computer pro-
grams allow health-care personnel to track vari-
ances (differences from the identified standard) and
use these variances in planning QI activities.
SCMs do not take the place of expert nursing
judgment. The fundamental purpose of the SCM
is to assist health-care providers in implementing
practices identified with good clinical judgment,
research-based interventions, and improved patient
outcomes. Data from SCMs allow comparisons of
outcomes, development of research-based deci-
sions, identification of high-risk patients, and
identification of issues and problems before they
escalate into disasters. Do not be afraid to learn
and understand the different SCMs.
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chapter 10 ■ Issues of Quality and Safety 155
Critical Pathways
Critical pathways are clinical protocols involving all
disciplines. They are designed for tracking a planned
clinical course for patients based on aver age and
expected lengths of stay. Financial outcomes can be
evaluated from critical pathways by assessing any
variances from the proposed length of stay (Haddad,
2010). The health-care agency can then focus on
problems within the system that extend the length
of stay or drive up costs because of overutilization
or repetition of services. For example:
Mr. J. was admitted to the telemetry unit with a
diagnosis of MI. He had no previous history of heart
disease and no other complicating factors such as
diabetes, hypertension, or elevated cholesterol levels.
His DRG-prescribed length of stay was 4 days. He
had an uneventful hospitalization for the f irst 2
days. On the third day, he complained of pain in the
left calf. The calf was slightly reddened and warm
to the touch. This condition was diagnosed as throm-
bophlebitis, which increased his length of hospital-
ization. The case manager’s review of the events
leading up to the complaints of calf pain indicated
that, although the physician had ordered compres-
sion stockings for Mr. J., the stockings never arrived,
and no one followed through on the order. The vari-
ances related to his proposed length of stay were
discussed with the team providing care, and mea-
sures were instituted to make sure that this oversight
would not occur again.
Critical pathways provide a framework for com-
munication and documentation of care. They are
also excellent teaching tools for staff members from
various disciplines. Institutions can use critical
pathways to evaluate the cost of care for differ-
ent patient populations (Haddad, 2010; Rotter,
Kinsman, James, Machotta, Gothe, Willis, Snow, &
Kugler, 2010).
Most institutions have adopted a chronological,
diagrammatic format for presenting a critical
pathway. Time frames may range from daily (day 1,
day 2, day 3) to hourly, depending on patient needs.
Key elements of the critical pathway include dis-
charge planning, patient education, consultations,
activities, nutrition, medications, diagnostic tests,
and treatment). Table 10-2 is an example of a criti-
cal pathway.
Although originally developed for use in acute
care institutions, critical pathways can be developed
for home care and long-term care. The patient’s
nurse is usually responsible for monitoring and
recording any deviations from the critical pathway.
When deviations occur, the reasons are discussed
with all members of the health-care team, and the
appropriate changes in care are made. The nurse
must identify general trends in patient outcomes
and develop plans to improve the quality of care
to reduce the number of deviations. Through
this close monitoring, the health-care team can
avoid last-minute surprises that may delay patient
discharge and can predict lengths of stay more
effectively.
Aspects of Health Care to Evaluate
A CQI program can evaluate three aspects of
health care: the structure within which the care
is given, the process of giving care, and the out-
come of that care. A comprehensive evaluation
should include all three aspects (Brook, Davis, &
Kamberg, 1980; Donabedian, 1969, 1977, 1987).
When evaluation focuses on nursing care, the inde-
pendent, dependent, and interdependent functions
of nurses may be added to the model (Irvine, 1998).
Each of these dimensions is described here, and
their interrelationship is illustrated in Table 10-3.
Structure
Structure refers to the setting in which the care is
given and to the resources (human, financial,
and material) that are available. The following
structural aspects of a health-care organization can
be evaluated:
■ Facilities. Comfort, convenience of layout,
accessibility of support services, and safety
■ Equipment. Adequate supplies, state-of-the-
art equipment, and staff ability to use
equipment
■ Staff. Credentials, experience, absenteeism,
turnover rate, staff-patient ratios
■ Finances. Salaries, adequacy, sources
Although none of these structural factors alone can
guarantee quality care, they make good care more
likely. A larger number of nurses each shift and a
higher proportion of RNs are associated with
shorter lengths of stay; higher proportions of RNs
are also related to fewer adverse patient outcomes
(Lichtig, Knauf, & Milholland, 1999; Rogers et al.,
2004).
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156 unit 3 ■ Career Considerations
table 10-2
Sample Critical Pathway: Heart Failure, Hospital; ELOS 4 Days Cardiology or Medical Unit
ND and
Categories
of Care Day 1 _______ Day 2 _______ Day 3 _______ Day 4 _______
Decreased cardiac
output R/T:
Decreased
myocardial
contractility,
altered electrical
conduction,
structural changes
Goals:
Participate in actions to
reduce cardiac
workload
Display VS within
acceptable limits;
dysrhythmias
controlled; pulse
oximetry within
acceptable range
Meet own self-care
needs with assistance
as necessary
Dysrhythmias
controlled or
absent
Free of signs of
respiratory distress
Demonstrate
measurable
increase in activity
tolerance
Fluid volume
excess
R/T compromised
regulatory
mechanisms:
hypertension,
sodium/water
retention
Verbalize understanding
of fluid/food restrictions
Verbalize understanding
of general condition
and health-care needs
Breathing sounds
clearing
Urinary output adequate
Weight loss (reflecting
fluid loss)
Plan for lifestyle/
behavior changes
Breath sounds clear
Balanced I&O
Edema resolving
Plan in place to meet
postdischarge needs
Weight stable or
continued loss if
edema present
Referrals Cardiology
Dietitian
Cardiac rehabilitation
Occupational therapist
(for ADLs)
Social services
Home care
Community
resources
Diagnostic studies ECG, echo, Doppler
ultrasound, stress test,
cardiac scan
CXR
ABGs/pulse oximeter
Cardiac enzymes
ANP, BNP
BUN/Cr
CBC/electrolytes, MG++
PT/aPTT
Liver function studies
Serum glucose
Albumin/total protein
Thyroid studies
Digoxin level (as
indicated)
UA
Echo-Doppler (if not
done day 1) or other
cardiac scans
Cardiac enzymes (if ≠)
BUN/Cr
Electrolytes
PT/aPTT (if taking
anticoagulants)
CXR
BUN/Cr
Electrolytes
PT/aPTT (as
indicated)
Repeat digoxin level
(if indicated)
Additional
assessments
Apical pulse, heart/breath
sounds q8h
Cardiac rhythm (telemetry)
q4h
BP, P, R q2h until stable,
q4h
Temp q8h
I&O q8h
Weight qAM
Peripheral edema q8h
Peripheral pulses q8h
Sensorium q8h
DVT check qd
Response to activity
Response to therapeutic
interventions
q8h bid
D/C
bid
bid
bid
D/C
qd
D/C
D/C
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chapter 10 ■ Issues of Quality and Safety 157
table 10-2
Sample Critical Pathway: Heart Failure, Hospital; ELOS 4 Days Cardiology
or Medical Unit —cont’d
ND and
Categories
of Care Day 1 _______ Day 2 _______ Day 3 _______ Day 4 _______
Medication
allergies
IV diuretic
ACEI, ARB, vasodilators,
beta blocker
IV/PO potassium
Digoxin
PO/cutaneous nitrates
Morphine sulfate
Daytime/hs sedation
PO/low-dose
anticoagulant
Stool softener/laxative
PO D/C
D/C
PO or D/C
D/C
Patient education Orient to unit/room
Review advance directives
Discuss expected
outcomes, diagnostic
tests/results
Fluid/nutritional
restrictions/needs
Cardiac education per
protocol
Review medications:
Dose, times, route,
purpose, side effects
Progressive activity
program
Skin care
Signs/symptoms to
report to health-
care provider
Plan for home-care
needs
Provide written
instructions for home
care
Schedule for follow-up
appointments
Additional nursing
actions
Bed/chair rest
Assist with physical care
Pressure-relieving mattress
Dysrhythmia/angina care
per protocol
Supplemental O2
Cardiac diet
BPR/ambulate as
tolerated, cardiac
program
Up ad lib/graded
program
D/C if able
(send home)
CP = critical path; ELOS = estimated length of stay; ND = nursing diagnosis.
Source: Doenges, M.E., Moorhouse, M.F., and Geissler, A.C. (2010). Nursing care plans: Guidelines for
individualizing patient care, ed. 8. Philadelphia: F.A. Davis, with permission.
table 10-3
Dimensions of QI in Nursing: Examples
Independent Function Dependent Function Interdependent Function
Structure Pressure ulcer risk assessment
form available
High-speed automatic dial-up system
puts nurses in touch with physicians
rapidly
Nursing case management model of
care adopted on rehabilitation unit
Process Assesses risk for development of
pressure ulcer and implements
preventive measures
Order to increase dosage of pain
medication obtained and
processed within 1 hour
Communicates with therapists about
need for customized wheelchair
Outcome Skin intact at discharge Relief from pain Able to enter narrow doorway to
bathroom unassisted
Source: Adapted from Irvine, D. (1998). Finding value in nursing care: A framework for quality improvement and
clinical evaluation. Nursing Economics, 16(3), 110–118.
Process
Process refers to the activities carried out by the
health-care providers and all the decisions made
while a patient is interacting with the organization
(Irvine, 1998). Examples include:
■ Setting an appointment
■ Conducting a physical assessment
■ Ordering a radiograph and magnetic resonance
imaging scan
■ Administering a blood transfusion
■ Completing a home environment assessment
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158 unit 3 ■ Career Considerations
■ Preparing the patient for discharge
■ Telephoning the patient post-discharge
Each of these processes can be evaluated in terms
of timeliness, appropriateness, accuracy, and com-
pleteness (Irvine, 1998). Process variables include
psychosocial interventions such as teaching and
counseling, and physical care measures. Process also
includes leadership activities such as interprofes-
sional team conferences. When process data are
collected, a set of objectives, procedures, or guide-
lines is needed to serve as a standard or gauge
against which to compare the activities. This set can
be highly specific, such as listing all the steps in a
catheterization procedure, or it can be a list of
objectives, such as offering information on breast-
feeding to all expectant parents or conducting
weekly staff meetings.
The American Nurses Association (ANA)
Standards of Care are process standards that answer
the question: What should the nurse be doing, and
what process should the nurse follow to ensure
quality care?
Outcome
An outcome is the result of all the health-care pro-
viders’ activities. Outcome measures evaluate the
effectiveness of nursing activities by answering such
questions as: Did the patient recover? Is the family
more independent now? Has team functioning
improved? Outcome standards address indicators
such as physical and mental health; social and phys-
ical function; health attitudes, knowledge, and
behavior; utilization of services; and customer sat-
isfaction. Evidence-based practice is linked to out-
comes in that outcomes research findings guide the
formation of appropriate strategies in the delivery
of safe, effective, and quality patient care (PCORI,
2012).
The outcome questions asked during an evalu-
ation should measure observable behavior, such as
the following:
■ Patient: Wound healed; blood pressure within
normal limits; infection absent
■ Family: Increased time between visits to the
emergency department; applied for food
stamps
■ Team: Decisions reached by consensus;
attendance at meetings by all team members
Some of these outcomes, such as blood pressure or
time between emergency department visits, are
easier to measure than other, equally important
outcomes, such as increased satisfaction or changes
in attitude. Although the latter cannot be measured
as precisely, it is important to include the full spec-
trum of biological, psychological, and social aspects
(Strickland, 1997). For this reason, considerable
effort has been put into identifying the patient
outcomes that are affected by the quality of nursing
care.
According to Benner, Sutphen, Leonard, and
Day (2010), patient care outcomes can be improved
by employing a better educated nursing workforce.
Although 60% of the nation’s nurses hold associate
degrees in nursing (ADN), the research supports
that better patient outcomes occur when nurses
hold baccalaureate degrees (Orsolini-Hain, 2008).
The American Association of Nurse Executives
(AONE) recommends that the educational prepa-
ration of the nurse be at the BSN level as this
educational level will “prepare the nurse of the
future to function as an equal partner” (AONE,
2005). The research and recommendations do not
negate the value of the associate degree nurse, but
promote the concept of lifelong learning and the
need to continue and obtain a baccalaureate degree.
The ANA identified 10 quality indicators in
acute care that relate to the availability and quality
of professional nursing services in hospitals. Across
the United States, data are being collected from
nursing units using these quality indicators. The
National Database for Nursing Quality Indica-
tors (NDNQI) is continuously updated (www
.nursingworld.org).
A major problem in using and interpreting out-
come measures is that outcomes are influenced by
many factors. For example, the outcome of patient
teaching done by a nurse on a home visit is affected
by the patient’s interest and ability to learn, the
quality of the teaching materials, the presence or
absence of family support, information (which may
conflict) from other caregivers, and the environ-
ment in which the teaching is done. If the teaching
is successful, can the nurse be given full credit for
the success? If it is not successful, who has failed?
In order to determine why an intervention such
as patient teaching succeeds or fails, it is necessary
to evaluate the process as well as the outcome. A
comprehensive evaluation includes all three aspects:
structure, process, and outcome. However, it is
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chapter 10 ■ Issues of Quality and Safety 159
much more difficult to gather and monitor outcome
data than to measure structure or process.
Risk Management
An important part of CQI is risk management,
a process of identifying, analyzing, treating, and
evaluating real and potential hazards. The Joint
Commission ( JC) recommends the integration of
a quality control/risk management program to
maintain continuous feedback and communication.
To plan proactively, an organization must identify
real or potential exposures that might threaten it.
As a nurse, it is your responsibility to report adverse
incidents to the risk manager, according to your
organization’s policies and procedures. In many
states, this is a legal requirement.
Risk events are categorized according to severity.
Although all untoward events are important, not
all carry the same severity of outcomes (Benson-
Flynn, 2001).
1. Service occurrence. A service occurrence is an
unexpected occurrence that does not result in a
clinically significant interruption of services
and that is without apparent patient or
employee injury. Examples include minor
property or equipment damage, unsatisfactory
provision of service at any level, or
inconsequential interruption of service. Most
occurrences in this category are addressed
within the patient complaint process.
2. Serious incident. A serious incident results
in a clinically significant interruption of
therapy or service, minor injury to a patient
or employee, or significant loss or damage
of equipment or property. Minor injuries
are usually defined as needing medical
intervention outside of hospital admission
or physical or psychological damage.
3. Sentinel events. A sentinel event is an
unexpected occurrence involving death or
serious/permanent physical or psychological
injury, or the risk thereof. The phrase “or the
risk thereof ” includes any process variation for
which a recurrence would carry a significant
chance of a serious adverse outcome. Such
events are called sentinel because they signal
the need for immediate investigation and
response. When a sentinel event occurs,
appropriate individuals within the organization
must be made aware of the event; they must
investigate and understand the causes of the
event; and they must make changes in the
organization’s systems and processes to reduce
the probability of such an event in the future
(jcaho.org/ptsafety_frm.html).
The subset of sentinel events that is subject to
review by the JC includes any occurrence that
meets any of the following criteria:
■ The event has resulted in an unanticipated
death or major permanent loss of function that
is not related to the natural course of the
patient’s illness or underlying condition.
■ The event is one of the following (even if the
outcome was not death or major permanent
loss of function): suicide of a patient in a
setting where the patient receives around-the-
clock care (e.g., hospital, residential treatment
center, crisis stabilization center), infant
abduction or discharge to the wrong family,
rape, hemolytic transfusion reaction involving
administration of blood or blood products
having major blood group incompatibilities, or
surgery on the wrong patient or wrong body
part (jcaho.org/ptsafety_frm.html).
Adhering to nursing standards of care as well as the
policies and procedures of the institution greatly
decreases the nurse’s risk. Common risk areas for
nursing include:
■ Medication errors
■ Documentation errors and/or omissions
■ Failure to perform nursing care or treatments
correctly
■ Errors in patient safety that result in falls
■ Failure to communicate significant data to
patients and other providers (Kalisch,
Landstrom, & Williams, 2009; Swansburg &
Swansburg, 2002)
Risk management programs also include attention
to areas of employee wellness and injury preven-
tion. Latex allergies, repetitive stress injuries, carpal
tunnel syndrome, barrier protection for tuber-
culosis, back injuries, and the rise of antibiotic-
resistant organisms all fall under the area of risk
management.
Adhering to standards of care and exercising
the amount of care that a reasonable nurse would
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160 unit 3 ■ Career Considerations
demonstrate under the same or similar circum-
stances can protect the nurse from litigation. Un-
derstanding what actions to take when something
goes wrong is imperative. The main goal is patient
safety. Reporting and remediation must occur
quickly.
Once an incident has occurred, you must com-
plete an incident report immediately. The inci-
dent report is used to collect and analyze data for
determination of future risk. The report should be
accurate, objective, complete, and factual. If there is
future litigation, the plaintiff ’s attorney can sub-
poena the report. The report should be prepared in
only a single copy and never placed in the medical
record (Swansburg & Swansburg, 2002). It is kept
with internal hospital correspondence.
Nurses have a responsibility to remain educated
and informed and to become active participants in
understanding and identifying potential risks to
their patients and to themselves. Ignorance of the
law is no excuse. Maintaining a knowledgeable,
professional, and caring nurse-patient relationship
is the first step in decreasing your own risk.
The Nursing Shortage and Patient Safety
The value of registered nurses to the health-care
system cannot be minimized. Nurses provide client
care within multiple settings. Operationally, nurses
have a pivotal role in ensuring patient safety and
positive patient outcomes (Dunton, Gajewski,
Klaus, & Pierson, 2007).
Factors Contributing to the Nursing Shortage
■ Increased demand for nurses. As health care
moves to a variety of community settings, only
the most acutely ill patients remain in the
hospital. The transfer of less acute patients to
nursing homes and community settings creates
additional job opportunities. Research
supporting improved patient outcomes when
patient care is provided by RNs as opposed to
unlicensed personnel will also increase demand
for RNs. According to Buerhaus (2013), “People
are coming into nursing at the same rate as the
baby-boom generation; more have earned
baccalaureate degrees than have earned associate
degrees.” Between 2001 and 2012, the number
of RN grads more than doubled, from 74,000
in 2002 to 181,000 (Auerbach, Staiger, Muench,
& Buerhaus, 2013). Buerhaus attributes this
increase to initiatives driven by Johnson &
Johnson’s “Campaign for Nursing’s Future,”
and reinforced by the Robert Wood Johnson
Foundation and state workforce centers.
■ Reduction in and shortage of nursing faculty.
As fewer younger nurses choose to become
educators and current faculty members retire,
the shortage of faculty continues to affect the
number of students admitted to nursing
programs. The American Association of
Colleges of Nursing (AACN) report on 2011–
2012 Enrollment and Graduations in
Baccalaureate and Graduate Programs in
Nursing stated 1,181 faculty vacancies existed
across the nation and that U.S. nursing schools
turned away 75,587 qualified applicants from
baccalaureate and graduate nursing programs
in 2011 due to an insufficient number of
faculty, clinical sites, classroom space, clinical
preceptors, and budget constraints.
■ Job dissatisfaction. Staffing levels, heavy
workloads, high patient acuity along with lack
of sufficient support staff, increased use of
overtime, and salary discrepancies between
nurses and other health-care professionals have
contributed to growing dissatisfaction and
lower retention of nurses. Many facilities are
now using workplace issues and incentives as a
retention strategy.
The need to control spiraling health-care costs,
along with the issues of supply and demand for
nursing services will continue. According to the
ANA, more than 60% of nurses graduate initially
from associate-degree nursing programs. You, per-
sonally, will be affected by trends in health-care
delivery, but you can also be a major voice in deci-
sion making. In his closing remarks at the Univer-
sity of Wisconsin, Buerhaus (2013) challenged
nurses to “Become a student of health care reform.
Make sure your skills sets offer value to an emerg-
ing delivery system that will be on the hunt for and
will reward those who provide value.” As in the
past, cost control and demand for nursing services
will most likely involve changing nurse staffing, the
model of care, and professional nursing practice
(Shekelle, 2013).
Safety in the U.S.
Health-Care System
Patient safety is the prevention of harm caused by
errors. The IOM defines errors as “the failure of a
planned action to be completed as intended (e.g.,
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chapter 10 ■ Issues of Quality and Safety 161
error of execution) or the use of a wrong plan to
achieve an aim (e.g., error of planning) (IOM,
2000, p. 57). It is important to note that errors are
unintentional and that not all errors lead to an
adverse event causing harm or death.
In the United States, medical errors account for
approximately 98,000 deaths per year (Pham,
Aswani, Rosen, Lee, Huddle, Weeks, & Pronovost,
2012). These include medication errors, falls,
handoff errors, diagnostic and surgical errors,
and health-care–acquired (nosocomial) infections.
The IOM indicates that 1.5 million adverse drug
events (ADEs) occur annually in the United
States. Hospital acquired infections (HAIs) may
result in death, increased financial costs, and
extended hospital stays. The most common HAIs
include urinary tract infections, surgical site infec-
tions, pneumonia, and bacteremia (Pham et al.,
2012).
Falls account for a large number of adverse
events in hospitals and nursing homes. Injuries
from falls are associated with an increase in mortal-
ity, extended lengths of stay, and a decrease in the
ability of the individual to revert back to his/her
previous health status (Haines, Hill, & Hill, 2011;
Oliver, Healy, & Haines, 2010). Most falls are the
result of unrecognized cognitive impairment, failure
of health-care personnel to institute safety mea-
sures, and impaired mobility.
Handoff errors involve a break in continuity of
care when different providers in one care area
assume responsibility of the patient or the patient
moves from one care area to another. These
are most commonly the result of communication
errors. If the responsibility for the patient is not
clearly transferred, necessary information to make
informed decisions may not be communicated
(Raduma-Tomas, Flin, Yule, & Williams, 2011;
Raduma-Tomas, Flin, Yule, & Close, 2012).
Approximately 40,000–80,000 deaths per year
occur because of diagnostic errors. Diagnostic
errors occur more often in certain specialties such
as oncology, neurology, and cardiology. According
to Brown, McCarthy, Kelen, & Lew, (2010), they
are also the greatest source of errors in emergency
departments.
Types of Errors
To Err is Human (2000) relied on the work of
Leape et al. (1993) to categorize types of errors
(Box 10-7). After categorizing types of errors,
Leape and colleagues found that 70% of all errors
were preventable.
Human errors can occur for many reasons. Skill-
based errors occur when slips or lapses in the actions
taken by the provider were not what was intended
(Duke University Medical Center, 2005). Rule-
based errors are those that occur when a standard
or “rule” is violated. An example of rule-based error
is an experienced nurse administering the wrong
medication by picking up the wrong syringe.
Studying events and identifying how each
occurred offers data that may be used to improve
safety.
■ Near miss. A near miss is an error or mishap
that results in no harm or very minimal patient
harm (IOM, 2000, p. 87). Near misses are
useful in identifying and remedying
vulnerabilities in a system before harm can
occur. An example of a near miss is catching a
medication error before the medication is
administered.
■ Adverse event. An adverse event is injury to a
patient caused by medical management rather
than an underlying condition of the patient
(IOM, 2000). The IOM reports have
highlighted the prevalence of errors, especially
preventable adverse events. Adverse events have
been classified into four types (see Box 10-7).
Diagnostic
Error or delay in diagnosis
Failure to employ indicated tests
Use of outmoded tests or therapy
Failure to act on results of monitoring or testing
Treatment
Error in the performance of an operation, procedure, or
test
Error in administering the treatment
Error in the dose or method of using a drug
Avoidable delay in treatment or in responding to an
abnormal test
Inappropriate (not indicated) care
Preventive
Failure to provide prophylactic treatment
Inadequate monitoring or follow-up of treatment
Other
Failure of communication
Equipment failure
Other system failure
box 10-7
Types of Errors (IOM, 2000, p. 36)
Leape, L., Lawthers, A.G., Brennan, T.A., et al. (1993). Preventing
medical injury. Qual Rev Bull. 19(5):144–149.
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162 unit 3 ■ Career Considerations
■ Accident. An accident is an event that
involves damage to a defined system that
disrupts the ongoing or future output of
that system. Accidents occur when multiple
systems fail and tend to be unplanned or
unforeseen. Accidents provide information
about systems.
■ Medication error. A medication error is a
preventable incident that occurs during the
medication use process that could or did lead
to patient harm.
Error Identification and Reporting
Nurses are on the front line in identifying and
reporting errors. In the past, individuals involved in
medical errors suffered punitive consequences; thus,
many errors went unreported. Providers and orga-
nizations may fear blame or punishment for mis-
takes or errors. This culture of blame prevents or
discourages individuals from coming forward.
Developing a Culture of Safety
To achieve safe patient care, a culture of safety must
exist. Organizations and senior leadership must
drive change to develop a culture of safety—a
blame-free environment in which reporting of
errors is promoted and rewarded. A culture of safety
promotes trust, honesty, openness, and transpar-
ency. In general, hospitals that practice a culture of
safety tend to show fewer reported cases of adverse
safety events (Mardon, Khanna, Sorra, Dyer, &
Famolaro, 2010).
Teamwork and involvement of the patient con-
tribute to promoting a culture of safety. When a
culture of safety exists, individual providers do not
fear reprisal and are not blamed for identifying or
reporting errors. Reported errors provide data and
information necessary to understand why or how
the error occurred, thus improving care and pre-
venting harm.
Event-reporting systems hold organizations
accountable and lead to improved safety. Manda-
tory reporting systems are operated by regulatory
agencies and have a strong focus on errors associ-
ated with serious harm or death. In addition, the
Food and Drug Administration (FDA) mandates
reporting of serious harm or death (adverse events)
related to drugs and medical devices. Failure to
report mandatory requirements may lead to fines,
withdrawal of participation in clinical trials, or loss
of licensure to operate.
The Joint Commission relies on root cause analy-
sis from each sentinel event. Root cause analysis is
the process of learning from consequences. The
consequences can be desirable, but most root cause
analyses deal with adverse consequences. An
example of a root cause analysis is a review of a
medication error, especially one resulting in a death
or severe complications. Principles of root cause
analysis include:
1. Determine what influenced the consequences,
i.e., determine the necessary and sufficient
influences that explain the nature and the
magnitude of the consequences.
2. Establish tightly linked chains of influence.
3. At every level of analysis, determine the
necessary and sufficient influences.
4. Whenever feasible, drill down to root causes.
5. Know that there are always multiple root
causes.
The Joint Commission also developed the Interna-
tional Center for Patient Safety, which establishes
National Patient Safety Goals each year and pub-
lishes Sentinel Event Strategies. Box 10-8 sum-
marizes the work of the International Center for
Patient Safety. These tools developed by the Joint
Commission offer health-care organizations goals
and strategies to prevent harm and death based on
what has been learned from sentinel events.
1. Sets patient safety standards
2. Implements and oversees sentinel event policy and
advisory group
3. Publishes Sentinel Event Alert newsletter and quality
check reports
4. Sets yearly national patient safety goals
5. Developed the universal protocol related to surgical
procedures
6. Evaluates organizations’ monitoring of quality of care
issues
7. Conducts patient safety research
8. Provides patient safety resources
9. Supports the Speak Up program
10. Involved with patient safety coalitions and legislative
efforts
box 10-8
Joint Commission International Center
for Patient Safety
Adapted from Joint Commission on Accreditation of Healthcare
Organizations (JCAHO), accessed November 26, 2005, from
jcpatientsafety.org
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chapter 10 ■ Issues of Quality and Safety 163
Organizations, Agencies, and Initiatives
Supporting Quality and Safety in the
Health-Care System
The ongoing movement to improve quality and
safety has led to the development of governmental
and private organizations (Box 10-9) in addition
to those mentioned in the historical perspective
at the beginning of this chapter. These organiza-
tions and agencies currently monitor, evaluate,
accredit, influence, research, finance, and advocate
for quality within the health delivery system.
Each organization works inside and outside the
system to drive change leading to improved health
outcomes and improved system quality. Each orga-
nization works within its mission to address various
characteristics of the health-care system or to
address patient needs. Some organizations serve
multiple roles beyond their primary mission.
Government Agencies
Federal and state-level government agencies pro-
vide tools and resources for improving quality and
safety within the U.S. health-care system. Govern-
ment agencies also oversee regulation, li censure, and
mandatory and voluntary reporting programs.
Within the U.S. Department of Health and
Human Services (HHS) reside multiple agencies
that support quality and safety. HHS is the U.S.
government’s principal agency for protecting the
health of all Americans and providing essential
human services, including health care (HHS, 2011).
HHS works closely with state and local govern-
ments to meet the nation’s health and human needs.
In addition to administering Medicare and
Medicaid, the Centers for Medicare and Medicaid
Services (CMS) administers quality initiatives
intended “to assure quality health care for all Amer-
icans through accountability and public exposure”
(CMS, 2008). Initiatives include:
■ MedQIC. This initiative aims to ensure each
Medicare recipient receives the appropriate
level of care. MedQIC is a community-based
QI program that provides tools and resources
to encourage changes in processes, structures,
and behaviors within the health-care
community.
■ Post–Acute Care Reform Plan. CMS is
examining post-acute transfers with the aim of
reducing care fragmentation and unsafe
transitions.
Government Agencies
• U.S. Department of Health and Human Services, www
.hhs.gov/
• Food and Drug Administration (FDA), www.fda.gov/
• Initiatives: Medwatch and Sentinel Initiative
• Health Resources and Services Administration (HRSA),
www.hrsa.gov/
• Initiatives: Health Information Technology and National
Practitioner Database
• Centers for Medicare and Medicaid Services (CMS),
www.cms.hhs.gov/
• Initiatives: Hospital Quality Initiative, MedQIC, American
Health Quality Association (AHQA)
• Agency for Healthcare Research and Quality (AHRQ),
www.ahrq.gov/
• Initiatives: Health IT, Improving Health Care Quality,
Medical Errors and Patient Safety, Measuring Quality
• VA National Center for Patient Safety, www.va.gov/
ncps/
Health-Care Provider Professional
Organizations
• American Nurses Association, http://nursingworld.org/
• Initiative: National Database of Nursing Quality
Indicators (NDNQI)
• Association of Perioperative Registered Nurses (AORN),
https://www.aorn.org/
• Initiative: Patient Safety First and AORN Toolkits
• American Hospital Association (AHA), www.aha.org/
• Initiative: AHA Quality Center
• Association of Academic Health Centers, www.aahcdc
.org/index.php
• Priorities: Health Profession Workforce and Health Care
Reform
Nonprofit Organizations, Foundations,
and Research
• The Leapfrog Group, www.leapfroggroup.org/
• Kaiser Family Foundation, www.kff.org/
• Markel Foundation-Connecting for Health, www.
connectingforhealth.org/aboutus/index.html#
• Robert Wood Johnson Foundation-Quality Equality in
Healthcare, www.rwjf.org/qualityequality/index.jsp
• National Patient Safety Foundation, www.npsf.org/
• The Commonwealth Fund, www.commonwealthfund
.org/aboutus/
Quality Organizations
• Institute for Healthcare Improvement (IHI), www.ihi.org/
ihi
• The Joint Commission, www.jointcommission.org/
• National Committee for Quality Assurance (NCQA),
http://web.ncqa.org/
• National Quality Forum, www.qualityforum.org/
box 10-9
Organizations and Agencies Supporting Quality and Safety
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164 unit 3 ■ Career Considerations
■ Hospital Quality Initiative. This is a major
initiative aimed at improving quality of care at
the provider and organization level. It creates a
uniform set of quality measurements by which
consumers can compare organizations and by
which organizations can benchmark progress
toward achieving goals in specified areas of care,
such as acute myocardial infarct, congestive
heart failure, pneumonia, and postsurgical
infections. Organizations provide data to CMS
through public reporting of quality measures.
These data feed the Hospital Compare Web site
(www.hospitalcompare.hhs.gov). Organizations
are incentivized to participate with an offering
of increased reimbursement.
Also under the HHS is the Agency for Healthcare
Research and Quality (AHRQ), which is the lead
federal agency charged with improving the quality,
safety, efficiency, and effectiveness of health care for
all Americans (HHS, 2008). Through multiple ini-
tiatives, the support of research, and evidence-based
decision-making, the AHRQ aims to fulfill its
mission:
■ Health IT. A multifaceted initiative that
includes (a) research support of $260 million
in grants and contracts to support and
stimulate investment in health information
technology (IT); (b) the newly created AHRQ
National Resource Center, which provides
technical assistance and research funding to
aid technology implementation within
communities; and (c) learning laboratories at
more than 100 hospitals nationwide to develop
and test health IT applications
■ National Quality Measures Clearinghouse
(NQMC). Web-accessible database provides
access to evidence-based quality measures and
measure sets; NQMC provides access for
obtaining detailed information on quality
measures and to further their dissemination,
implementation, and use in order to inform
health-care decisions
■ Medical Errors and Patient Safety. Web site
providing access to evidence-based tools and
resources for consumers and providers
■ AHRQ Quality Indicators. Set of quality
indicators used by organizations to highlight
potential quality concerns, identify areas that
need further study and investigation, and track
changes over time
The U.S. Department of Defense (DoD) and the
Veterans Health Administration (VHA) have
taken leadership positions in developing tools,
resources, and programs aimed at improving safety,
promoting change, and promoting a culture of
safety within the DoD and VHA. The VHA
National Center for Patient Safety developed a
toolkit for fall prevention and management, tools
for escape and elopement management, and cogni-
tive aids for root cause analysis and health failure
mode and effect analysis.
Health-Care Provider Professional
Organizations
Professional organizations directly address the mis-
sions and concerns regarding quality and safety of
the professionals they represent. Each organization
offers programs, access to evidence-based practices,
toolkits, and newsletters to aid their members in
driving quality within their own practice and
organization.
The vital quality and safety initiative of the
ANA is the National Database of Nursing Quality
Indicators (NDNQI), a database of unit-specific
nurse-sensitive information collected at hospitals.
Data are collected and evaluated to improve quality.
The indicators reflect the structure, process, and
outcomes of nursing care and lead to improved
quality and safety at the bedside. The ANA also
has a strong focus on safe nurse staffing levels to
promote safe, quality patient care.
Many specialty organizations within nursing
have also placed safe, quality patient care on their
agendas and part of their strategic plans. By devel-
oping and implementing standards of care, these
organizations outline nursing care standards to
obtain positive patient outcomes. Many health-care
institutions promote and require implementation
of these specialized standards within their own
patient care units (www.aacn.org; www.aann.org;
www. apna.org).
Nonprof it Organizations and Foundations
With few exceptions, nonprofit organizations and
foundations are generally focused on consumer
education, policy development, and research to
improve quality and safety within the health-care
system. Many organizations serve multiple mis-
sions. The Kaiser Family Foundation (2005) has a
strong emphasis on U.S. and international nonpar-
tisan health policy and health policy research. Self-
funded research and public opinion polling on
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chapter 10 ■ Issues of Quality and Safety 165
topics related to quality and safety in the health-
care system contribute to policy and legislation
development.
Also having a multifaceted mission, the
renowned Robert Wood Johnson Foundation
(RWJF) serves multiple missions and seeks to
improve health and health care for all Americans.
RWJF’s success comes from leveraging partner-
ships and its endowment to “building evidence and
producing, synthesizing and distributing knowl-
edge, new ideas and expertise” (RWJF, 2008, 2011)
in eight program areas. RWJF is responsible for
successfully funded projects and research that
improve quality and safety for all Americans.
The Leapfrog Group is a nonprofit organization
interested in improving safety, quality, and afford-
ability of health care through incentives and rewards
to those who use and pay for health care (Leapfrog
Group, 2007, 2011). With a focus on reducing pre-
ventable medical mistakes, the Leapfrog Group
touted their benefits to improve safety and quality
to consumers and business owners with three leaps:
(a) improve transparency by reporting hospital
survey results addressing quality and safety indi-
cators; (b) incentivize better quality and safety
performance; and (c) collaborate with other orga-
nizations to improve quality and safety. To date,
there is limited evidence that the Leapfrog Group
has effectively improved quality or safety. Limita-
tions to success may be in part because too few
hospitals have participated in the surveys and too
few consumers have used the available information
to make health decisions; however, there is an indi-
cation that, with time, participation could improve
with adjustments in strategy by the Leapfrog
Group (Galvin, Delbanco, Milstein, & Belden,
2005).
Quality Organizations
Each of the quality organizations strives to improve
system-wide quality for Americans through a
variety of programs and methods.
The National Committee for Quality Assurance
(NCQA) was established in 1990 to accredit health
plans and certify organizations. Its success in sup-
porting quality and safety resides in its Health
Effectiveness Data and Information Set (HEDIS).
Over 90% of U.S. health plans use HEDIS to
measure performance. HEDIS allows consum-
ers and employers to evaluate health plans using
data from HEDIS as a report card of the plan’s
success.
The Joint Commission was established in 1951
with a focus on structural measures of quality,
assessment of the physical plant, number of patient
beds per nurse, credentialing of service providers,
and other standards for each department. This
system of evaluation has given way to a more
process- and outcome-focused model: CQI. Today,
The JC accredits more than 19,000 health-care
organizations. Evaluation of nursing services is an
important part of the accreditation. JC–accredited
agencies are measured against national standards
set by health-care professionals. Hospitals, health-
care networks, long-term care facilities, ambulatory
care centers, home health agencies, behavioral
health-care facilities, and clinical laboratories are
among the organizations seeking JC accredita-
tion. Although accreditation by the JC is volun-
tary, Medicare and Medicaid reimbursement cannot
be sought by organizations not accredited by the
JC.
Integrating Initiatives and Evidenced-Based
Practices Into Patient Care
As you familiarize yourself with each of these orga-
nizations and their respective initiatives, consider
how they will affect the management of patient
care. Your responsibility as a professional RN is to
acknowledge their presence, understand and value
their importance, and participate in your facility-
adopted initiatives and evidence-based practices.
Additionally, as a leader and manager, you will be
expected to drive changes based upon endeavors of
many of these organizations, agencies, and initia-
tives ensuring that quality and safety continue to
improve.
The IOM report proposed five core compe-
tencies (Box 10-10) in which all health-care pro-
fessionals need to be effective as providers and
leaders in the 21st-century health-care system.
Nurses are key to improving patient safety (RWJF,
2011). The IOM’s report The Future of Nursing:
Leading Change Advancing Health (2011) focused
on nurs ing education, research, and leadership as
ways to improve patient safety. Nurses need to be
full partners with physicians and other members of
the interprofessional team in the delivery of health
care.
By integrating these competencies into 21st-
century health profession education, you can begin
to support health-care reform while engaging in
safe and effective patient care. As a practicing pro-
fessional, you can use the competencies to guide
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166 unit 3 ■ Career Considerations
future professional development and ensure a posi-
tive impact on health-care reform while improving
quality and safety.
Influence of Nursing
Nurses are empowered through self-determination,
meaning, competence, and impact (Whitehead,
Weiss, & Tappen, 2010). Additionally, nurses play
vital roles in collective bargaining and decision
making within their organizations, empowered
through professional organization such as the ANA
(see Chapter 8). It is through these organizations
that nurses can promote safety and quality in
nursing practice. Working within organizations and
health-care institutions to create guidelines for safe
staffing, develop systems that measure patient
acuity by nursing time and expertise, and encourag-
ing shared decision making promote safe practice
(Aiken et al., 2012; Pham et al., 2012).
Nurses are respected and trusted health-care
professionals. To influence change in the health-
care system, professional nurses must first acknowl-
edge power within the profession and recognize
their central role in health care. To be effective,
nurses must leverage their professional expertise
and the trust and respect they have garnered. Nurses
need to act, not stand on the sidelines, and raise the
volume of their collective voice. It is critical that
nurses speak up and seek an active role in shaping
health-care reform:
■ Become informed. Research topics of interest
to you and your practice. Rely on appropriate
Internet sites and your professional
organizations as resources for current policy
and legislative topics.
■ Plan. After selecting a topic, prepare your
plan: gather facts and figures that will support
your ideas and position. Outline them, and
address your audience in person, on paper, or
via the Web. The most influential people are
prepared and believe in their topic.
■ Take action. Shape public opinion by the
method of your choice. Start small, and build
your impact. (1) Write a letter to your
representative (local, state, federal), ANA
leadership or state-level delegate, the editor of
your local newspaper, or to the editor of your
favorite nursing journal/magazine. (2) Attend a
meeting where your topic will be addressed in
a public forum or at a professional gathering.
Meet the people who are influential, and share
your ideas or learn from others. (3) Vote for
candidates and officers in your professional
organizations and within the government. (4)
Visit your representative (local, state, federal)
or ANA leadership or state-level delegate to
share your ideas. (5) Volunteer. Ask what you
can do to help. (6) Testify before decision-
making bodies. (7) Educate yourself on the
Affordable Care Act so that you can educate
others.
Conclusion
Pressure from quality organizations, consumers,
payers, and providers has shifted the focus in the
health-care system from patient care to issues of
cost and quality. Experts indicate that quality pro-
motes decreased costs, increased satisfaction, and
better patient outcomes. This is an opportunity
for nurses to become more professional and empow-
Provide patient-centered care. Identify, respect, and
care about patients’ differences, values, preferences, and
expressed needs; relieve pain and suffering; coordinate
continuous care; listen to, clearly inform, communicate with,
and educate patients; share decision making and
management; and continuously advocate disease
prevention, wellness, and promotion of healthy lifestyles,
including a focus on population health.
Work in interprofessional teams. Cooperate,
collaborate, communicate, and integrate care in teams to
ensure that care is continuous and reliable.
Employ evidence-based practice. Integrate best
research with clinical expertise and patient values for
optimum care, and participate in learning and research
activities to the extent feasible.
Apply quality improvement. Identify errors and
hazards in care; understand and implement basic safety
design principles, such as standardization and
simplification; continually understand and measure quality
of care in terms of structure, process, and outcomes in
relation to patient and community needs; and design and
test interventions to change processes and systems of care
with the objective of improving quality.
Utilize informatics. Communicate, manage knowledge,
mitigate error, and support decision making using
information technology.
box 10-10
Core Competencies for Health Professionals (IOM, 2003a, p. 4)
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chapter 10 ■ Issues of Quality and Safety 167
Study Questions
1. How have historical, social, political, and economic trends affected nursing practice? Give
specific examples and their implications.
2. What problems have you identified during your clinical experiences that could be considered
issues to be addressed using CQI?
3. What SCMs have you seen implemented in practice? Which ones might you use to assist you
in planning care? If you have not seen any, ask the nurse manager what is used on the unit.
4. How do nursing organization care models affect quality and safety outcomes?
5. Discuss the role of the nurse in CQI and risk management.
6. Based on patient safety goals for the current year, what will you do to ensure adherence to
these goals?
7. What are evidence-based practices that promote quality and safety within the health-care
system?
8. Describe how regulatory agencies and accrediting agencies affect patient care and outcomes at
the bedside.
9. Review the nonprofit organizations and government agencies that influence and advocate for
quality and safety in the health-care system. What do the organizations or agencies do that
supports the hallmarks of quality? What have been the results of their efforts for patients,
facilities, the health-care delivery system, and the nursing profession? How have the
organizations or agencies affected your facility and professional practice?
ered to organize and manage patient care so that it
is safe, efficient, and of the highest quality. Begin
early in your career to participate actively in QI
initiatives and familiarize yourself with the causes
of medical errors. Participate on committees to
create policies that promote safety and quality.
Focus attention on the following in patient care
delivery (Hansten & Washburn, 2001, p. 24D):
1. Think critically. Use your creative, intuitive,
logical, and analytical processes continually in
working with patients and their families.
2. Plan and report outcomes. Emphasizing
results is a necessary part of managing
resources in today’s cost-conscious
environment. Focusing on the outcomes moves
the nurse and other members of the
interprofessional team away from tasks.
3. Make introductory rounds. Begin each shift
with the interprofessional team members
introducing themselves, describing their roles,
and providing patient updates.
4. Plan in partnership with the patient. In
conjunction with the introductory rounds,
spend a few minutes early in the shift with
each patient, discussing care objectives and
long-term goals. This event becomes the center
of the nursing process for the shift and ensures
that the patient, nurse, and other members of
the interprofessional team are working toward
the same outcomes.
5. Communicate the plan. Avoid confusion
among members of the interprofessional team
by communicating the intended outcomes and
the important role that each member plays in
the plan.
6. Evaluate progress. Schedule time during the
shift quickly to evaluate outcomes and the
progress of the plan and to make revisions as
necessary.
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168 unit 3 ■ Career Considerations
Case Study to Promote Critical Reasoning
The director of CQI has called a meeting of all the interprofessional team members on your floor.
Based on last quarter’s statistics, the readmission rate of patients who have infections after hip
replacements for osteoarthritis is twice that of patients for the first half of the year. The director
has requested that the staff identify members who wish to be CQI team members investigating
this problem. You, the staff nurse, have volunteered to be a member of the team. The team will
consist of the physical therapist on the unit, a physician’s assistant who works with the hospital
orthopedic surgeons, the clinical educator, the nursing case manager, and you.
1. Why were these people selected for the team?
2. What data need to be collected to evaluate this situation?
3. What are the potential outcomes for patients with who have had hip replacements?
4. Develop a flowchart of a typical hospital discharge and readmission rate for patients who have
had hip replacements.
10. Explain how technology enhances and promotes safe patient care, educates patients and
consumers, evaluates health-care delivery, and enhances the nurse’s knowledge base in your
practice and at your organization.
11. How would you begin discussion on quality and safety issues with the nurse manager or
colleague?
12. What issues may arise when the care delivery system is changed? What does the RN need to
consider when implementing these changes?
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chapter 10 ■ Issues of Quality and Safety 169
References
Affordable Care Act. 2010. Retrieved on February 3,
2014, from www.hhs.gov/healthcare/rights
Aiken, L.H., Sermeus, W., Van den Heede, K., Sloan,
D.M., Russe, R., McKee, M., Bruyneel, L., Rafferty,
A.M., Griffiths, R., & Moreno-Casbas, M.T. (2012).
Patient safety, satisfaction, and quality of hospital care:
Cross sectional surveys of nurses and patients in 12
countries in Europe and the United States. British
Medical Journal, 2012:344:e1717. doi: 10.1136/
bmj.e1717. Retrieved October 4, 2013, from www
.bmj.com/content/344/bmj.e1717
Ajjawi, R., & Higgs, J. (2008). Learning to reason: A
journey of professional socialization. Advances in Health
Sciences Education, 13(2), 133–150.
American Association of Colleges of Nursing. (2008).
Essentials of baccalaureate education. Retrieved October
4, 2013, from www.aacn.nche.edu/
American Association of Colleges of Nursing. (2012).
Nursing shortage fact sheet. Retrieved October 4,
2013, from www.aacn.nche.edu/media-relations/
FacultyShortageFS
American Association of Colleges of Nursing (AACN).
(2012). Creating a more qualified nursing workforce.
Retrieved October 4, 2013, from www.aacn.nche.edu/
Media/FactSheets/ImpactEdNP.htm
American Association of Nurse Executives (2005). BSN
level nursing resources. Retrieved from http://www
.anoe.org/resources/leadership%20tools/BSN.shtml
American Nurses Association. (2008). ANA’s health
care agenda. Retrieved October 3, 2013, from
www.nursingworld.org/Content/HealthcareandPolicy
Issues/Agenda/ANAsHealthSystemReformAgenda
Anderson, L.M., Scrimshaw, S.C., Fullilove, M.T., Fielding,
J.E., & Normand, J. (2003). Culturally competent
healthcare systems: A systematic review. American
Journal of Preventive Medicine, 24(3S), 68–79.
Auerbach, D.I., Staiger, D.O., Muench, U., & Buerhaus, P.I.
(2013). The nursing workforce in an era of health care
reform. New England Journal of Medicine, 368(16),
1470–1472.
Baldwin, J.H., Conger, C.O., Maycock, C., & Abegglen,
J.C. (2002). Health care delivery system influences
changes in nursing educational materials. Public Health
Nursing, 19(4), 246–254.
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010).
Educating nurses: A call for radical transformation. San
Francisco: Jossey-Bass.
Benson-Flynn, J. (2001). Incident reporting: Clarifying
occurrences, incidents, and sentinel events. Home
Healthcare Nurse, 19, 701–706.
Billings, D.M., & Halstead, J.A. (2011). Teaching in
nursing: A Guide for Faculty (4th ed.). St. Louis: Elsevier
Saunders.
Booth, R.G. (2006). Educating the future health professional
nurse. International Journal of Nursing Education
Scholarship, 3(1), 1–10.
Brook, R.H., Davis, A.R., & Kamberg, C. (1980). Selected
reflections on quality of medical care evaluations in the
1980s. Nursing Research, 29(2), 127.
Brown, T.W., McCarthy, M.L., Kelen, G.D., and Lew, F.
(2010). An epidemiologic study of closed emergency
department malpractice claims in a national database of
physician malpractice insurers. Academic Emergency
Medicine, 17(5), 553–560.
Buerhaus, P.I. (2013). This era’s health care reform built on
quality/cost ratio. University of Wisconsin School of
Nursing, Retrieved October 5, 2013, from www.son
.wisc.edu/buerhaus-health-care-reform-2013-littlefield-
leadership-lecture.htm
Calzone, K.A., Cashion, A., Feetham, S., Jenkins, J., Prows,
C.A., Williams, J.K., & Wung, S.F. (2010). Nursing
transforming healthcare using genetics and genomics.
Nursing Outlook, 58(5). 26–35.
Centers for Medicare and Medicaid Services (CMS).
(2008). Retrieved February 3, 2014, from www. cms
.gov
Cole, L., & Houston, S. (1999). Linking outcomes
management and practice improvement. structured care
methodologies: Evolution and use in patient care
delivery. Outcomes Management for Nursing Practice,
3(2), 53.
Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J.,
et al. (2007). Quality and safety education for nurses.
Nursing Outlook, 55(3), 122–131.
Davis, K. (2001). Preparing for the future: A 2020 vision
for American health care. Academic Medicine, 76(4),
304–306.
Davis, K. (2010). A new era in American health care:
Realizing the potential of reform. New York: The
Commonwealth Fund.
Donabedian, A. (1969). A guide to medical care
administration. In Medical care appraisal: Quality and
Utilization, vol. II. New York: American Public Health
Association.
Donabedian, A. (1977). Evaluating the quality of medical
care. Milbank Memorial Fund Quarterly, 44 (part 2),
166.
Donabedian, A. (1987). Some basic issues in evaluating
the quality of health care. In Rinke, L.T. (ed.). Outcome
measures in home care. New York: National League of
Nursing.
Donaldson, M.S. (ed.). (1998). Statement on quality of
care. Washington, DC: National Academy Press.
Retrieved August 1, 2008, from www.nap.edu/
Doenges, M.E., Morrhouse, M., & Murr, A. (2009).
Nursing care plans (8th ed.). Philadelphia: F.A. Davis.
Co.
Dubois C.A., D’Amour D., Pomey M.P., Girard F., & Brault
I. (2013). Conceptualizing performance of nursing care
as a prerequisite for better measurement: A systematic
and interpretive review. Biomed Central Nursing, 12(7).
doi: 10.1186/1472-6955-12-7.
Duke University Medical Center. (2005). Anatomy of an
error: Basic tenet of human error. Retrieved August 7,
2008, from http://patientsafetyed.duhs.duke.edu/
index.html
Dunton, N., Gajewski, B., Klaus, S., & Pierson, B., (2007).
“The Relationship of Nursing Workforce Characteristics
to Patient Outcomes” OJIN: The Online Journal of Issues
in Nursing. 12 (3). Retrieved on June 19, 2014 from
http://www.nursingworld.org/MainMenuCategories/
ANAMarketplace/ANAPeriodicals/OJIN/
TableofContents/Volume122007/No3Sept07/
NursingWorkforceCharacteristics.html
Elwood, T.W. (2007). The future of health care in
the United States. Journal of Allied Health, 36(1),
3–10.
Ervin, N.E., Bickes, J.T., & Schim, S.M. (2006).
Environments of care: A curriculum model for preparing
a new generation of nurses. Journal of Nursing
Education, 45(2), 75–80.
3663_Chapter 10_0147-0172.indd 1693663_Chapter 10_0147-0172.indd 169 9/15/2014 4:36:43 PM9/15/2014 4:36:43 PM
Process CyanProcess CyanProcess MagentaProcess MagentaProcess YellowProcess YellowProcess BlackProcess Black
170 unit 3 ■ Career Considerations
Galvin, R.S., Delbanco, S., Milstein, A., & Belden, G.
(2005, Jan/Feb). Has the Leapfrog Group had an
impact on the health care market? Health Affairs, 24(1),
228–233.
Haddad, S.M. (2010). Clinical pathways: Effects on
professional practice, patient outcomes, length of stay
and hospital costs: RHL commentary. WHO. Retrieved
October 5, 2013, from http://apps.who.int/rhl/
effective_practice_and_organizing_care/cd006632
_haddadsm_com/en/.
Haines, T.P., Hill, A.M., & Hill, K.D. (2011). Patient
education to prevent falls among older hospital
inpatients: A randomized controlled trial. Archives of
Internal Medicine, 171(6), 516–524.
Hansten, R., & Washburn, M. (2001). Outcomes-based
care delivery. American Journal of Nursing, 101(2),
24A–D.
Heller, B.R., Oros, M.T., & Durney-Crowley, J. (2000). The
future of nursing education: 10 trends to watch. Nursing
and Health Care Perspectives, 21(1), 9.
Hunt, D.V. (1992). Quality in America: How to implement a
competitive quality program. Homewood, IL: Business
One Irwin.
Hunter, K.M. (2011). Implementation of an electronic
medication administration record and bedside
verification system. Online Journal of Nursing Informatics,
15(2), 672–678. Retrieved October 5, 2013, from
http://ojini.org/issues/?p=672
Institute of Medicine. (2000). To err is human: Building a
safer health system. Kohn, L.T., Corrigan, J.M., &
Donaldson, M.S. (eds.). Washington, DC: National
Academy Press.
Institute of Medicine. (2001). Crossing the quality chasm: A
new health system for the 21st century. Washington,
DC: National Academy Press.
Institute of Medicine. (2003a). Health professions
education: A bridge to quality. Washington, DC:
National Academy Press.
Institute of Medicine. (2003b). Priority areas for national
actions: Transforming health care quality. Quality
Chasm Series. Washington, DC: National Academies
Press.
Institute of Medicine. (2004). Keeping patients safe:
Transforming the work environment for nurses.
Washington, DC: National Academy Press.
Institute of Medicine. (2006). Crossing the quality chasm:
The IOM quality health care initiative. Retrieved August
8, 2008, from www.iom.edu/CMS/8089.aspx
Institute of Medicine (2011). The future of nursing: Leading
change, advancing health. Washington: DC: National
Academies Press.
Irvine, D. (1998). Finding value in nursing care: A
framework for quality improvement and clinical
evaluation. Nursing Economics, 16(3), 110–118.
Jackson, S.E. (2006). The influence of managed care on
U.S. baccalaureate nursing education programs. Journal
of Nursing Education, 45(2), 67–74.
Joint Commission. (2010). Retrieved February 3, 2014,
from www.jointcommission.org/quality_improvement
_tools.aspx
Joint Commission. (2008). Sentinel event. Retrieved October
2, 2013, from www.jointcommission.org/
SentinelEvents/
Joint Commission on Accreditation of Healthcare
Organizations (JCAHO). (2005). Retrieved November
26, 2005, from http://jcpatientsafety.org
Kaiser Family Foundation. (2005). Trends and indicators in
the changing health care marketplace. Retrieved June
14, 2008, from www.kff.org/insurance/7031/index.
cfm
Kalisch, B., Landstrom, G., & Williams, R.A. (2009).
Missed nursing care: Errors of omission, Nursing
Outlook, 57(1), 3–9.
Kersbergen, A.L. (2000). Managed care shifts health care
from an altruistic model to a business framework.
Nursing & Health Care Perspectives, 21(2), 81–83.
Kirk, M. (2002). The impact of globalization and
environmental change on health: Challenges for nurse
education. Nurse Education Today, 22(1), 60–71.
Lantham, B., & Maxson-Cooper, P. (2003). Is six sigma the
answer for nursing to reduce medical errors and
enhance patient safety? Nursing Economics, 21(1).
Lea, D.H., Skirton, H., Read, C.Y., & Williams, J.K.
(2011). Implications for educating the next generation of
nurses on genetics and genomics in the 21st century.
Journal of Nursing Scholarship, 43(4), 3–12.
Leape, L.L., Bates, D.W., & Petrycki, S. (1993). Incidence
and preventability of adverse drug events in hospitalized
adults. Journal of Internal Medicine, 8, 289–294.
Leapfrog Group. (2007). About us. Retrieved August 20,
2008, from www.leapfroggroup.org/about_us
Leapfrog Group. (2011). About us. Retrieved December 7,
2013, from www.leapfroggroup.org/about_us
Lichtig, L.K., Knauf, R.A., & Milholland, D.K. (1999).
Some impacts of nursing on acute care hospital
outcomes. Journal of Nursing Administration, 29(2),
25–33.
Mardon, R.E., Khanna, K., Sorra J., Dyer, N., & Famolaro,
T. (2010). Exploring relationships between hospital
patient safety culture and adverse event. Journal of
Patient Safety, 6(4). 226–232.
McLaughlin, C., & Kaluzny, A. (2006). Continuous quality
improvement in health care: theory, implementations,
and applications, 3rd ed. Sudbury, MA: Jones and
Bartlett.
Menix, K.D. (2000). Educating to manage the accelerated
change environment effectively: Part 1. Journal for
Nurses in Staff Development, 16(6), 282–288.
Milton, C.L. (2011). An ethical exploration of quality and
safety initiatives in nurse practice. Nursing Science
Quality, 24(2), 107–110.
Nightingale, F., & Barnum, B.S. (1992). Notes on nursing:
What it is, and what it is not, commemorative ed.
Philadelphia: Lippincott-Raven.
Oliver, D., Healey, F., & Haines, T.P. (2010). Preventing
falls and fall-related injuries in hospitals. Clinical
Geriatric Medicine, 26(4), 645–692.
O’Neill, E.H., & Pew Health Professions Commission.
(1998). Recreating health professional practice for a
new century. San Francisco: Pew Health Professions
Commission.
Orsolini-Hain, L.M. (2008). An interpretive
phenomenological study on the influences on associate
Degree Prepared Nurses to Return to School to Earn a
higher degree in nursing. San Francisco: University of
California, San Francisco.
Patient-Centered Outcomes Research Institute (PCORI).
(2012). Improving health care systems. Retrieved
October 4, 2013, from www.pcori.org/assets/PFA-
Improving-Healthcare-Systems-05222012
PEW Health Commission. (1998). Fourth report of the Pew
health professions commission. Retrieved February 3,
2014, from http://Fourth_report_of_the_Pew_Health_
Professi.htm
Pham, J.C., Aswani, M.S., Rosen, M., Lee, H.W., Huddle,
M., Weeks, K., & Pronovost, P.J. (2012). Reducing
3663_Chapter 10_0147-0172.indd 1703663_Chapter 10_0147-0172.indd 170 9/15/2014 4:36:43 PM9/15/2014 4:36:43 PM
Process CyanProcess CyanProcess MagentaProcess MagentaProcess YellowProcess YellowProcess BlackProcess Black
chapter 10 ■ Issues of Quality and Safety 171
medical errors and adverse events. Annual Review of
Medicine, 63, 447–463. Retrieved October 5, 2013,
from www.annualreviews.org
Plan to reduce racial and ethnic health disparities. Retrieved
October 5, 2013, from minorityhealth.hhs.gov/npa/
files/Plans/HHS/HHS_Plan_complete .
Poon, E.G., Keohane, C.A., Yoon, C.S., Ditmore, M.,
Bane, A., Levtzion-Korach, O., & Moniz, T. (2010).
Effect of bar-code technology on the safety and
medication administration. The New England Journal of
Medicine, 362(18), 1698–1707.
Raduma-Tomas, M.A., Flin, R., Yule, S.J., & Close, S.
(2012). The importance of preparation for doctors’
handovers in an acute medical assessment unit: A
hierarchal task analysis. Quality and Safety in Health
Care, 21, 211–217.
Raduma-Tomas, M.A., Flin, R., Yule, S.J., & Williams, D.
(2011). Doctors’ handovers in hospitals: A literature
review. Quality and safety in health care, 20,
128–133.
Robert Wood Johnson Foundation. (2008). About us.
Retrieved August 20, 2008, from www.rwjf.org/about/
Robert Wood Johnson Foundation (2011). Nurses are key
to improving patient safety. Retrieved from http://www
.rwjf.org/en/about-rwjf/newsroom/newsroom-
content/2011/04/nurses-are-key-to-improving-patient-
safety.html
Rogers, A.E., Hwang, W., Scott, L.D., Aiken, L.H., et al.
(2004). The working hours of hospital staff nurses
and patient safety: Both errors and near errors are more
likely to occur when hospital staff nurses work twelve or
more hours at a stretch. Health Affairs, 23(4),
202–212.
Rotter, T., Kinsman, L., James, E.L., Machotta, A., Gothe,
H., Willis, J., Snow, P., & Kugler, J. (2010). Clinical
pathways: Effects on professional practice, patient
outcomes, length of stay and hospital costs. The
Cochrane Library, 7. Retrieved October 2, 2013, from
http://thecochranelibrary.com
Sargeant, J., Loney, E., and Murphy, G. (2008) Effective
interprofessional teams. Journal of Continuing Education
in the Health Professions, 28(4), 228–234.
Schroeder, P., ed. Monitoring and Evaluation in Nursing.
Gaithersburg, MD: Aspen.
Shekelle, P.G. (2013). Nurse–patient ratios as a patient
safety strategy: A systematic review. Annals of Internal
Medicine, 158(5), 404–409.
Strickland, O. (1997). Challenges in measuring patient
outcomes. Nursing Clinics of North America, 32,
495–512.
Swansburg, R., & Swansburg, R. (2002). Introduction to
management and leadership for nurse managers, 3rd
ed. Boston: Jones and Bartlett.
Trossman, S. (2006). Issues update. It’s in the genes: The
ANA and nurse leaders want RNs and students to
practice with genetics and genomics in mind. American
Journal of Nursing, 106(2), 74–75.
U.S. Department of Health and Human Services. (2008).
About HHS. Retrieved August 20, 2008, from www.
hhs.gov/
U.S. Department of Health and Human Services (HHS).
(2011). http://www.hhs.gov/
Weiss, M.E., Yakusheva, O., & Bobay, K.L. (2011).
Quality and cost analysis of nurse staffing, discharge
preparation and postdischarge utilization. Health Service
Research, 46(5), 1–22.
Whitehead, D.K., Weiss, S.A., & Tappen, R.M. (2010).
Essentials of nursing leadership and management,
5th ed. Philadelphia: F.A. Davis.
World Health Organization (WHO). (2009). “World health
statistics 2009.” Retrieved October 4, 2013, from
www.who.itl
3663_Chapter 10_0147-0172.indd 1713663_Chapter 10_0147-0172.indd 171 9/15/2014 4:36:43 PM9/15/2014 4:36:43 PM
Process CyanProcess CyanProcess MagentaProcess MagentaProcess YellowProcess YellowProcess BlackProcess Black
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173
Chapter 11
Promoting a Healthy Work Environment
OBJECTIVES
After reading this chapter, the student should be able to:
■ Recognize threats to safety in the workplace.
■ Identify agencies responsible for overseeing workplace
safety.
■ Describe methods for dealing with violence in the
workplace.
■ Identify the role of the nurse in dealing with catastrophes
including terrorism threats.
■ Recognize situations that may reflect sexual harassment.
■ Make suggestions for improving the physical and social work
environment.
■ Identify signs and symptoms of stress, reality shock, and
burnout.
■ Describe the impact of stress, reality shock, and burnout on
the individual and the health-care team.
■ Discuss the factors that affect job satisfaction.
■ Develop strategies to manage personal and professional
stresses.
OUTLINE
Workplace Safety
Threats to Safety
Addressing Threats to Safety
OSHA
Centers for Disease Control and Prevention (CDC)
American Nurses Association (ANA)
The Joint Commission
Institute of Medicine (IOM)
Developing Workplace Safety Programs
Violence
Preventing Violent Behavior
If Violent Behavior Occurs
Horizontal Violence
Sexual Harassment
Discrimination
Latex Allergy
Needlestick (Sharps) Injuries
Your Employer’s Responsibility
Employee Responsibilities
Ergonomic Injuries
Back Injuries
Repetitive Stress Injuries
Toxic Environments
Impaired Workers
Disabled Employees
Natural Disasters and Terrorism Threats
Shift Work Disorders
Mandatory Overtime
Staffing Ratios
Reporting Questionable Practices
Social Environment
Working Relationships
Involvement in Decision Making
Professional Growth and Innovation
Encourage New Ideas and Critical Thinking
Reward Professional Growth
Cultural Diversity
Physical Environment
Stress, Burnout, and Job Satisfaction
Stress
Sources of Stress
Why Is Health Care a Stressful Occupation?
Responses to Stress
Managing Stress
Burnout
Stages of Burnout
Buffers Against Burnout
Job Satisfaction
The Work Itself
The Health-Care Team
The Employing Organization
Initial Concerns
Differences in Expectations
Additional Pressures on the New Graduate
Easing the Transition
Ineffective Coping Strategies
Conclusion
Almost half of our waking hours are spent in the
workplace. Yet, the quality of the workplace envi-
ronment is neglected to a surprising extent in many
health-care organizations. It is neglected by admin-
istrators who would never allow peeling paint or
poorly maintained equipment but who leave their
staff, their most costly and valuable resource,
unmaintained and unrefreshed. The current “do
more with less” attitude places additional pressure
on staff and management alike (Chisholm, 1992).
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174 unit 3 ■ Career Considerations
Many nurses are still struggling to achieve healthy
environments where they work (Bylone, 2011).
Much of the responsibility for enhancing the
workplace rests with the people who have the
authority and resources to encourage organization-
wide improvements. Nurses, however, have begun
to take more responsibility for identifying work-
place issues and advocating improvement. This
chapter focuses on these many issues.
Workplace Safety
Threats to Safety
A health-care facility may be one of the most dan-
gerous work environments in the United States.
Health and safety threats include infectious dis-
eases, physical violence, ergonomic injuries related
to the movement and repositioning of patients,
exposure to hazardous chemicals and radiation, and
sharps injuries (ANA, 2007). Consider the follow-
ing two examples:
In spring 2001, a Florida nurse with 20 years’
psychiatric nursing experience died of head and
face trauma. Her assailant, a former wrestler, had
been admitted involuntarily in the early morning
to the private mental health-care facility. An inves-
tigation found that the facility did not have proce-
dures for handling workplace violence and no
method of summoning help in an emergency
(Arbury, 2002).
Somewhere between 600,000 and 1,000,000
needlestick injuries occur annually in the United
States. Why is this a concern? Percutaneous expo-
sure is the principal route for human immunodefi-
ciency virus (HIV) infection as well as hepatitis B
and C and other blood-borne pathogens.
The American Nurses Association (ANA) sur-
veyed 4,614 nurses to learn about their primary
concerns related to workplace safety. Their top con-
cerns were stress and overwork (74%) and ergo-
nomic injury (62%). An encouraging finding was
that more nurses reported the availability of devices
for patient transfers and for reducing sharps inju-
ries, fewer assaults, and less illness due to work
environment (ANA, 2012). When surveyed about
factors considered essential to a healthy workplace
environment, employees listed collaborative work
relationships, good communication, empowerment,
recognition, opportunities for growth, effective
leadership, adequate staffing, and workplace safety
(Lindberg &Vingard, 2012).
Threats to safety in the workplace vary from one
setting to another and from one individual to
another. A pregnant staff member may be more
vulnerable to risks from radiation; staff members
working in the emergency room are at more risk
for HIV and tuberculosis exposure than are the
staff in the newborn nursery. All staff members
have the right to be made aware of potential risks
and be provided with as much protection as pos-
sible. No worker should feel uncomfortable or
unsafe in the workplace.
Addressing Threats to Safety
The modern movement for safety in the workplace
began near the end of the Industrial Revolution.
The National Council for Industrial Safety (now
the National Safety Council) was formed in 1913.
The Occupational Safety and Health Act of 1970
created both the National Institute of Occupational
Safety and Health (NIOSH) and the Occupa-
tional Safety and Health Administration (OSHA).
OSHA, part of the U.S. Department of Labor, is
responsible for developing and enforcing workplace
safety and health regulations. NIOSH, part of the
U.S. Department of Health and Human Services,
supports research, education, and training. The
National Safety Council (NSC) partners with
OSHA to provide training. The NSC maintains
that safety in the workplace is the responsibility of
both the employer and the employee. The employer
must ensure a safe, healthful work environment,
and employees are accountable for knowing and
following safety guidelines and standards (National
Safety Council, 1992). The journey to “world-class
safety,” says the NSC, is a process of continuous
assessment and improvement (National Safety
Council, 2013).
OSHA
The goal of OSHA is to prevent injuries and illness
and save the lives of employees across the United
States (OSHA, 2013a). Employers must comply
with OSHA regulations for providing a safe,
healthful work environment. They are also required
to keep records of all occupational (job-related)
illnesses and accidents such as chemical exposures,
lacerations, hearing loss, respiratory exposure, mus-
culoskeletal injuries, and exposure to infectious
diseases. Workplace inspections may be conducted
with or without prior notification to the employer.
Catastrophic or fatal accidents and employee com-
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chapter 11 ■ Promoting a Healthy Work Environment 175
plaints may trigger an OSHA inspection. OSHA
encourages employers and employees to work
together to identify and remove workplace hazards
before contacting OSHA. If the employer has not
been able to resolve the safety or health issue,
however, the employee may file a formal complaint,
and an inspection will be ordered (U.S. Department
of Labor, 1995). Any violations found are posted
where all employees can view them. The employer
has the right to contest the OSHA decision. The
law also states that the employer cannot punish or
discriminate against employees for exercising their
rights related to job safety and health hazards or
participating in OSHA inspections (U.S. Depart-
ment of Labor, 1995).
OSHA inspections of health-care facilities have
focused especially on blood-borne pathogens,
lifting and ergonomic (proper body alignment)
guidelines, confined-space regulations, respiratory
guidelines, and workplace violence. OSHA added
protecting the work site against terrorism after the
September 11, 2001 attacks (www.osha.gov).
Centers for Disease Control and
Prevention (CDC)
The CDC partners with other agencies to investi-
gate health problems, conduct research, implement
prevention strategies, and promote safe and healthy
environments. CDC publishes continuous updates
of recommendations for prevention of HIV trans-
mission in the workplace and universal precautions
related to blood-borne pathogens and other infec-
tious diseases. CDC also targets public health
emergency preparedness and response related to
biological and chemical agents and threats (CDC,
1992; www.cdc.gov/). CDC recommendations can
be found in the Mortality and Morbidity Weekly
Report (MMWR), on the Internet (www.cdc.gov/
health/diseases), or at its toll-free phone number
(800-311-3435).
American Nurses Association (ANA)
The ANA Web site (www.nursingworld.org) pro-
vides up-to-date information related to workplace
advocacy and safety for all nurses. In 1999, ANA
established its Commission on Workplace Advo-
cacy, which addresses issues such as collective bar-
gaining, workplace violence, mandatory overtime,
staffing ratios, conflict management, dele gation, eth-
ical issues, compensation, needlestick safety, latex
allergies, pollution prevention, and ergonomics.
The Joint Commission
To maintain Joint Commission ( JC) accreditation,
organizations must have an extensive on-site review,
including workplace safety, by a team of JC health-
care professionals at least once every 3 years.
Institute of Medicine (IOM)
The Institute of Medicine (IOM) is a private, non-
governmental organization whose mission is to
improve the health of people everywhere; thus, the
topics it studies are very broad (www.iom.edu). In
1996 the IOM began a quality initiative to assess
the nation’s health-care system. One result was the
2004 report, “Keeping Patients Safe: Transforming
the Work Environment of Nurses.” The report
identified concerns related to organizational man-
agement, workforce deployment practices, work
design, and organizational culture (Beyea, 2004).
Box 11-1 lists the most important federal laws
enacted to protect individuals in the workplace.
Developing Workplace Safety Programs
Workplace safety programs should protect staff
members from harm and the organization from any
liability that could result.
1. The first step in development of a workplace
safety program is to recognize a potential hazard.
OSHA (U.S. Department of Labor, 1995)
requires employers to inform employees of any
potential health hazards and provide as much
protection from these hazards as possible. In
many cases, initial warnings come from the
CDC, NIOSH, and other federal, state, and
local agencies. For example, employers must
provide tuberculosis testing and hepatitis B
vaccine; protective equipment such as gloves,
gowns, and masks; and immediate treatment
after exposure for all staff members who may
have contact with blood-borne pathogens. They
are expected to remove hazards, educate
employees, and establish institution-wide
policies and procedures to protect their
employees (Herring, 1994; Roche, 1993). If not
provided with protective gloves, for example,
employees may refuse to participate in any
activities involving blood or blood products.
Reasonable accommodations must also be
made. For example, a nurse with latex allergies
may be placed in an area such as patient
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176 unit 3 ■ Career Considerations
education where exposure to blood-borne
pathogens is unlikely (Strader & Decker, 1995;
U.S. Department of Labor, 1995).
2. The second step in a workplace safety program
is a thorough assessment of the amount of risk
entailed. For example:
Nancy Wu is the nurse manager on a busy geriatric
unit. Most patients require total care: bathing,
feeding, and positioning. She observed that several
of the staff members working on the unit use poor
body mechanics when lifting and moving the
patients. In the last month, several went to Employee
Health complaining of back pain. This week, she
noticed that the patients seemed to remain in the
same position for long periods and were rarely out
of bed or left in a chair for the entire day. When
she confronted the staff, the response was the same
from all of them: “I have to work for a living. I can’t
afford to risk a back injury for someone who may
not live past the end of the week.” Nancy was con-
cerned about the care of the patients as well as
the apparent lack of information her staff had
about prevention of back injuries. She decided to
seek assistance from the nurse practitioner in
Employee Health to develop a back injury preven-
tion program.
Assessment of the workplace may require consider-
able data gathering. Formal committees are often
formed to assess these risks. Staff from various
levels and departments should be included.
3. The third step is to create a plan to provide
optimal protection for staff members without
interfering with the provision of quality patient
care. For example, some devices that are worn
to prevent transmission of tuberculosis interfere
with communication with the patient. Some
attempts have been made to limit visits or
withdraw home health-care nurses from high-
crime areas, but this leaves homebound patients
without care (Nadwairski, 1992). These are not
acceptable solutions. Developing a safety plan
includes the following:
■ Distinguish real from imagined risks
■ Consult federal, state, and local regulations
and experts on work safety
Adapted from Strader, M., & Decker, P. (1995). Role transition to patient care management. Norwalk, CT: Appleton and Lange; osha.gov/
needlesticks/needlefact; Lilly Ledbetter Fair Pay Act of 2009, S.181, 123 Stat. 5 and General Industry Regulations Book, Subpart Z Occupational
Safety and Health Standards, Title 29 Code of Federal Regulations, Part 1910.
• Equal Pay Act of 1963: Employers must provide
equal pay for equal work, regardless of gender.
• Title VII of Civil Rights Act of 1964: Employees
may not be discriminated against on the basis of race,
color, religion, sex, or national origin.
• Age Discrimination in Employment Act of
1967: Private and public employers may not
discriminate against persons 40 years of age or older
except when a certain age group is a bona fide
occupational qualification.
• Pregnancy Discrimination Act of 1968:
Pregnant women cannot be discriminated against in
employment benefits if they are able to perform job
responsibilities.
• Fair Credit Reporting Act of 1970: Job
applicants and employees have the right to know of the
existence and content of any credit files maintained on
them.
• Vocational Rehabilitation Act of 1973: An
employer receiving financial assistance from the federal
government may not discriminate against individuals with
disabilities and must develop affirmative action plans to
hire and promote individuals with disabilities.
• Family Education Rights and Privacy
Act—Buckley Amendment of 1974: Educational
institutions may not supply information about students
without their consent.
• Immigration Reform and Control Act of
1986: Employers must screen employees for the right to
work in the United States without discriminating on the
basis of national origin.
• Americans with Disabilities Act of 1990:
Persons with physical or mental disabilities or who are
chronically ill cannot be discriminated against in the
workplace. Employers must make “reasonable
accommodations” to meet the needs of the disabled
employee. These include such provisions as installing
foot or hand controls; readjusting light switches,
telephones, desks, tables, and computer equipment;
providing access ramps and elevators; offering flexible
work hours; and providing readers for blind employees.
• Family Medical Leave Act of 1993: Employers
with 50 or more employees must provide up to 13
weeks of unpaid leave for family medical emergencies,
childbirth, or adoption.
• Needlestick Safety and Prevention Act of
2001: This act directed OSHA to revise the blood-
borne pathogens standard to establish in greater detail
requirements that employers identify and make use of
effective and safer medical devices.
• Lilly Ledbetter Fair Pay Act of 2009: This act
supports fair pay and provides protection against
discrimination in compensation based upon race, color,
religion, sex, or national origin.
box 11-1
Federal Laws Enacted to Protect the Worker in the Workplace
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chapter 11 ■ Promoting a Healthy Work Environment 177
■ Seek evidence-based practices related to the
problem
■ Develop a plan to reduce risks
■ Calculate the costs of the program/plan
■ Seek administrative support for the plan
4. The fourth and final stage in developing a
workplace safety program is implementing the
plan. Educating the staff, providing the
necessary safety supplies and equipment, and
modifying the environment may be necessary.
Violence
Workplace violence includes physical assault,
threats of assault, and verbal abuse. Nurses’ frequent
and close contact with individuals in distress makes
them a potential target (Magnavita & Heponiemi,
2011). The overall private sector rate for assault
resulting in injury is 2 per 10,000 full-time work-
ers; compare this to the rate for health service
workers at 9.3. The incidence rate for social service
workers is 15, and the rate for nurses and personal
care workers is 25 per 10,000 (www.bls.gov/news.
release/archives/osh2_02242010 ). Most of the
incidents involve patients (McPhaul & Lipscomb,
2004). Some of the circumstances surrounding
health-care work contribute to workers’ susceptibil-
ity (Edwards, 1999; www.nursingworld.org/dlwa/
osh/wp5; www.cdc.gov/niosh/pdfs/2002-101 ;
www.osha.gov/) in the following:
■ Units for treating violent individuals
■ Patients needing seclusion or restraint
■ Increased numbers of acute and chronic
mentally ill patients being released without
effective follow-up
■ Working late or until very early morning hours
■ Working in high-crime areas
■ Working in buildings with poor security
■ Treating weapons-carrying patients and
families
■ Inexperienced staff who have not been trained
to manage crises or handle volatile situations
■ Long wait times for service
■ Overcrowded, uncomfortable waiting areas
To assess the risk of violence, nurses must know
their workplace. Ask the following:
■ How frequently do assaultive incidents, threats,
and verbal abuse occur in your facility? Where?
Who is involved? Are incidents reported?
■ Are current emergency response systems
effective?
■ Are staffing patterns sufficient? Is the staff
experienced in handling these situations
(http://www.nursingworld.org/MainMenu
Categories/ANAMarketplace/ANAPeriodicals/
OJIN/TableofContents/Vol-18-2013/No1-Jan
-2013/Measurement-and-Monitoring-Worker
-Aggression-Exposure.html)?
■ Are post-assaultive treatment and support
available to staff ?
Although assaults that result in severe injury or
death usually receive media coverage, most assaults
on nurses by patients or coworkers are not even
reported by the nurse. For example:
Robert Jones works on the evening shift in the emer-
gency department (ED) at a large urban hospital
that frequently receives victims of gunshot wounds,
stabbings, and other gang-related incidents. Many
are high on alcohol or drugs. Robert has just inter-
viewed a 21-year-old male patient awaiting treat-
ment for injuries resulting from a f ight after an
evening of heavy drinking. Because his injuries
have been determined not to be life-threatening, he
had to wait to see a physician. “I’m tired of waiting.
Let’s get this show on the road,” he screamed as
Robert walked by. “I’m sorry you have to wait, Mr.
P., but the doctor is busy with another patient and
will get to you as soon as possible.” He handed him
a cup of juice he had been bringing to another
patient. The patient grabbed the cup, threw it in
Robert’s face, and then grabbed his arm. Slamming
him against the wall, the patient jumped off the
stretcher and yelled obscenities at him. He continued
to scream until a security guard intervened.
Be aware of clues that may indicate a potential for
violence (Box 11-2). These behaviors may occur in
patients, family members, visitors, or even other
staff members.
Not only are episodes of violence underreported,
there are persistent misperceptions that assaults are
part of the job and that the victim somehow caused
the assault. Underreporting may also be due to a
lack of institutional reporting policies or employee
fear that the assault was a result of negligence or
poor job performance (U.S. Department of Labor,
1995). Box 11-3 lists some of the faulty reasoning
that leads to placing blame on the victim of the
assault.
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178 unit 3 ■ Career Considerations
Actions to address violence in the workplace
include (1) identifying the factors that contribute
to violence and controlling as many as possible,
and (2) preparing staff to prevent and manage vio-
lence (Carroll & Sheverbush, 1996; Collins, 1994;
Mahoney, 1991).
Preventing Violent Behavior
Preventing an incident is better than having to
intervene after violence has occurred. The follow-
ing are suggestions to nurses about how to partici-
pate in workplace safety related to prevention of
violence (www.nursingworld.org/osh/wp5/htm):
■ Participate in or initiate regular workplace
assessments. Identify unsafe areas and factors
within the organization that contribute to
assaultive behavior, such as inadequate staffing,
high-activity times of day, invasion of personal
space, seclusion or restraint activities, and lack
of experienced staff. Work with management
to make and monitor changes.
■ Be alert for behaviors that precede violence such
as verbal expressions of anger and frustration,
threatening body language, signs of drug or
alcohol use, or presence of a weapon. Evaluate
each situation for potential violence. Have an
exit strategy.
■ Know your patients. Be aware of any history of
violent behaviors, diagnoses suggesting
potential for violent behavior, and alcohol or
drug intoxication.
■ Maintain behavior that helps to defuse anger.
Present a calm, caring attitude. Do not match
threats, give orders, or present with behaviors
that may be interpreted as aggressive.
Acknowledge the person’s feelings.
■ If you cannot defuse the situation, then remove
yourself from it quickly, call security, and
report the situation to management.
Box 11-4 lists some additional actions that can be
taken to protect staff members and patients from
violence in the workplace.
If Violent Behavior Occurs
What if, in spite of all precautions, violence occurs?
What should you do? You should:
■ Report to your supervisor. Report threats as
well as actual violence. Include a description of
the situation, names of victims, witnesses, and
perpetrators, and any other pertinent
information.
• History of violent behavior
• Delusional, paranoid, or suspicious speech
• Aggressive, threatening statements
• Rapid speech, angry tone of voice
• Pacing, tense posture, clenched fists, tightening jaw
• Alcohol or drug use
• Policies that set unrealistic limits
box 11-2
Behaviors Indicating a Potential for
Violence
Adapted from Kinkle, S. (1993). Violence in the ED: How to stop it
before it starts. American Journal of Nursing, 93(7), 22–24; Carroll,
C., & Sheverbush, J. (September 1996). Violence assessment in
hospitals provides basis for action. The American Nurse, 18.
• Victim gender: Women receive more blame than
men.
• Subject gender: Female victims receive more blame
from women than from men.
• Severity: The more severe the assault, the more often
the victim is blamed.
• Beliefs: The world is a just place, and therefore the
person deserves the misfortune.
• Age of victim: The older the victim, the more he or
she is held to blame.
box 11-3
When an Assault Occurs: Placing Blame
on Victims
Adapted from Lanza, M.L., & Carifio, J. (1991). Blaming the victim:
Complex (nonlinear) patterns of causal attribution by nurses in
response to vignettes of a patient assaulting a nurse. Journal of
Emergency Nursing, 17(5), 299–309.
• Security personnel and escorts
• Panic buttons in medication rooms, stairwells, activity
rooms, and nursing stations
• Bulletproof glass in reception, triage, and admitting
areas
• Locked or key-coded access doors
• Closed-circuit television
• Metal detectors
• Use of beepers and/or cellular phones
• Handheld alarms or noise devices
• Lighted parking lots
• Escort or buddy system
• Enforce wearing of photo identification badges
box 11-4
Steps Toward Increasing Protection From
Workplace Violence
Adapted from Simonowitz, J. (1994). Violence in the workplace:
You’re entitled to protection. RN, 57(11), 61–63; nursingworld.org/
dlwa/osh/wp6.
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chapter 11 ■ Promoting a Healthy Work Environment 179
■ Call security. Nurses are entitled to the same
protections as anyone else who has been
assaulted.
■ Get medical attention. This includes medical
care, counseling, and evaluation.
■ Contact your collective bargaining unit, your
state nurses association, or OSHA if the
problems persist.
■ Be proactive. Get involved in policy making
(Gilmore-Hall, 2001; www.nursingcenter.com).
Horizontal Violence
Horizontal violence among employees may also
occur. Although very disturbing, it rarely leads to
physical violence. Also called incivility or bullying,
it may include verbal abuse, punishment, humiliat-
ing comments, and malicious gossip. Bullies in the
workplace may be coworkers, superiors, or subordi-
nates. Regardless of their place on the organiza-
tional chart, they can cause a great deal of distress
to others in the workplace. In fact, The Joint Com-
mission characterizes horizontal violence as a sen-
tinel event because it may pose a threat to patient
safety (Kear, 2012). In a sample of 2,659 RNs from
19 facilities in New York state, 22% reported they
were expected to do other’s work, 9% had been
reprimanded in front of others, 9.8% reported
attempts to destroy their credibility, 9.2% reported
being constantly criticized, and 6% had been
threatened with negative consequences (Sellers &
Millenbach, 2012).
A study of new graduates in Canada found that
the majority had noted at least some incivility in
their workplace, more from their coworkers than
their supervisors (Smith, Andrusyszyn, & Spence-
Laschinger, 2010). Nursing managers in Canada
have noted an increase in the reporting of horizon-
tal violence as staff has become more aware of their
rights and protections as employees (Rocker, 2012).
Although lower in intensity than physical violence,
the long-term effects of incivility are far from
benign and need to be addressed. The following are
a few ways in which these behaviors can be
addressed (Kear, 2012; Lewis & Malecha, 2011):
■ Establish a zero tolerance policy for these
behaviors
■ Develop a code of conduct
■ Administrators, supervisors, and managers can
model appropriate behavior
■ Discuss strategies for handling such behavior
in staff meetings
■ Report bullying behavior to your nurse
manager
■ Confront bullying and belittling behavior, and
express your concerns objectively
Kear (2012) provides an objective response to this
behavior: “When you call me incompetent, I feel
angry. Instead, I would like you to teach me what
I may not know . . .” (p. 1). It requires courage to
confront these behaviors directly but failing to do
so encourages them.
Sexual Harassment
After months of interviewing, a new supervisor
was hired, a young male nurse whom the staff
members jokingly described as “a blond Tom Cruise.”
The new supervisor was an instant hit with the
predominantly female executives and staff members.
However, he soon found himself on the receiving end
of sexual jokes and innuendoes. He had been trying
to prove himself a competent supervisor, with hopes
of eventually moving up to a higher management
position. He viewed the behavior of the female staff
members and supervisors as undermining his cred-
ibility, as well as being embarrassing and annoying.
He attempted to have the unwelcome conduct
stopped by discussing it with his boss, a female nurse
administrator. She told him jokingly that it was
nothing more than “good-natured fun” and besides,
“men can’t be harassed by women” (Outwater,
1994).
Sexual harassment is a persistent problem in the
workplace. The reasons are complex, but sex-role
stereotypes and the unequal balance of power
between men and women are major contributors.
Unfortunately, underreporting of this problem is
common, even though the emotional costs of anger,
humiliation, and fear are high (www.nursingworld
.org/dlwa/wpr/wp3/htm).
The EEOC issued a statement in 1980 that
sexual harassment is prohibited by Title VII of the
Civil Rights Act of 1964. Two forms are identified,
both based on the premise that the action is unwel-
come sexual conduct:
1. Quid pro quo. Sexual favors are solicited
in exchange for favorable job benefits or
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180 unit 3 ■ Career Considerations
continuation of employment. The employee
must demonstrate that he or she was required
to endure unwelcome sexual advances to keep
the job or job benefits and that rejection of
these behaviors would have resulted in
deprivation of a job or benefits. Example: An
administrator approaches a nurse for a date in
exchange for the promise of a promotion.
2. Hostile environment. This is the most
common sexual harassment claim and the most
difficult to prove. The employee making the
claim must prove that the harassment is based
on gender and that it has affected conditions of
employment or created an environment so
offensive that the employee could not
effectively discharge the responsibilities of the
job (Outwater, 1994). If an environment can be
shown to be hostile or abusive, there is no
further need to establish that it was also
psychologically injurious. Although sexual
harassment against women is more common,
men can be victims as well (Box 11-5).
Do not ignore the issue of sexual harassment in the
workplace. If you supervise other employees, review
your agency’s policies and procedures and seek
appropriate guidance from Human Resources if
needed. If an employee approaches you with a com-
plaint, a confidential investigation of the charges
has to be initiated. Do not dismiss any incidents or
charges of sexual harassment involving yourself or
others as “just having fun” or respond that “there is
nothing anyone can do.” Responses such as this can
have serious consequences in the workplace (Out-
water, 1994).
The ANA cites four tactics to fight sexual
harassment (www.nursingworld.org/dlwa/wpr/
wp3/htm):
1. Confront. Indicate immediately and clearly to
the harasser that the attention is unwanted. If
you are in a unionized facility, ask the nursing
representative to accompany you.
2. Report. Report the incident immediately to
your supervisor. If the harasser is your
supervisor, report the incident to a higher
authority and file a formal complaint.
3. Document. Document the incident
immediately while it is fresh in your mind—
what happened, when and where it occurred,
and how you responded. Name any witnesses.
Keep thorough records in a safe place away
from work.
4. Support. Seek support from friends, relatives,
and organizations such as your state nurses
association. If you are a student, seek support
from a trusted faculty member or advisor. Your
employer has a responsibility to maintain a
harassment-free workplace. You should expect
your employer to demonstrate commitment to
creating a harassment-free workplace, provide
strong written policies prohibiting sexual
harassment and describing how employees will
be protected, and educate all employees verbally
and in writing.
Discrimination
The laws that prohibit discrimination in the work-
place are based on the Fifth and Fourteenth
Amendments to the Constitution, mandating due
process and equal protection under the law. The
federal Equal Employment Opportunity Commis-
sion (EEOC) oversees the administration and
enforcement of issues related to workplace equality.
Although there may be exemptions from any law,
it is important that nurses recognize that there is
significant legislation that prohibits employers
from making workplace decisions based on race,
color, sex, age, disability, religion, or national origin.
The employer may ask questions related to these
issues but cannot make decisions about employ-
ment based on them.
Latex Allergy
Since the 1987 recommendations for universal pre-
cautions from the CDC, the use of gloves has
greatly increased exposure of health-care workers
to natural rubber latex (NRL). The two major
routes of exposure to NRL are skin and inhalation,
• Pressure to participate in sexual activities
• Asking about another person’s sexual activities,
fantasies, preferences
• Making sexual innuendoes, jokes, comments, showing
sexual graffiti or visuals
• Continuing to ask for a date after the other person has
expressed disinterest
• Making suggestive facial expressions or gestures with
hands or body movements
• Making remarks about a person’s gender or body
box 11-5
Behaviors That Could Be Defined as Sexual
Harassment
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chapter 11 ■ Promoting a Healthy Work Environment 181
particularly when glove powder acts as a carrier for
NRL protein (OSHA latex alert: www.cdc.gov/
niosh/latexalt). Reactions range from contact der-
matitis with scaling, drying, cracking, and blistering
skin, to generalized urticaria, rhinitis, wheezing,
swelling, shortness of breath, and anaphylaxis.
Allergic contact dermatitis (sometimes called
chemical sensitivity dermatitis) results from the
chemicals added to latex during harvesting, pro-
cessing, or manufacturing. These chemicals can
cause a skin rash similar to that of poison ivy (www
.cdc.gov/niosh/docs/98-113/).
Latex allergy should be suspected if an employee
develops symptoms after latex exposures. A com-
plete medical history can reveal latex sensitivity, and
blood tests approved by the U.S. Food and Drug
Administration are available to detect latex anti-
bodies. Skin testing and glove-use tests are also
available.
A midwife began experiencing hives, nasal conges-
tion, and conjunctivitis. Within a year, she devel-
oped asthma, and 2 years later she went into shock
after a routine gynecological examination during
which latex gloves were used. The midwife also suf-
fered respiratory distress in latex-containing envi-
ronments when she had no direct contact with latex
products. She was unable to continue working
(Bauer et al., 1993).
A physician with a history of seasonal allergies,
runny nose, and eczema on his hands suffered severe
rhinitis, shortness of breath, and then collapsed
minutes after putting on a pair of latex gloves. A
cardiac arrest team successfully resuscitated him
(Rosen, Isaacson, Brady, & Corey, 1993).
Complete latex avoidance is the most effective
approach. Medications may reduce allergic symp-
toms, and special precautions are needed to prevent
exposure during medical and dental care. Employ-
ees with a latex allergy should consider wearing a
medical alert bracelet.
Many employees in a health-care setting can use
alternative gloves of vinyl or nitrile. If an employee
must use NRL gloves, gloves with lower protein
content and those that are powder-free should be
considered. Good housekeeping practices should be
used to remove latex-containing dust from the
workplace. Those with histories of allergies to
pollens, grasses, and certain foods or plants (avocado,
banana, kiwi, chestnut) and histories of multiple
surgeries may be at greater risk.
The following will help to decrease the potential
for latex allergy problems (www.cdc.gov/niosh/
docs/98-113/):
■ Evaluate any cases of hand dermatitis or other
signs of latex allergy.
■ Use latex-free procedure trays and crash carts.
■ Use nonlatex gloves for activities that do not
involve contact with infectious materials.
■ Avoid using oil-based creams or lotions, which
can cause glove deterioration.
■ Seek ongoing training and the latest
information related to latex allergy.
■ Wash, rinse, and dry hands thoroughly after
removing gloves or when changing gloves.
■ Use powder-free gloves.
If you develop a latex allergy, be aware of the
following precautions (www.cdc.gov/niosh/docs/
98-113/):
■ Avoid all types of latex exposure.
■ Wear a medical alert bracelet.
■ Carry an EpiPen with auto-injectable
epinephrine.
■ Alert your employer and colleagues to your
latex sensitivity.
■ Carry nonlatex gloves.
The number of new cases of latex allergy has
decreased due to improved diagnostic methods,
improved education, more accurate labeling, and use
of powder-free gloves. Although current research
does not demonstrate whether the amount of aller-
gen released during shipping and storage of medica-
tions from vials with rubber closures is sufficient to
induce a systemic allergic reaction, nurses should
take special precautions when patients are identified
as high risk for latex allergies. Nursing staff should
work closely with the pharmacy staff to follow uni-
versal one-stick-rule precautions, which assumes
that every pharmaceutical vial may contain a natural
rubber latex closure, and the nurse should remain
with any patient at the start of medication admin-
istration and keep frequent observations and vital
signs for 2 hours (Hamilton et al., 2005).
Needlestick (Sharps) Injuries
In 1997 a 27-year-old nurse, Lisa Black, attended
an in-service session on post-exposure prophy-
laxis for needlesticks. A short time later, she was
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182 unit 3 ■ Career Considerations
attempting to aspirate blood from a patient’s intra-
venous line when the patient moved, and the needle
went into Lisa’s hand. Nine months later she tested
positive for HIV and 3 months after that for hepa-
titis C (Trossman, 1999a).
There are several legal sources of protection from
sharps injuries. The Needlestick Safety and Pre-
vention Act went into effect April 18, 2001. The
revised OSHA Blood Borne Pathogens Stan-
dard obligates employers to consider safer needle
devices when they conduct their annual review
(Foley, 2012). JC surveyors routinely ask if health-
care organization leaders are familiar with the
Needlestick Safety and Prevention Act and what
action has been taken to comply (www.osha.gov/
needlesticks/needlefaq.html; jointcommission.org/
sentinel_event_alert_issue_22_preventing_needle
stick_and_sharps_injuries/). Although much progress
has been made in preventing sharps injuries, a
recent consensus statement from ANA and other
groups calls for more attention to (Daley, 2012):
■ Greater safety in surgical settings
■ Sharps safety outside the hospital
■ Including nurses in selection of safety devices
■ Encouraging product design and development
to fill existing gaps (e.g., in dentistry, use of
longer needles)
■ Increased staff training
Your Employer’s Responsibility
All health-care facilities should have a written plan
to prevent sharps injuries that is updated annually.
Staff should receive annual training during work
hours and have a right to be involved in the selec-
tion of safety devices. Additional control measures
include (Foley, 2012):
■ The employee must be evaluated and treated
within 2 hours of a sharps injury, including
free hepatitis B vaccine.
■ Safety and efficacy of sharps purchased must
be evaluated.
■ Recapping of needles and related practices
should be prohibited.
■ Contaminated work surfaces must be cleaned
according to established guidelines.
■ Employers must provide personal protective
equipment of good quality, including gloves,
gowns, and masks in all needed sizes.
The surgical setting presents special challenges to
prevention of sharps injuries due to such factors as
the intense pressures of the situation, open wounds
susceptible to contamination, and extensive use of
sharp instruments. Thirty percent of sharps injuries
occur here, and the encouraging decline in injuries
seen in other areas of the hospital has not yet been
seen in the surgical setting. Some recommenda-
tions for addressing this risk include (Guglielmi &
Ogg, 2012):
■ Use blunt tip suture needles where possible.
■ Use safety scalpels, either sheathed or
retractable.
■ Initiate the hands-free technique (HFT) or
neutral passing zone (a container or sterile
towel) instead of passing instruments
hand-to-hand.
■ Double glove to increase protection from
punctures.
■ Share information (educate) with staff about
sharps injury prevention.
Employee Responsibilities
What are your responsibilities related to preventing
sharps injuries? You will need to learn how to use
new devices, and make certain that the current
safety requirements are enforced. Also: (ANA,
1993; Brooke, 2001; www.osha.gov/Publications/
osha3161 ):
■ Always use universal precautions.
■ Use and dispose of sharps properly.
■ Obtain immunization against hepatitis B.
■ Get involved in sharps selection.
■ Keep your training up to date.
■ Report all exposures immediately following
your facility’s protocol.
■ Comply with post-exposure follow-up
procedures/policies.
If you have questions about treatment for a needle-
stick, you can call the National Clinician’s
Post-Exposure Prophylaxis (PEPLine) number, 1-
888-448-4911 (Handelman, Perry, & Parker, 2012).
Ergonomic Injuries
Poor ergonomics is a safety concern factor for both
nurses and patients (Durr, 2004).
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chapter 11 ■ Promoting a Healthy Work Environment 183
Back Injuries
Occupation-related back injuries affect more than
75% of nurses over the course of their careers. Every
year, 12% of nurses leave the profession due to back
injury, and 52% complain of chronic back pain.
Nursing aides, orderlies, and attendants ranked
second and registered nurses sixth in a list of at-risk
occupations for strains and sprains (U.S. Depart-
ment of Labor, 2002). The problem with lifting a
patient is not just one of overcoming heavy weight
but also of overcoming improper lifting technique
(OSHA, 2013b). Size, shape, and deformities of the
patient as well as the patient’s balance, combative-
ness, uncooperativeness, and contractures must be
considered. Any unexpected movement or resis-
tance from the patient can throw the nurse off
balance and result in a back injury. Limited space,
equipment, beds, chairs, and commodes also con-
tribute to back injury risk (Edlich, Woodard, &
Haines, 2001).
OSHA issued an ergonomics guideline for the
nursing home industry on March 13, 2003 (www
.osha.gov/ergonomics/guidelines/nursinghome/
index.html)
The back injury guide for health-care workers
(www.dir.ca.gov/dosh/dosh_publications/backinj
) and the OSHA guidelines for nursing homes
(www.osha.gov/ergonomics/guidelines/nursing-
home/index.html) are comprehensive resources.
Employers must keep their workplaces free from
recognized hazards, including ergonomic hazards.
ANA conducted a campaign entitled “Handle
With Care” aimed at preventing back and other
musculoskeletal injuries. Health-care facilities that
have invested in recommended assistive patient
handling programs report cost savings in the thou-
sands of dollars both for direct costs of back injuries
and for lost workdays (www.nursingworld.org/
MainMenuCategories/WorkplaceSafety/Healthy
-Work-Environment/SafePatient/Resources/Handle
withCare ). In addition, assistive patient han-
dling equipment improves the quality care of
patients, improving patients’ comfort, dignity, and
safety during transfers.
Repetitive Stress Injuries
The use of computers continues to increase expo-
nentially for all health-care personnel. Repetitive
stress injuries (RSIs) affect people who spend long
hours at computers, switchboards, and the like
where repetitive motions are performed. The most
common RSIs are carpal tunnel syndrome and
mouse elbow. Badly designed computer worksta-
tions present the highest risk of RSIs. Preventive
measures include the following (Feiler & Stichler,
2011; Krucoff, 2001):
■ Keep the monitor screen straight ahead of you,
about an arm’s length away. The top of the
screen should be at eye level.
■ Align the keyboard so that your forearms,
wrists, and hands are parallel to the floor. Tilt
if needed to keep wrists in neutral position.
■ Position the mouse (if used) directly next to
you and on the same level as the keyboard.
■ Keep thighs parallel to the floor as you sit on
the chair. Feet should touch the floor and the
chair back should be ergonomically sound.
■ Vary tasks. Avoid long sessions of sitting. Do
not use excessive force when typing or clicking
the mouse.
Toxic Environments
Inside air pollution is a more recently identified
problem. Dioxin emissions, mercury, and battery
waste are often not handled properly in the hospital
environment. Disinfectants, chemicals, waste anes-
thesia gases, and laser plumes that float in the air
are other sources of pollution exposure for nurses.
Rethinking product choices, such as avoiding the
use of polyvinyl chloride or mercury products, pro-
viding convenient collection sites for battery and
mercury waste, and making waste management
education for employees mandatory are starts
toward a more pollution-free environment (Slat-
tery, 1998). Better ventilation and air filtration can
keep the air cleaner (Feiler & Stichler, 2011). Recy-
cled paper and products, minimizing use of toxic
disinfectants, and waste disposal choices that reduce
incineration to a minimum are needed. Nurses as
professionals need to be aware of the consequences
of the medical waste produced by the health sector,
supporting continued education for both nurses
and patients.
Impaired Workers
Shawna had been a nurse for 20 years. Serious
marital problems were affecting her work. To ease
the tension one evening, she took a Xanax from
a patient’s medication drawer and it seemed
to ease her tension. She surreptitously took more
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184 unit 3 ■ Career Considerations
pati ent medications, eventually escalating to nar-
cotic analgesics.
Jorge began weekend binge-drinking in college.
Ten years later, he is still drinking almost every
weekend. He does not believe he is an alcoholic
because he can “control” his drinking. But after he
began showing up at work hung over and making
multiple medication errors, he was f ired. At the exit
interview, no mention was made of his drinking
problem because the agency feared a lawsuit for
defamation of character.
Joanne has been late for work frequently, often
appearing unkempt. She has been overheard making
terse remarks to patients such as, “Who do you think
I am—your maid?” and spends longer and longer
periods off the unit. The floor has a large number of
surgical patients who receive pain medications.
Joanne’s patients began complaining of pain even
after pain medication administration has been
charted. Joanne frequently “forgets” to waste her
residual intramuscular narcotics in front of another
nurse.
In the 1980s, the National Nurses’ Society on
Addictions (NNSA) and the ANA task forces
jointly passed a resolution calling for acknowledg-
ment of substance abuse problems and guidelines
for impaired nurse programs (Heise, 2003).
Health-care professionals are not immune to
alcoholism or chemical dependency. Various kinds
of mental illnesses may also affect a nurse’s ability
to deliver safe, competent care. The most common
signs of impairment are (Blair, 2005; Damrosch &
Scholler-Jaquish, 1993):
■ Witnessed consumption of alcohol or
controlled substances on the job
■ Changes in dress, appearance, posture, gestures
■ Slurred speech; abusive/incoherent language
■ Reports of impairment or erratic behavior
■ Witnessed unprofessional conduct
■ Significant lack of attention to detail
■ Witnessed theft of controlled substances
■ Assigned patients routinely requesting pain
medication within a short period of being
medicated
Impaired-nurse programs, which are conducted by
state boards of nursing, work with the employer to
assist the impaired nurse to remain licensed while
receiving help for his or her problem. (Damrosch
& Scholler-Jaquish, 1993; Sloan & Vernarec, 2001).
Often coworkers become protective and take on
more work to ease the burden of their coworker.
Although it is difficult to report a colleague, ignor-
ing the problem or covering for an impaired col-
league can pose serious risks for the patient and the
nurse. Many state boards make it mandatory for
nurses to report suspected impaired coworkers, and
they accept anonymous reports. In many states,
state law also requires hospitals and health-care
providers to report impaired practitioners, but
grants immunity from civil liability if the report was
made in good faith (Blair, 2005; Sloan & Vernarec,
2001).
Disabled Employees
The Americans with Disabilities Act, enacted in
1990, makes it unlawful to discriminate against a
qualified individual with a disability. Employers are
required to provide reasonable accommodations for
the disabled person. A reasonable accommodation
is a modification or adjustment to the job, work
environment, work schedule, or work procedures
that enables a qualified person with a disability to
perform the job. Both you and your employer may
seek information from the Equal Employment
Opportunity Commission (EEOC) for informa-
tion (http://www.nursingworld.org/MainMenu
Categories/ANAMarketplace/ANAPeriodicals/
O J I N / Ta b l e o f C o n t e n t s / Vo l u m e 9 2 0 0 4 /
No3Sept04/HandleWithCare.html).
Natural Disasters and
Terrorism Threats
Since the 2001 anthrax outbreak and attacks on the
World Trade Center, concern related to biological
and chemical agents has heightened. The ANA
provides nurses with valuable information on how
they can better care for their patients, protect
themselves, and prepare their hospitals and com-
munities to respond to acts of bioterrorism and
nat ural disasters (http://www.nursingworld.org/Main
MenuCategories/Policy-Advocacy/Positions-and
-Resolutions/Issue-Briefs/Disaster-Preparedness
). Nurses are often called upon when a disaster
occurs: Many worked with the ANA to provide
support for the victims of Hurricane Katrina. A
nurse holding a newborn rescued from the severely
damaged NYU Langone Medical Center became a
symbol of the rescue efforts following the destruc-
tion caused by Super Storm Sandy (2012).
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chapter 11 ■ Promoting a Healthy Work Environment 185
Following are some steps that can be imple-
mented in the workplace to better prepare for these
threats: (www.nurses.com/doc.mvc/AWHONN
-Takes-Action-Against-Bioterrorism-0001):
■ Know the evacuation procedures and routes for
your facility.
■ Monitor your patient caseload for any unusual
disease patterns and notify appropriate
authorities as needed.
■ Know the backup systems available for
communication and staffing in the event of
emergencies.
■ Become familiar with the disaster policies in
your facility.
Enhancing the Quality of Work Life
We turn our attention from safety to quality of the
work environment. The American Association of
Critical-Care Nurses (AACN) published standards
for a healthy work environment noting that “rela-
tionship issues are real obstacles” to provision of
safe care (2005, p. 188). These standards include
skilled communication, real collaboration, effective
decision making, adequate staffing, meaningful rec-
ognition, and effective leadership. There is evidence
that a healthy work environment increases patient
satisfaction and reduces nurses’ stress and burnout
(Kramer & Schmalenberg, 2008).
Shift Work Disorders
Although nurses who work nights permanently
often can readjust their sleep-wake cycle from night
to day, even permanent night-workers may be
subject to continuous sleep deprivation. Those who
continuously rotate shifts may seriously disturb
their circadian rhythms: A typical night shift work-
er’s scenario is to feel sleepy during work and travel
home but have difficulty falling asleep during the
day. Symptoms that continue for more than a
month indicate the presence of shift work disorder.
Those who suffer this disorder have a higher risk
of ulcer, heart disease, depression, chronic fatigue,
poor work performance, and accidents both on and
off work (O’Malley, 2011). Suggestions for nurses
who rotate shifts (Shandor, 2012; O’Malley, 2011)
include the following:
■ Shorter (8-hour) shifts allow you to get at least
7 hours’ sleep before returning to work.
■ Try to schedule the same shifts for an entire
scheduling period instead of rotating different
shifts within one scheduling period.
■ Try to schedule the same days off consistently.
■ If you become sleepy during the shift, try
exercise (take a walk or climb stairs), bright
light, a brief nap if possible, and a cup of
coffee (not near the end of your shift).
■ If you work evenings or nights, do not eat a
big meal or take caffeine or alcohol at the end
of the shift as this interferes with sleep. Try to
avoid using sleep medications.
■ If driving home in bright morning light, put
on sunglasses.
■ Try to sleep a continuous block of time at
regularly scheduled times instead of catching a
few hours here and there.
■ Make sure the room you are sleeping in is a
comfortable temperature and as dark and
noise-free as possible.
■ Find time to maintain good nutrition and
daily exercise.
■ Self-scheduling increases perceived control and
may reduce the stress of shift work.
It is evident from this list that there are a number
of ways an employer can help reduce the stress of
shift work. Making healthy food available around
the clock and providing nap facilities can help
employees stay healthy and alert during their shifts
(Shandor, 2012).
Mandatory Overtime
When nurses are routinely forced to work beyond
their scheduled hours, they can suffer a range of
emotional and physical effects. As patient acuity
and workloads increase, overtime puts both patients
and nurses at greater risk. Working overtime should
be a choice, not a requirement, but nurses have been
threatened with dismissal or charge of patient
abandonment if they refuse to participate in man-
datory overtime (http://www.nursingworld.org/
MainMenuCategories/ThePracticeofProfessional
Nursing/NurseStaffing/OvertimeIssues/Overtime
).
The ANA opposes the use of mandatory over-
time, stating that nurses should be allowed to refuse
overtime if they believe that they are too fatigued
to provide quality care (http://www.nursingworld
.org/MainMenuCategories/WorkplaceSafety/
Healthy-Work-Environment/Work-Environment/
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186 unit 3 ■ Career Considerations
NurseFatigue). In a 2006 position statement re-
garding nurses working when fatigued, the ANA
takes the position that, regardless of the number of
hours worked, each registered nurse has an ethical
responsibility to carefully consider her/his level of
fatigue when deciding whether to accept any as-
signment extending beyond the regularly scheduled
workday or week, including a mandatory or volun-
tary overtime assignment (ANA, 2006). Rogers
et al. (2004) found that nurses’ error rates increase
significantly during overtime, after 12 hours or after
working more than 60 hours per week. Currently,
half of staff nurses are scheduled routinely to
work 12-hour shifts, and 85% of staff nurses rou-
tinely work longer than scheduled hours.
Staffing Ratios
Findings from 12 key studies cite specific effects of
low nurse staffing on patient outcomes: incidences
of failure to rescue, inpatient mortality, pneumonia,
urinary tract infections, and pressure ulcers. Effects
on the nurses themselves include needlestick inju-
ries and eventual burnout (Aiken et al., 2002). Hos-
pital length of stay and finances are affected as well.
The ANA recommends moving staffing deci-
sions away from the industrial model of measuring
time and motion to a professional model that
examines the factors needed to provide quality care.
The effect of changes in staffing levels should
be evaluated on the basis of nursing-sensitive indi-
cators (http://www.nursingworld.org/MainMenu
Categories/ANAMarketplace/ANAPeriodicals/
OJIN/TableofContents/Volume122007/No3
Sept07/MandatoryNursetoPatientRatios.html).
Is this important? In 2002, Dr. Linda Aiken and
her colleagues identified a relationship between
staffing, mortality, nurse burnout, and job dissa tis-
faction (Aiken et al., 2002). With each additional
patient assigned to a nurse, the following occurred:
■ A 30-day mortality increase of 7%
■ Failure-to-rescue rate increase of 7%
■ Nursing job dissatisfaction increase of 15%
■ Burnout rate increase of 23%
■ 43% of nurses surveyed suffering from burnout
A survey of 820 nurses and 621 patients in 20
hospitals across the United States (Vahey et al.,
2004) showed that units characterized by nurses as
having adequate staff, good administrative support
for nursing care, and good relations between physi-
cians and nurses were twice as likely as other units
to report high satisfaction with nursing care.
Reporting Questionable Practices
Most employers have policies that encourage the
reporting of behavior that may adversely affect the
workplace environment, including but not limited
to (ANA, 1994):
1. Endangering a patient’s health or safety
2. Abusing authority
3. Violating laws, rules, regulations, or standards
of professional ethics
4. Grossly wasting funds
The Code for Nurses (ANA, 2001) is very specific
about nurses’ responsibility to report questionable
behavior that may affect the welfare of a patient. If
you become aware of inappropriate or questionable
practices in the provision of health care, concern
should be expressed to the person carrying out the
questionable practice and attention called to the
possible detrimental effect on the patient’s welfare.
Use official channels if it becomes necessary to
report these practices. ANA’s Code of Ethics
further states that
When incompetent, unethical, illegal, or impaired
practice is not corrected within the employment
setting and continues to jeopardize patient well-
being and safety, the problem should be reported to
appropriate authorities such as practice committees
of the pertinent professional organizations, the
legally constituted bodies concerned with licensing of
specif ic categories of health workers and professional
practitioners, or the regulatory agencies concerned
with evaluating standards or practice (ANA, 2001).
Protection should be afforded to both the accused
and the person doing the reporting, but this is not
always the case:
Two Texas nurses not only lost their jobs but also
were charged with misuse of official information
when they reported a physician to the medical
board for patient safety concerns. The charges
against one were dropped eventually and the other
was found not guilty in court. The Texas Nurses
Association (TNA) Legal Defense Fund helped
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chapter 11 ■ Promoting a Healthy Work Environment 187
pay their legal expenses and the nurses won a civil
judgment of $750,000 against the county. The phy-
sician was placed on 4 years’ probation. “Nurses
need to be able to advocate for patient safety,” said
Cindy Zolnierek, TNA Director of Practice, “and
anything that stands in the way is not good for
patients or nurses” (Trossman, 2011b, p. 11). For
more information about related legislation in Texas,
go to www.texasnurses.org.
Whistleblower is the term used for an employee who
reports employer violations to an outside agency.
You cannot assume that doing the right thing will
protect you. Speaking up could get you fired unless
you are protected by a union contract or other
formal employment agreement. Your professional
organization (the ANA) may also be able to support
you. In May 1994, the U.S. Supreme Court ruled
that nurses who direct the work of other employees
may be considered supervisors and therefore may
not be covered by the protections guaranteed under
the National Labor Relations Act. This ruling may
cause nurses to have no protection from retaliation
if they report illegal practices in the workplace
(ANA, 1995b). The 1995 brochure from the ANA
(1995a), Protect Your Patients—Protect Your License,
states, “Be aware that reporting quality and safety
issues may result in reprisals by an employer.” Does
this mean that you should never speak up? Case
law, federal and state statutes, and the federal False
Claims Act may afford a certain level of protection.
Some states have whistleblower laws, but they often
apply only to state employees or to certain types of
workers. Although these laws may offer some pro-
tection, the most important point is to work
through the employer’s chain of command and
internal procedures. You may also (a) make sure
that whistleblowing is addressed at your facility,
either through a collective bargaining contract or
workplace advocacy program; (b) contact your state
nurses association to find out if your state offers
whistleblower protection or has such legislation
pending; (c) be politically active by contacting your
state legislators and urging them to support a
pending bill or by educating your elected state offi-
cials on the need for such protection for all health-
care workers; and (d) contact your U.S. congressional
representatives and urge them to support the
Patient Safety Act (http://www.nursingworld.org/
MainMenuCategories/Policy-Advocacy/Expired
Content-GOVA/2006/whistle12768.html).
Social Environment
Working Relationships
Many aspects of the social environment received
attention in earlier chapters. Team building, com-
municating effectively, and developing leadership
skills are essential to the development of working
relationships.
The day-to-day interactions with one’s peers
and supervisors have a major impact on the quality
of the workplace environment. Most employees feel
keenly the difference between a supportive and a
nonsupportive environment. For example:
Ms. B. came to work already tired. Her baby was
sick and had been awake most of the night. Her team
expressed concern about the baby when she told them
she had a diff icult night. Each team member vol-
untarily took an extra patient so that Ms. B. could
have a lighter assignment that day. When Ms. B.
expressed her appreciation, her team leader said, “We
know you would do the same for us.” Ms. B. worked
in a supportive environment.
Ms. G. came to work after a sleepless night. Her
young son had been diagnosed with leukemia, and
she was very worried about him. When she men-
tioned her concerns, her team leader interrupted her,
saying, “Please leave your personal problems at
home. We have a lot of work to do, and we expect
you to do your share.” Ms. G. worked in a nonsup-
portive environment.
In a supportive environment, people are willing to
make difficult decisions, take risks, and “go the
extra mile” for team members and the organization.
In a non-supportive environment, members are
afraid to take risks, avoid making decisions, and
usually limit their commitment. Incivility, discussed
earlier in this chapter, contributes to a nonsupport-
ive environment.
Involvement in Decision Making
Having a voice in the decisions made about one’s
work and patients is very important to health-care
professionals. Many actions can be taken to
empower nurses: remove barriers to their participa-
tion in decision making, publicly express confi-
dence in their capability and value, reward initiative
and assertiveness, and provide role models who
demonstrate confidence and competence. The
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188 unit 3 ■ Career Considerations
following illustrates the difference between empow-
erment and powerlessness:
Soon after completing orientation, Nurse A heard a
new nurse aide scolding a patient for soiling the bed.
Nurse A did not know how incidents of potential
verbal abuse were handled in this institution, so she
reported it to the nurse manager. The nurse manager
asked Nurse A several questions and thanked her for
the information. The new aide was counseled
immediately after their meeting. Nurse A noticed a
positive change in the aide’s manner with patients
after this incident. Nurse A felt good about having
contributed to a more effective patient care team.
Nurse A felt empowered and will take action again
when another occasion arises.
A colleague of Nurse B was an instructor at a
community college. This colleague asked Nurse B if
students would be welcome on her unit. “Of course,”
replied Nurse B. “I’ll speak with my head nurse
about it.” When Nurse B did so, the response was
that the unit was too busy to accommodate students.
In addition, Nurse B received a verbal reprimand
from the supervisor for overstepping her authority
by discussing the placement of students. “All requests
for student placement must be directed to the educa-
tion department,” she said. The supervisor directed
Nurse B to write a letter of apology for having made
an unauthorized commitment to the community
college. Nurse B was afraid to make any decisions or
public statements after this incident. Nurse B felt
alienated and powerless.
Professional Growth and Innovation
The difference between a climate that encourages
staff growth and creativity and one that does not can
be quite subtle. In fact, many people are only partly
aware, if at all, whether they work in an environ-
ment that fosters professional growth and learning.
Yet the effect on the quality of the work done is
pervasive, and it is an important factor in distin-
guishing the merely good health-care organization
from the excellent health-care organization.
The increasingly rapid accumulation of knowl-
edge in health-care mandates continuous learning
for safe practice. Much of the responsibility for staff
development and promotion of innovation lies with
upper-level management. Some of the ways in
which first-line managers can develop and support
a climate of professional growth are to encourage
critical thinking, provide opportunities to take
advantage of educational programs, encourage new
ideas and projects, and reward professional growth.
Encourage New Ideas and
Critical Thinking
Intellectual curiosity is a hallmark of the profes-
sional. An inquisitive frame of mind is relatively
easy to suppress in a work environment. Patients
and staff quickly perceive a nurse’s impatience or
defensiveness when too many questions are raised.
Their response will be to simply give up asking
these questions. But if you are a critical thinker and
support other critical thinkers, you can contribute
to an open-minded work environment.
Participating in brainstorming sessions, group
conferences, and discussions encourages the gen-
eration of new ideas. Although new nurses may
think they have nothing to offer, this is rarely the
case. It is important for them to participate in
activities that encourage them to contribute fresh,
new ideas.
Reward Professional Growth
A primary source of discontent in the workplace is
lack of recognition. Everyone enjoys praise and rec-
ognition. A smile, a card or note, or a verbal “thank
you” goes a long way with coworkers in recognizing
a job well done. Staff recognition programs have
also been identified as a means of increasing self-
esteem, social gratification, morale, and job satisfac-
tion (Hurst, Croker, & Bell, 1994).
Cultural Diversity
Ms. V. is beginning orientation as a new staff nurse.
She has been told that part of her orientation will
be a morning class on cultural diversity. She says to
the Human Resources person in charge of orienta-
tion, “I don’t think I need to attend that class. I treat
all people as equal. Besides, anyone living in our
country has an obligation to learn the language and
ways of those of us who were born here, not the other
way around.”
Mr. M. is a staff nurse on a medical-surgical
unit. A young man with HIV infection has been
admitted. He is scheduled for surgery in the morning
and has requested that his significant other be
present for the preoperative teaching. Mr. M. reluc-
tantly agrees but mumbles under his breath to a
coworker, “It wouldn’t be so bad if they didn’t flaunt
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chapter 11 ■ Promoting a Healthy Work Environment 189
their homosexuality and act like a married couple.
Why can’t he act like a man and get his own pre-op
instructions?”
Diversity in health-care organizations includes eth-
nicity, race, culture, gender, sexual orientation, life-
style, primary language, age, physical capabilities,
and career stages of employees. Working with and
caring for people who have different customs, tradi-
tions, communication styles, and beliefs can be
rewarding as well as challenging. An organization
that fosters diversity encourages respect and under-
standing of human characteristics and acceptance
of the similarities and differences that make us
human.
Consider these factors in understanding cultural
diversity (Davidhizar, Dowd, & Giger, 1999):
1. Communication. Communication and culture
are closely bound. Not only is culture
transmitted through communication, it
influences how people express themselves.
Vocabulary, voice qualities, intonation, rhythm,
speed, silence, touch, body postures, eye
movements, and pronunciation differ among
cultural groups and vary among persons from
similar cultures. Using respect as a central core
to a relationship, everyone needs to assess
communication preferences of others in the
workplace.
2. Space. Personal space is the area that
surrounds a person’s body. The amount of
personal space individuals prefer varies from
person to person and from situation to
situation. Cultural beliefs also influence a
person’s perception of personal space. In the
workplace, an understanding of coworkers’
comfort related to personal space is important.
Often, this comfort or discomfort is relayed in
nonverbal rather than verbal communication.
3. Social organization. For some people, the
importance of family supersedes that of other
personal, work, or national causes. For example,
caring for a sick child may override the
importance of being on time or even coming to
work, regardless of staffing needs or policies.
4. Time. Time orientation is often related to
culture. Some cultures are more past-oriented,
emphasizing traditions. People from cultures
with a future orientation may be more likely to
forego current pleasure for later rewards,
returning to school for a higher degree or
earning certification, for example. Working
with people who have different time
orientations may cause difficulty in managing
rotating shifts, planning schedules, setting
deadlines, and even defining what “on time”
means.
5. Internal or external control. Individuals with
an external locus of control believe in the
primacy of fate or chance. People with an
internal locus of control believe they can
influence, even determine, outcomes. In the
workplace, nurses are expected to operate from
an internal locus of control. This approach may
be different from what a person has grown up
with.
Indications of an organization’s diversity “fitness”
include the following (Mitchell, 1995):
■ Minorities are represented at all levels of
personnel.
■ Individual cultural preferences pertaining to
issues of social distance, touching, voice
volume and inflection, silence, and gestures are
respected.
■ There is awareness of special family and
holiday celebrations important to people of
different cultures.
You can be a culturally competent practitioner and
a role model for others by becoming:
■ Aware of and sensitive to your own culture-
based preferences
■ Willing to explore your own biases and values
■ Knowledgeable about other cultures
■ Respectful of and sensitive to diversity among
individuals
■ Skilled using culturally sensitive intervention
strategies
Physical Environment
The use of lighting, colors, and music to improve
the workplace environment is increasing. Com-
puter workstations are designed to promote effi-
ciency in the patient care unit. When well designed,
health information technologies are generally
found by nurses to be useful and supportive of
quality care (Waneka & Spetz, 2010). Relocation
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190 unit 3 ■ Career Considerations
of supplies and substations closer to patient rooms
to reduce the number of steps; improved visual and
auditory scanning of patients from the nurses’
station or decentralized workstations; better light
and ventilation, especially in medication prepara-
tion areas; a unified information system; and
reduced need for patient transport are all possible
with changes in the physical environment (Feiler &
Stichler, 2011).
Stress, Burnout, and
Job Satisfaction
Stress
In the workplace, stress is related to a mismatch
between an individual’s perception of the demands
being made and his or her perception of the ability
to meet those demands. An individual’s stress
threshold also depends on the individual’s charac-
teristics, experiences, coping mechanisms, and the
circumstances of the event (McVicar, 2003).
Sources of Stress
The nature of nurses’ work creates the potential for
experiencing stress (McGibbon, Peter, & Gallop,
2010), especially for younger, less experienced
nurses (Purcell, Keitash, & Cobb, 2011). Some set-
tings seem to generate more stressful situations
than others. In the emergency department, for
example, nurses reported several sources:
■ Inadequate staffing, shift work, and
overcrowding
■ Aggression and violence on the part of patients
and their families
■ The death of a young patient
■ High-acuity patients, especially those needing
resuscitation (Healy & Tyrrell, 2011)
Nurses in a pediatric intensive care unit reported
some additional sources:
■ Bodily caring, especially when it was necessary
to inflict pain on a child
■ Being “tethered” (p. 1360) to their patients
continuously for 12 hours
■ Dealing with inexperienced medical residents
■ Taking on others’ work (e.g., therapy on the
weekend, double-checking doctors’ orders)
without credit for it
■ Malfunctioning equipment (McGibbon, Peter,
& Gallop, 2010)
Additional sources of stress, including risk of infec-
tion, inadequate pay, and emotionally intensive
work, were reported by a group of Latvian nurses
(Circenis & Millere, 2012). Outside demands such
as family caregiving can also be a source (Tucker,
Weymiller, Cutshall, Rhudy, & Lohse, 2012). Small
stressors can accumulate with negative effects on
one’s health (Evans, Becker, Zahn, Bilotta, &
Keesee, 2011).
However, although most discussions emphasize
the stressful nature of nurses’ work, a study of over
2,000 staff nurses from a Midwestern medical
center actually found they reported an average level
of perceived stress (Tucker et al., 2012), suggesting
most nurses learn how to manage these stresses.
Why Is Health Care a Stressful Occupation?
Job-related stress is broadly defined by the National
Institute for Occupational Safety and Health as the
“harmful physical and emotional responses that
occur when the requirements of the job do not
match the capabilities, resources, or needs of the
worker.” Much of the stress experienced by nurses
is related to the nature of their work: continued
intensive, intimate contact with people who often
have serious physical, mental, emotional, and/or
social problems and sometimes fatal diseases.
Efforts to save patients or help them achieve a
peaceful ending to their lives are not always suc-
cessful. Some patients return to their destructive
behaviors. The continued loss of patients alone can
lead to burnout.
Health-care providers experiencing burnout
may become cynical and even hostile toward their
coworkers and colleagues (Carr & Kazanowski,
1994; Dionne-Proulx & Pepin, 1993; Goodell &
Van Ess Coeling, 1994; Stechmiller & Yarandi,
1993; Tumulty, Jernigan, & Kohut, 1994).
In some instances, human service profession-
als also experience lower pay, longer hours, and
more extensive regulation than do professionals
in other fields. Inadequate advancement opportuni-
ties for women and minorities in lower-status,
lower-paid positions may also contribute to job
dissatisfaction.
The often unrealistic and sometimes sexist
image of nurses in the media adds to the problem.
Neither the school ideal nor the media image is
realistic, but either may make nurses feel dis-
satisfied with themselves and their jobs, keeping
stress levels high (Corley et al., 1994; Fielding &
Weaver, 1994; Grant, 1993; Kovner, Hendrickson,
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chapter 11 ■ Promoting a Healthy Work Environment 191
Knickman, & Finkler, 1994; Malkin, 1993; Nakata
& Saylor, 1994; Pines, 2004; Skubak, Earls, &
Botos, 1994).
Responses to Stress
“Whether the stress you experience is the result of
major life changes or the cumulative effect of minor
everyday hassles, it is how you respond to these expe-
riences that determines the impact stress will have
on your life” (Davis, Eshelman, & McCay, 2000).
Some people manage potentially stressful events
more effectively than others (Crawford, 1993;
Teague, 1992). A patient situation that one nurse
considers stressful may not seem at all stressful to
a coworker. The following is an example:
A new graduate was employed on a busy telemetry
floor. Often, when patients were admitted, they
were in acute distress, with shortness of breath,
diaphoresis, and chest pain. Family members were
distraught and anxious. Each time the new gradu-
ate had to admit a patient, she experienced a “sick-
to-the-stomach” feeling, tightness in the chest, and
diff iculty concentrating.
She was afraid that she would miss something
important and that the patient would die during
admission. The more experienced nurses seemed to
handle each admission with ease, even when the
patient’s physical condition was severely compromised.
Managing Stress
Psychologists noted over 100 years ago (1908) that
too little stress can cause a lackadaisical attitude,
while too much hurts performance and eventually
one’s health. A moderate amount can stimulate
high performance without deleterious effects (Beck,
2012, p. 72) (see Box 11-6 for signs that your work-
related stress level is too high).
There are some actions you can take to manage
your stress; others need to be initiated by your
employer. A health-promoting lifestyle, including
attention to exercise, adequate sleep, and spiritual
concerns is fundamental to caring for oneself
( Johnson, 2011; Tucker et al., 2012). Riahi (2011,
p. 729) suggests the following to maintain a
healthy work life: self-reflect on your perceived
role, develop hardiness through use of positive cop-
ing styles, and embrace various forms of prevention
and stress-reduction actions.
Recent research suggests that mindfulness-
based stress reduction (e.g., noting your physical
response to stress) and cognitive behavioral train-
ing (screening out negative thoughts) are more
helpful than earlier relaxation approaches, but
they do require a substantial investment of time
(Shellenbarger, 2012).
Realistic expectations of yourself and your new
profession will also reduce stress related to unreal-
istic goals.
There is much that your employer can do as well
to reduce workplace stress and mitigate its effects.
These include:
■ Provision of well-prepared preceptors and
mentors for newly employed nurses
■ Sufficient staffing so employees can take
breaks and vacation time
■ Peer support groups
■ Debriefing after critical events have occurred
■ Well-developed employee-assistance programs
(EAPs) for counseling when needed
■ Stress reduction training and workshops
■ On-site exercise rooms
■ On-site relaxation rooms
Hoolahan and Greenhouse (2012) describe a “res-
toration room” that was created from a conference
room for use by nursing staff as a safe place to go
and to calm themselves. Staff called this “chair
time” and occasionally used it for family members
as well after critical incidents occurred.
Ultimately, you are in control. Every day you are
faced with choices. By gaining power over your
choices and the stress they cause, you empower
yourself.
Instead of being preoccupied with the past or
the future, acknowledge the present moment and
say the following to yourself (Davidson, 1999):
■ I choose to relish my days.
■ I choose to enjoy this moment.
■ I choose to be fully present to others.
• Dreading going to work
• Thinking frequently about mistakes, failures
• Avoiding patients, colleagues, assignments
• Using alcohol or drugs to relax after work
• Worrying about all of the above
box 11-6
Signs That Your Stress Level Is Too High
Adapted from Beck, M. (2012/June 19). Anxiety can bring out the
best. Wall Street Journal, D1.
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192 unit 3 ■ Career Considerations
■ I choose to fully engage in the activity at hand.
■ I choose to proceed at a measured, effective pace.
■ I choose to acknowledge all I have achieved so
far.
■ I choose to focus on where I am and what I
am doing.
■ I choose to acknowledge that this is the only
moment in which I can take action.
People cannot live in a problem-free world, but
they can learn how to handle stress. Using the sug-
gestions in this chapter, you will be able to adopt a
healthier personal and professional lifestyle. The
self-assessment questions in Box 11-7 can help you
manage stress and help you understand your
responses better. Boxes 11-8, 11-9, and 11-10 offer
some guidelines for dealing with stress in the
workplace.
Burnout
The ultimate result of unmediated job stress is
burnout. The term burnout was a favorite buzzword
of the 1980s and continues to be part of today’s
vocabulary. Herbert Freudenberger formally identi-
fied it as a leadership concern in 1974. The litera-
ture on job stress and burnout continues to grow as
new books, articles, workshops, and videos regularly
appear. A useful definition of burnout is the “pro-
gressive deterioration in work and other perfor-
mance resulting from increasing difficulties in
coping with high and continuing levels of job-
related stress and professional frustration” (Paine,
1984, p. 1).
Much of the burnout experienced by nurses has
been attributed to the frustration that arises because
care cannot be delivered in the ideal manner. For
those whose greatest satisfaction comes from caring
for patients, anything that interferes with providing
the highest quality care causes work stress and feel-
ings of failure.
People who expect to derive a sense of signifi-
cance from their work enter their professions with
high hopes and motivation and relate to their work
as a calling. When they feel that they have failed,
that their work is meaningless, that they make no
difference in the world, they may start feeling help-
less and hopeless and eventually burn out (Pines,
2004, p. 67).
Stages of Burnout
Goliszek (1992) identified four stages of burnout:
1. High expectations and idealism. At the first
stage, the individual is enthusiastic, dedicated,
• What does the term health mean to me?
• What prevents me from living this definition of health?
• Is health important to me?
• Where do I find support?
• Which coping methods work best for me?
• What tasks cause me to feel pressured?
• Can I reorganize, reduce, or eliminate these tasks?
• Can I delegate or rearrange any of my family
responsibilities?
• Can I say no to less important demands?
• What are my hopes for the future in terms of (1) career,
(2) finances, (3) spiritual life and physical needs,
(4) family relationships, (5) social relationships?
• What do I think others expect of me?
• How do I feel about these expectations?
• What is really important to me?
• Can I prioritize in order to have balance in my life?
box 11-7
Questions for Self-Assessment
• Guided imagery
• Yoga
• Tai chi
• Meditation
• Relaxation tapes or music
• Exercise
• Favorite sports or hobbies
• Quiet corners or favorite places
box 11-8
Useful Relaxation Techniques
• Spend time on outside interests and take time for
yourself.
• Increase your professional knowledge.
• Identify problem-solving resources.
• Identify realistic expectations for your position. Make
sure you understand what is expected of you; ask
questions if anything is unclear.
• Assess the rewards your work can realistically deliver.
• Develop good communication skills and treat coworkers
with respect.
• Join rap sessions with coworkers. Be part of the
solution, not part of the problem.
• Do not exceed your limits—you do not always have to
say yes.
• Deal with other people’s anger by asking yourself,
“Whose problem is this?”
• Recognize that you can teach other people how to
treat you.
box 11-9
Coping With Daily Work Stress
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chapter 11 ■ Promoting a Healthy Work Environment 193
and committed to the job and exhibits a high
energy level and a positive attitude.
2. Pessimism and early job dissatisfaction. In the
second stage, frustration, disillusionment, or
boredom with the job develops, and the
individual begins to exhibit the physical and
psychological symptoms of stress.
3. Withdrawal and isolation. As the individual
moves into the third stage, anger, hostility, and
negativism are exhibited. The physical and
psychological stress symptoms worsen. Up
through this stage, simple changes in job goals,
attitudes, and behaviors may reverse the
burnout process.
4. Detachment and loss of interest. As the
physical and emotional stress symptoms
become severe, the individual exhibits low self-
esteem, chronic absenteeism, cynicism, and
total negativism. Once the individual has
moved into this stage and remains there for
any length of time, burnout is inevitable.
Sharon had wanted to be a nurse for as long as she
could remember. She married early, had three chil-
dren, and put her dreams of being a nurse on hold.
Now her children are grown, and she f inally real-
ized her dream by graduating last year from the
local community college with a nursing degree.
However, she has been overwhelmed at work, criti-
cal of coworkers and patients, and argumentative
with supervisors. She is having diff iculty adapting
to the restructuring changes at her hospital and goes
home angry and frustrated every day. She cannot
stop working for f inancial reasons but is seriously
thinking of quitting nursing and taking some com-
puter classes. “I’m tired of dealing with people.
Maybe machines will be more friendly and predict-
able.” Sharon is experiencing burnout.
Box 11-11 lists factors to consider to determine
whether you may be experiencing stress or burnout.
Buffers Against Burnout
The idea that personal hardiness provides a buffer
against burnout has been explored in recent years.
Hardiness includes the following:
■ A sense of personal control rather than
powerlessness
■ Commitment to work and life’s activities
rather than alienation
■ Seeing life’s demands and changes as
challenges rather than as threats
The hardiness that comes from having this per-
spective leads to the use of adaptive coping
responses, such as optimism, effective use of support
systems, and healthy lifestyle habits (Duquette,
Sandhu, & Beaudet, 1994; Nowak & Pentkowski,
1994). In addition, letting go of guilt, fear of change,
and the self-blaming, “wallowing-in-the-problem”
syndrome will help you buffer yourself against
burnout (Lenson, 2001).
Adapted from Bowers, R. (1993). Stress and your health. National Women’s Health Report, 15(3), 6.
1. Express yourself! Communicate your feelings and
emotions to friends and colleagues to avoid isolation
and share perspectives. Sometimes, another opinion
helps you see the situation in a different light.
2. Take time off. Taking breaks, or doing something
unrelated to work, will help you feel refreshed as you
begin work again.
3. Understand your individual energy patterns. Are you a
morning or an afternoon person? Schedule stressful
duties during times when you are most energetic.
4. Do one stressful activity at a time. Although this may
take advanced planning, avoiding more than one
stressful situation at a time will make you feel more in
control and satisfied with your accomplishments.
5. Exercise! Physical exercise builds physical and
emotional resilience. Do not put physical activities “on
the back burner” as you become busy.
6. Tackle big projects one piece at a time. Having
control of one part of a project at a time will
help you to avoid feeling overwhelmed and out of
control.
7. Delegate if possible. If you can delegate and share in
problem solving, do so. Not only will your load be
lighter, but others will be able to participate in
decision making.
8. It’s okay to say no. Do not take on every extra
assignment or special project.
9. Be work-smart. Improve your work skills with new
technologies and ideas. Take advantage of additional
job training.
10. Relax. Find time each day to consciously relax and
reflect on the positive energies you need to cope with
stressful situations more readily.
box 11-10
Ten Daily De-Stressors
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194 unit 3 ■ Career Considerations
Job Satisfaction
Job satisfaction encompasses the feelings or atti-
tudes, positive or negative, that an individual has
about his or her work. The nature of the work,
people with whom one works, and the organization
in which this all takes place are usually the focus of
job satisfaction studies. Factors found to be impor-
tant in nurses’ satisfaction with their work are the
work itself, the health-care team, and the employ-
ing organization.
The Work Itself
Ability to provide high-quality patient care is very
important to most nurses. In a study of 1,091
medical-surgical nurses, Amendolair (2012) found
a positive relationship between perceived ability to
express caring behaviors and job satisfaction. Their
ability to do so was related to the amount of time
available to spend with patients.
The Health-Care Team
Nurses work with and interact with many different
people in a day: patients, families, nursing assis-
tants, many kinds of therapists, housekeeping and
transport staff, social workers, and physicians, to
name a few. How well they all work together,
whether cooperatively and collegially or in constant
conflict, affects job satisfaction. In a study of 3,675
nursing staff from five hospitals, Kalisch and col-
leagues (2010) found that higher levels of team-
work (trust, cohesiveness, mutual help and
understanding, and leadership) and adequate staff-
ing lead to greater job satisfaction.
The Employing Organization
An organization that supports its most valuable
asset, its staff members, is one that keeps its expe-
rienced nurses. Effective nurse leaders are key to
accomplishing the goal of a healthy work environ-
ment (Blake, 2012). Higher pay, better benefits, and
the means to turn sources of dissatisfaction into
actual improvements in the work environment (one
could call this empowerment) are elements contrib-
uting to retention of experienced nurses (Seago,
Spetz, Ash, Herrera, & Keane, 2011).
New Graduates’ Concerns
Most employers expect new graduates to come to
the work setting able to organize their work, set
priorities, and provide leadership to ancillary per-
sonnel. Even though nursing programs are designed
to help students prepare for the demands of the
work setting, new nurses still need to continue to
learn and practice their skills on the job. Experi-
enced nurses say that what they learned in school
is only the beginning; school provided them with
the fundamental knowledge and skills needed to
continue to grow and develop as they practiced
nursing in various capacities and work settings.
Graduation is not the end of learning but the
Adapted from Golin, M., Buchlin, M., & Diamond, D. (1991). Secrets of Executive Success. Emmaus, PA: Rodale Press; and Goliszek, A. (1992).
Sixty-Six Second Stress Management: The Quickest Way to Relax and Ease Anxiety. Far Hills, NJ: New Horizon.
• Do you feel more fatigued than energetic?
• Do you work harder but accomplish less?
• Do you feel cynical or disenchanted most of the time?
• Do you often feel sad or cry for no apparent reason?
• Do you feel hostile, negative, or angry at work?
• Are you short-tempered? Do you withdraw from friends
or coworkers?
• Do you forget appointments or deadlines? Do you
frequently misplace personal items?
• Are you becoming insensitive, irritable, and
short – tempered?
• Do you experience physical symptoms such as
headaches or stomachaches?
• Do you feel like avoiding people?
• Do you laugh less? Feel joy less often?
• Are you interested in sex?
• Do you crave junk food more often?
• Do you skip meals?
• Have your sleep patterns changed?
• Do you take more medication than usual? Do you use
alcohol or other substances to alter your mood?
• Do you feel guilty when your work is not perfect?
• Are you questioning whether the job is right for you?
• Do you feel as though no one cares what kind of work
you do?
• Do you constantly push yourself to do better, yet feel
frustrated that there is no time to do what you want to
do?
• Do you feel as if you are on a treadmill all day?
• Do you use holidays, weekends, or vacation time to
catch up?
• Do you feel as if you are “burning the candle at both
ends”?
box 11-11
Assessing Your Risk for Stress and Burnout
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chapter 11 ■ Promoting a Healthy Work Environment 195
beginning of a journey toward becoming an expert
nurse (Benner, 1984).
In most associate degree programs, students are
assigned to care for one to three patients a day,
working up to six or seven patients under a precep-
tor’s supervision by the end of their program.
Compare this with your first real job as a nurse: You
may work 7–10 days in a row on 8- to 12-hour
shifts, caring for 10 or more patients. You may also
have to supervise several licensed practical nurses,
technicians, and nursing assistants. These big
changes from school to employment cause many
new graduates to experience reality shock (Kraeger
& Walker, 1993; Kramer, 1981).
Initial Concerns
The first few weeks on a new job are the “honey-
moon” phase. The new employee is excited and
enthusiastic about the new position. Coworkers
usually go out of their way to make the new person
feel welcome and overlook any problems that arise.
But honeymoons do not last forever. The new grad-
uate is soon expected to behave like everyone else
and discovers that expectations for a professional
employed in an organization are quite different
from expectations for a student in school. Behaviors
that brought rewards in school, such as crafting
detailed care plans, taking extra time to prepare a
patient for discharge, or delaying another task to
look up the side effects of a new medication, are
not necessarily valued by the organization. In fact,
some of them are criticized. The new graduate who
is not prepared for this change may feel confused,
shocked, angry, and disillusioned. The stress can be
high if it is not resolved.
Typical concerns of new nurses in their first 3
months of employment are related to skills, profes-
sional roles, patient care management, criticism
from other staff members, knowledge of unit
routine, and competing demands of school, family,
and work (Godinez, Schweiger, Gruver, & Ryan,
1999; Heslop, 2001).
Well-supervised orientation programs are very
helpful for newly licensed nurses. In some cases, the
orientation program may be cut short and the new
nurse required to function on his or her own very
quickly. One way to minimize initial work stress is
to ask questions about the orientation program
before accepting a position: How long will it be?
With whom will I be working? When will I be on
my own? What happens if at the end of the orien-
tation I still need more assistance?
Differences in Expectations
Regardless of the career one chooses, there is no
perfect job. After 2 or 3 months, the new nurse
begins to experience a formal separation from being
a student to embracing the professional nursing
role. To cope with reality, several facts of work life
need to be recognized (Goliszek, 1992, pp. 36, 46):
1. Expectations may not be met. You can accept
this and react constructively or you can
continue to experience disappointment and
frustration.
2. To at least some extent, you need to adapt to
the demands of your job, not expect the work
to be adapted to your needs. Having a positive
attitude and a sense of humor helps to
maintain flexibility.
3. Feelings of helplessness or powerlessness at
work cause frustration and job stress. If you go
to work every day feeling that you do not make
a difference, it is time to reevaluate your
position and your goals. How you perceive your
contribution to health care will definitely
influence your reality.
When efficiency is the goal, the speed and amount
of work done are rewarded rather than the quality
of the work. This creates a conflict for the new
graduate, who while in school was allowed to take
as much time as needed to provide good care. The
following is an example:
Brenda, a new graduate, was assigned to give medi-
cations to all her team’s patients. Because this was a
fairly light assignment, she spent some time looking
up the medications and explaining their actions to
the patients receiving them. Brenda also straight-
ened up the medicine cart and restocked the supplies,
which she thought would please her task-oriented
team leader. At the end of the day, Brenda reported
these activities with some satisfaction to the team
leader. She expected the team leader to be pleased
with the way she used the time. Instead, the team
leader looked annoyed and told her that whoever
passes out medications always does the blood pres-
sures as well and that the other nurse on the team,
who had a heavier assignment, had to do them. Also,
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196 unit 3 ■ Career Considerations
because supplies were always ordered on Fridays for
the weekend, it would have to be done again tomor-
row, so Brenda had in fact wasted her time. Brenda
had encountered differences in expectations and dis-
covered how much more she needed to learn about
the routines in her workplace.
Additional Pressures on the
New Graduate
The first job a person takes after finishing school
is often considered a proving ground where newly
gained knowledge and skills are tested. Some new
graduates set up mental tests for themselves that
they feel must be passed before they can be confi-
dent of their ability to function. Passing these self-
tests also confirms achievement of identity as a
practitioner rather than a student.
At the same time, new graduates are undergoing
testing by their coworkers, who are also interested
in finding out whether the new graduate can handle
the job. Sometimes new graduates are given tasks
they are not ready to handle. If this happens,
Kramer (1981) recommends that new graduates
refuse to take the test rather than fail it. Another
opportunity for proving themselves will soon come
along.
Easing the Transition
Instead of focusing on the stress, new nurses can
meet the transition to professional nursing by
adapting to good stress:
■ Develop a professional identity.
Opportunities to challenge one’s competence
and develop an identity as a professional can
begin in school. Success in meeting these
challenges can immunize the new graduate
against the loss of confidence that accompanies
reality shock.
■ Learn about the organization. The new
graduate who understands how organizations
operate will not be as shocked as the naïve
individual. When you begin a new job, it
is important to learn as much as you can
about the organization and how it really
operates.
■ Use your energy wisely. Much energy goes
into learning a new job. You may see many
things that you think need to be changed, but
you need to recognize that to implement
change requires your time and energy.
■ Communicate effectively. Confront problems
that might arise with coworkers. Use the
problem-solving and negotiating skills you’ve
learned in this course.
■ Seek feedback often and persistently. Seeking
feedback pushes the people you work with to
be more specific about their expectations of
you.
■ Develop a support network. Identify
colleagues who have held onto their
professional ideals with whom you can share
your problems and the work of improving
the organization. Their recognition of your
work can keep you going when rewards from
the organization are meager. A support
network is a source of strength when resisting
pressure to give up professional ideals and a
source of power when attempting to bring
about change.
■ Mentoring. New graduates need help with
organizing their work, time management,
communicating with other members of the
health-care team, especially with physicians,
and recognition of critical changes in their
patients. Even experienced nurses, when newly
hired or transferred to different positions,
usually need to learn the culture of the new
organization, their role on the new team, and
new skills (Ellisen, 2011). Mentors can provide
the support needed to increase new nurses’
clinical success, job satisfaction, and retention
(Cottingham, DiBartolo, Battistoni, & Brown,
2010; Burr, Stichler, & Poettler, 2011; Weng,
Huang, Tsai, Chang, Lin, & Lee, 2010). For
example:
At Sharp Mary Birch Hospital for Women and
Newborns in San Diego, new graduates, nurses
returning to work after some time away, and nurses
entering a new specialty area are matched with an
experienced mentor for their f irst year. The program
includes a 3-hour orientation for mentors and
mentees, quarterly support workshops, and ongoing
support. It has not only reduced their new graduate
turnover rate but also helps to recruit new nurses
(Burr et al., 2011).
A mentor-mentee relationship may be formal as in
the example above or it may develop informally
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chapter 11 ■ Promoting a Healthy Work Environment 197
over time. Formal relationships usually include
some training for the mentor and mentee, have
specific objectives, and often have mentors assigned
to mentees, while those in informal mentoring rela-
tionships usually choose each other (Harrington,
2011). Either approach can be a valuable and
rewarding experience for both mentor and mentee
(see Table 11-1)
Ineffective Coping Strategies
Some less successful ways of coping with these
problems are listed.
■ Abandon professional ideals. When faced
with reality shock, some new graduates
abandon their professional ideals. This may
eliminate their conflict but puts the needs of
the organization before their needs or the
needs of the patient.
■ Leave the profession. A significant proportion
of those who do not want to give up their
professional ideals escape these conflicts by
leaving their jobs and abandoning their
profession. There would probably be fewer
shortages of nurses if more health-care
organizations met these professional ideals
(Kramer & Schmalenberg, 1993).
When you have made it through the first 6 months
of employment and are finally starting to feel like
a “real” nurse, you are probably beginning to realize
that a completely stress-free work environment is
almost impossible to achieve. Shift work, overtime,
distraught families, staff shortages, and pressure to
do more with less continue to contribute to place
demands on nurses. An inability to deal with this
table 11-1
Mentor and Mentee Responsibilities
Mentor Responsibilities Mentee Responsibilities
Utilizes excellent communication and listening skills Demonstrates eagerness to learn
Shows sensitivity to needs of nurses, patients, and
workplace
Participates actively in the relationship by keeping all appointments
and commitments
Encourages excellence in others Seeks feedback and uses it to modify behaviors
Shares and provides counsel Demonstrates flexibility and an ability to change
Exhibits good decision-making skills Is open in the relationship with mentor
Shows an understanding of power and politics Demonstrates an ability to move toward independence
Demonstrates trustworthiness Able to evaluate choices and outcomes
continued stress may lead to burnout unless you
take steps to prevent it.
Conclusion
Workplace safety is an area of increasing concern
for employer and employees alike. Staff members
have a right to be informed of any potential risks
in the workplace. Employers have a responsibil-
ity to provide adequate equipment and supplies
to protect employees and to create programs and
policies to inform employees about minimizing
risks as much as possible. Issues of workplace vio-
lence, sexual harassment, impaired workers, ergo-
nomics and workplace injuries, and terrorism
should be addressed to protect both employees and
patients.
A social environment that promotes professional
growth and creativity and a physical environment
that offers comfort and maximum work efficiency
should be considered in improving the quality of
work life. Cultural awareness, respect for the diver-
sity of others, and increased contact between groups
should also be addressed.
Many waking hours are spent in the workplace.
It can offer a climate of professional growth, excite-
ment, and satisfaction. Everyone is responsible for
promoting a safe, healthy work environment for
each other.
You already know that the work of nursing is not
easy and may sometimes be very stressful. Yet
nursing is also a profession filled with a great deal
of personal and professional satisfaction. Periodi-
cally ask yourself the questions designed to help you
assess your stress level and review the stress man-
agement techniques described in this chapter to
reduce your risk for burnout.
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198 unit 3 ■ Career Considerations
Study Questions
1. Why is it important for nurses to understand the major federal laws and agencies responsible
to protect the individual in the workplace?
2. What actions can nurses take if they believe that OSHA guidelines are not being followed in
the workplace?
3. What are nurses’ responsibilities in dealing with the following workplace issues: transmission
of blood-borne pathogens, violence, sexual harassment, and impaired coworkers?
4. What information do you need to obtain from your employer related to disasters or a terrorist
threat?
5. What will you look for in the work environment that will support positive patient outcomes?
6. Consider experiences you have had in your clinical rotations: were the environments
supportive or nonsupportive? What recommendations would you make for improvement?
7. Discuss the characteristics of health-care organizations that may lead to burnout among
nurses. How could they be changed or eliminated?
8. How can a new graduate adequately prepare for the work world? What is your plan to make
the transition from student to practicing professional successful?
9. What qualities would you look for in a mentor? What qualities would you try to demonstrate
as a mentee? Can you identify someone you know who might become a mentor to you?
10. How are the signs of stress, burnout, and reality shock related?
11. How can you help colleagues deal with substance abuse problems? What if a colleague does
not recognize that he/she has a problem? What might you do to help your colleague?
12. Identify the physical and psychological signs and symptoms you exhibit during stress. What
sources of stress are most likely to affect you? How do you deal with these signs and
symptoms?
Case Studies to Promote Critical Reasoning
Diversity
You have been hired as a new RN on a busy pediatric unit in a large metropolitan hospital. The
hospital provides services for a culturally diverse population, including African American, Asian,
and Hispanic people. Family members often attempt alternative healing practices specific to their
culture and bring special foods from home to entice a sick child to eat. One of the more
experienced nurses said to you, “We need to discourage these people from fooling with all this
hocus-pocus. We are trying to get their sick kid well in the time allowed under their managed care
plans, and all this medicine-man stuff is only keeping the kid sick longer. Besides, all this stuff
stinks up the rooms and brings in bugs.” You have observed how important these healing rituals
and foods are to the patients and families and believe that both the families and the children have
benefited from this nontraditional approach to healing.
1. What are your feelings about nontraditional healing methods?
2. How would you respond to the experienced nurse?
3. How can you be a patient advocate without alienating your coworkers?
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chapter 11 ■ Promoting a Healthy Work Environment 199
4. What could you do to assist your coworkers in becoming more culturally sensitive to their
patients and families?
5. How can health-care facilities incorporate both Western and nontraditional medicine? Should
they do this? Why or why not?
Burnout
Shawna, a new staff member, has been working from 7 a.m. to 3 p.m. on an infectious disease
floor since obtaining her RN license 4 months ago. Most of the staff members with whom she
works with have been there since the unit opened 5 years ago. On a typical day, the staffing
includes a nurse manager, two RNs, an LPN, and one technician for approximately 40 patients.
Most patients are HIV-positive with multisystem failure. Many are severely debilitated and need
help with their activities of daily living. Although staff members encourage family members and
loved ones to help, most of them are unavailable because they work during the day. Several days a
week, the nursing students from Shawna’s community college program are assigned to the floor.
Tina, the nurse manager, does not participate in any direct patient care, saying that she is “too
busy at the desk.” Laverne, the other RN, says the unit depresses her and that she has requested a
transfer to pediatrics. Lynn, the LPN, wants to “give meds” because she is “sick of the patients’
constant whining,” and Sheila, the technician, is “just plain exhausted.” Lately, Shawna has noticed
that the other staff members seem to avoid the nursing students and reply to their questions with
annoyed, short answers. Shawna is feeling alone and overwhelmed and goes home at night
worrying about the patients, who need more care and attention. She is afraid to ask Tina for more
help because she does not want to be considered incompetent or a complainer. When she confided
in Lynn about her concerns, Lynn replied, “Get real—no one here cares about the patients or us.
All they care about is the bottom line! Why did a smart girl like you choose nursing in the first
place?”
1. What is happening on this unit in leadership terms?
2. Identify the major problems and the factors that contributed to these problems.
3. What factors might have contributed to the behaviors exhibited by Tina, Lynn, and Sheila?
4. How would you feel if you were Shawna?
5. Is there anything Shawna can do for herself, for the patients, and for the staff members?
6. What do you think Tina, the nurse manager, should do?
7. How is the nurse manager reacting to the changes in her staff members?
8. What is the responsibility of administration?
9. How are the patients affected by the behaviors exhibited by all staff members?
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200 unit 3 ■ Career Considerations
References
Aiken, L.H., Clarke, S.P., Slane, D.M., Sochalski, J., et al.
(2002). Hospital nurse staffing and patient mortality,
nurse burnout, and job dissatisfaction. Journal of the
American Medical Association, 288(16), 1987–1993.
Amendoliar, D. (2012). Caring behaviors and job
satisfaction. Journal of Nursing Administration, 42(1),
34–39.
American Association of Critical-Care Nurses. (2005).
AACN standards for establishing and sustaining healthy
work environments: A journey to excellence. American
Journal of Critical Care 14(3), 187–197.
American Nurses Association. (2012). ANA survey:
Improved work environment, more can be done.
Available at: www.theamericannurse.org/index
.php/2012/02/07/
ana-survey-improved-work-environment-more-can-be-done/
American Nurses Association. (1993). HIV, hepatitis-B,
hepatitis-C: Blood-borne diseases. Washington, DC:
ANA.
American Nurses Association. (1994). Guidelines on
reporting incompetent, unethical, or illegal practices.
Washington, DC: ANA.
American Nurses Association. (1995a). Protect your
patients—Protect your license. Washington, DC: ANA.
American Nurses Association. (1995b). The Supreme Court
has issued the ultimate gag order for nurses.
Washington, DC: ANA.
American Nurses Association. (2001). Code for nurses.
Washington, DC: ANA.
American Nurses Association. (2006/December 8).
Assuring patient safety: Registered nurses’ responsibility
in all roles and settings to guard against working when
fatigued. Washington, DC: ANA.
American Nurses Association. (2007). Occupational health.
Retrieved July 10, 2009, from www.nursingworld.org/
MainMenuCategories/OccupationalandEnvironmental/
occupationalhealth.aspx
Arbury, S. (2002). Healthcare workers at risk. Job Safety
and Health Care Quarterly, 13(2), 30–31.
Bauer, X., Ammon, J., Chen z., Beckman, W. et al. (1993).
Health risk in hospitals through airborne allergens for
patients pre-sensitized to latex. Lancet, 342,
1148–1149.
Beck, M. (2012/June 19). Anxiety can bring out the best.
Wall Street Journal, D1.
Benner, P. (1984). From novice to expert. Menlo Park, CA:
Addison-Wesley.
Beyea, S. (2004). A critical partnership-safety for nurses
and patients. AORN, 79(6), 1299–1302.
Blair, D. (2005). Spot the signs of drug impairment. Nursing
Management, 36(2), 20–21, 52.
Blake, N. (2012). Practical steps for implementing healthy
work environments. Creating a Healthy Workplace,
23(1), 14–17.
Bowers, R. (1993). Stress and your health. National
Women’s Health Report, 15(3), 6.
Brooke, P. (2001). The legal realities of HIV exposure. RN,
64(12), 71–73.
Burr, S., Stichler, J.F., & Poettler, D. (2011). Establishing a
mentoring program. Nursing for Women’s Health, 15(3),
215–224.
Bylone, M. (2011). Healthy work environment 101. AACN
Advanced Critical Care, 22(1), 10–21.
Carr, K., & Kazanowski, M. (1994). Factors affecting job
satisfaction of nurses who work in long-term care. Journal
of Advanced Nursing, 19, 878–883.
Carroll, C., & Sheverbush, J. (September 1996). Violence
assessment in hospitals provides basis for action. The
American Nurse, 18.
Centers for Disease Control and Prevention (CDC). (1992).
Surveillance for occupationally acquired HIV infection—
United States, 1981–1992. MMWR, 41(43),
823–825.
Chisholm, R.F. (1992). Quality of working life: A crucial
management perspective for the year 2000. Journal of
Health and Human Resources Administration, 15(1),
6–34.
Circenis, K., & Millere, I. (2012). Stress related work
environments: Nurses survey result. International Journal
of Collaborative Research on Internal Medicine & Public
Health, 4(6), 1150–1157.
Collins, J. (1994). Nurses’ attitudes toward aggressive
behavior following attendance at “The Prevention and
Management of Aggressive Behavior Programme.”
Journal of Advanced Nursing, 20, 117–131.
Corley, M., Farley, B., Geddes, N., Goodloe, L., et al.
(1994). The clinical ladder: Impact on nurse satisfaction
and turnover. Journal of Nursing Administration, 24(2),
42–48.
Cottingham, S., DiBartolo, M.C., Battistoni, S., & Brown, T.
(2010). Partners in nursing: A mentoring initiative to
enhance nurse retention. Nursing Education Perspectives,
32(4), 250–255.
Crawford, S. (1993). Job stress and occupational health
nursing. American Association of Occupational Health
Nurses Journal, 41, 522–529.
Daley, K.A. (2012/September). Editorial: Moving the
sharps agenda forward. American Nurse Today, 1.
Damrosch, S., & Scholler-Jaquish, A. (1993). Nurses’
experiences with impaired nurse coworkers. Applied
Nursing Research, 6(4), 154–160.
Davidhizar, R., Dowd, S., & Giger, J. (1999). Managing
diversity in the healthcare workplace. Health Care
Supervisor, 17(3), 51–62.
Davidson, J. (1999). Managing stress (2nd ed.). New York:
Pearson.
Davis, M., Eshelman, E., & McCay, M. (2000). The
Relaxation and stress reduction workbook, 5th ed.
Oakland, CA: New Harbinger Publications.
Dionne-Proulx, J., & Pepin, R. (1993). Stress management in
the nursing profession. Journal of Nursing Management,
1, 75–81.
Duquette, A., Sandhu, B., & Beaudet, L. (1994). Factors
related to nursing burnout: A review of empirical
knowledge. Issues in Mental Health Nursing, 15,
337–358.
Durr, L. (2004). Commission on workforce issues: What
nurses should expect in the workplace: The ANA Bill of
Rights for registered nurses. Virginia Nurses Today,
12(2), 17.
Edlich, R., Woodard, C., & Haines, M. (2001). Disabling
back injuries in nursing personnel. Journal of Emergency
Nursing, 27(2), 150–155.
Edwards, R. (1999). Prevention of workplace violence.
Aspen’s Advisor for Nurse Executives, 14(8), 8–12.
Ellisen, K. (2011/August). Recruitment & retention report:
Mentoring smart. Nursing Management, 42(8), 12–16.
Evans, G.W., Becker, F.D., Zahn, A., Bilotta, E., & Keesee,
A.M. (2011). Capturing the ecology of workplace stress
with cumulative risk assessment. Environment and
Behavior, 44(1), 136–154.
Feiler, J.L., & Stichler, J.F. (2011). Ergonomics in healthcare
facility design: Part 2. Journal of Nursing Administration,
41(3), 97–99.
3663_Chapter 11_0173-0202.indd 2003663_Chapter 11_0173-0202.indd 200 9/15/2014 4:36:49 PM9/15/2014 4:36:49 PM
Process CyanProcess CyanProcess MagentaProcess MagentaProcess YellowProcess YellowProcess BlackProcess Black
chapter 11 ■ Promoting a Healthy Work Environment 201
Fielding, J., & Weaver, S. (1994). A comparison of hospital
and community-based mental health nurses: Perceptions
of their work environment and psychological health.
Journal of Advanced Nursing, 19, 1196–1204.
Foley, M. (2012/September). Essential elements of a
comprehensive sharps injury-prevention program.
American Nurse Today, 2–4.
General Industry Regulations Book, Subpart Z Occupational
Safety and Health Standards, Title 29 Code of Federal
Regulations, Part 1910.
Gilmore-Hall, A. (2001). Violence in the workplace. Issues
Update, ANA, 55–56. Available at: www.nursingcenter
.com
Godinez, G., Schweiger, J., Gruver, J., & Ryan, P. (1999).
Role transition from graduate to staff nurse: A qualitative
analysis. Journal for Nurses in Staff Development, 15(3),
97–110.
Golin, M., Buchlin, M., & Diamond, D. (1991). Secrets of
executive success. Emmaus, PA: Rodale Press.
Goliszek, A. (1992). Sixty-six second stress management:
The quickest way to relax and ease anxiety. Far Hills,
NJ: New Horizon.
Goodell, T., & Van Ess Coeling, H. (1994). Outcomes of
nurses’ job satisfaction. Journal of Nursing
Administration, 24(11), 36–41.
Grant, P. (1993). Manage nurse stress and increase
potential at the bedside. Nursing Administration
Quarterly, 18(1), 16–22.
Guglielmi, C., & Ogg, M.J. (2012/September). Practical
strategies to prevent surgical sharps injuries. American
Nurse Today, 8–10.
Guglielmi, C., & Ogg, M.J. (2012/September).
Moving the sharps safety agenda forward: Consensus
statement and call to action. American Nurse Today,
11–16.
Hamilton, R., Brown, R., Veltri, M., Feroli, R., et al. (2005).
Administering pharmaceuticals to latex allergy patients
from vials containing natural rubber latex closures.
American Journal Health Systems Pharmacy, 62,
1822–1827.
Handelman, E., Perry, J.L., & Parker, G. (2012/September).
Reducing sharps injuries in non-hospital settings.
American Nurse Today, 5–7.
Harrington, S. (2011). Mentoring new nurse practitioners to
accelerate their development as primary care providers:
A literature review. Journal of the American Academy of
Nurse Practitioners, 23, 168–174.
Healy, S., & Tyrrell, M. (2011). Stress in emergency
departments: Experiences of nurses and doctors.
Emergency Nurse, 19(4), 31–37.
Heise, B. (2003). The historical context of addictions within
the nursing profession. Journal of Addictions Nursing,
14, 117–124.
Herring, L.H. (1994). Infection control. New York: National
League for Nursing.
Heslop, L. (2001). Undergraduate student nurses:
Expectations and their self-reported preparedness for the
graduate year role. Journal of Advanced Nursing, 36,
626–634.
Hoolahan, S.E., & Greenhouse, P.K. (2012). Energy
capacity model for nurses: The impact of relaxation and
restoration. Journal of Nursing Administration, 42(2),
103–109.
Hurst, K.L., Croker, P.A., & Bell, S.K. (1994). How about a
lollipop? A peer recognition program. Nursing
Management, 25(9), 68–73.
Johnson, L. (2011/August). Easing workplace stressors.
Healthcare Traveler, 28–34.
Kalisch, B.J., Lee, H., & Rochman, M. (2010). Nursing staff
teamwork and job satisfaction. Journal of Nursing
Management, 18, 938–947.
Kear, M. (2012/December). Caring and civility go hand-in-
hand. The Florida Nurse, 1, 3.
Kinkle, S. (1993). Violence in the ED: How to stop it
before it starts. American Journal of Nursing, 93(7),
22–24.
Kovner, C., Hendrickson, G., Knickman, I., & Finkler, S.
(1994). Nurse care delivery models and nurse
satisfaction. Nursing Administration Quarterly, 19(1),
74–85.
Kraeger, M., & Walker, K. (1993). Attrition, burnout, job
dissatisfaction and occupational therapy manager.
Occupational Therapy in Health Care, 8(4), 47–61.
Kramer, M. (January 27–28, 1981). Coping with reality
shock. Workshop presented at Jackson Memorial
Hospital, Miami, FL.
Kramer, M., & Schmalenberg, C. (1993). Learning from
success: Autonomy and empowerment. Nursing
Management, 24(5), 58–64.
Kramer, M., Schmalenberg, C., & McGuire P. (2008).
Essentials of a magnetic environment. Volume Career
Directory. January 2008, 23–27.
Krucoff, M. (2001). How to prevent repetitive stress injury in
the workplace. American Fitness, 19(1), 31.
Lanza, M.L., & Carifio, J. (1991). Blaming the victim:
Complex (nonlinear) patterns of causal attribution by
nurses in response to vignettes of a patient assaulting a
nurse. Journal of Emergency Nursing, 17(5), 299–309.
Lenson, B. (2001). Good stress—Bad stress. New York:
Marlowe and Company.
Lewis, P.S., & Malecha, A. (2011). The impact of
workplace incivility on the work environment, manager
skill and productivity. Journal of Nursing Administration,
41(7/8), S17–S24.
Lilly Ledbetter Fair Pay Act of 2009, S.181, 123 Stat. 5
Lindberg, P., & Vingård, E. (2012). Indicators of healthy
work environments—a systematic review. Work: A
Journal of Prevention, Assesment and rehabilitation,
41 (Supl 1), 3032–3038.
Magnavita, N., & Heponiemi, T. (2011). Workplace
violence against nursing students and nurses: An Italian
experience. Journal of Nursing Scholarship, 43(2),
203–210.
Mahoney, B. (1991). The extent, nature, and response to
victimization of emergency nurses in Pennsylvania.
Journal of Emergency Nursing, 17, 282–292.
Malkin, K.F. (1993). Primary nursing: Job satisfaction and
staff retention. Journal of Nursing Management, 1,
119–124.
McGibbon, E., Peter, E., & Gallop, R. (2010). An
institutional ethnography of nurses’s stress. Qualitative
Health Research, 20(11), 1353–1378.
McLennan, M. (2005). Nurses’ views on work enabling
factors. Journal of Nursing Administration, 35(6),
311–318.
McPhaul, K. & Lipscomb, J. (September 30, 2004).
“Workplace violence in health care: Recognized but not
regulated.” Online Journal of Issues in Nursing, 9(3),
Manuscript 6. Available at: www.nursingworld.org/
MainMenuCategories/ANAMarketplace/
ANAPeriodicals/OJIN/TableofContents/Volume92004/
No3Sept04/ViolenceinHealthCare.aspx
McVicar, A. (2003). Workplace stress in nursing: A literature
review. Journal of Advanced Nursing, 44(6), 633–642.
Mitchell, A. (1995). Cultural diversity: The future, the market
and the rewards. Caring, 14(12), 44–48.
3663_Chapter 11_0173-0202.indd 2013663_Chapter 11_0173-0202.indd 201 9/15/2014 4:36:49 PM9/15/2014 4:36:49 PM
Process CyanProcess CyanProcess MagentaProcess MagentaProcess YellowProcess YellowProcess BlackProcess Black
202 unit 3 ■ Career Considerations
Nadwairski, J.A. (1992). Inner-city safety for home care
providers. Journal of Nursing Administration, 22(9),
42–47.
Nakata, J., & Saylor, C. (1994). Management style and
staff nurse satisfaction in a changing environment.
Nursing Administration Quarterly, 18(3), 51–57.
National Institute for Occupational Safety and Health
(NIOSH). Accessed July 27, 2002, at www.cdc.gov/
niosh/homepage.html
National Safety Council. (1992). Accident prevention
manual for business and industry. Chicago: National
Safety Council.
National Safety Council. (2013). Continue on a journey to
safety excellence. Available at: www.nsc.org/safety
_work/Pages/Home.aspx
Nowak, K., & Pentkowski, A. (1994). Lifestyle habits,
substance use, and predictors of job burnout in
professional women. Work and Stress, 8(1), 19–35.
O’Malley, P. (2011). Staying awake and asleep: The
challenge of working nights and rotating shifts. Clinical
Nurse Specialist, 25(1), 15–17.
OSHA (2013a). OSHA trade news release. Available
at: www.osha.gov/pls/oshaweb/owadisp.show
_document?p_table= NEWS_RELEASES. . .
OSHA (2013b). OSHA technical manual. Available at:
www.osha.gov/dts/osta/otm/otm_vii/otm_vii_1.html
Outwater, L.C. (1994). Sexual harassment issues. Caring,
13(5), 54–56, 58, 60.
Paine, W.S. (1984). Professional burnout: Some major
costs. Family and Community Health, 6(4), 1–11.
Perry, J. (2001). Attention all nurses! New legislation puts
safer sharps in your hands. American Journal of Nursing,
101(9), 24AA–24CC.
Pines, A. (2004). Adult attachment styles and their
relationship to burnout: A preliminary, cross-cultural
investigation. Work & Stress, 18(1), 66–80.
Purcell, S.R., Keitash, M., & Cobb, S. (2011). The
relationship between nurses’ stress and nurse staffing
factors in a hospital setting. Journal of Nursing
Management, 19, 714–720.
Riahi, S. (2011). Role stress amongst nurses at the
workplace: Concept analysis. Journal of Nursing
Management, 19, 1721–731.
Roche, E. (23 February 1993). Nurses’ risks and their
rights. Vital Signs, 3.
Rocker, C., (2012/September 24) “Responsibility of a
frontline manager regarding staff bullying.” OJIN: The
Online Journal of Issues in Nursing, 18(2).
Rogers, A.E., Hwang, W., Scott, L.D., Aiken, L.H., et al.
(2004). The working hours of hospital staff nurses and
patient safety: Both errors and near errors are more likely
to occur when hospital staff nurses work twelve or more
hours at a stretch. Health Affairs, 23(4), 202–212.
Rosen, A., Isaacson, D., Brady, M., & Corey J.P. (1993).
Hypersensitivity to latex in healthcare workers: Report of
five cases. Otolaryngology—Head and Neck Surgery,
109, 731–734.
Seago, J.A., Spetz, J., Ash, M., Herrera, C-N., & Keane, D.
(2011). Hospital RN job satisfaction and nurse unions.
Journal of Nursing Administration, 41(3), 109–114.
Sellers, K.F., & Millenbach, L. (2012). The degree of
horizontal violence in RNs practicing in New York State.
Journal of Nursing Administration, 42(10), 483–487.
Shandor, A. (2012/May). The health impacts of nursing
shift work. MSN Thesis, Minnesota State University,
Mankoto, MN.
Shellenbarger, S. (2012/October 10). To cut office stress,
try butterflies and meditation? The Wall Street Journal,
D2.
Simonowitz, J. (1994). Violence in the workplace: You’re
entitled to protection. Registered Nurse, 57(11), 61–63.
Skubak, K., Earls, N., & Botos, M. (1994). Shared
governance: Getting it started. Nursing Management,
25(5), 80I-J, 80N, 80P.
Slattery, M. (September/October 1998). Caring for
ourselves to care for our patients. The American Nurse,
12–13.
Sloan, A., & Vernarec, E. (2001). Impaired nurses:
Reclaiming careers. Medical Economics, 64(2), 58–64.
Smith, L.M., Andrusyszyn, M.A., & Spence-Laschinger,
H.K.S. (2010). Effects of workplace incivility and
empowerment on newly-graduated nurses’ organizational
commitment. Journal of Nursing Management, 18,
1004–1015.
Stechmiller, J., & Yarandi, H. (1993). Predictors of burnout
in critical care nurses. Heart Lung, 22, 534–540.
Strader, M.K., & Decker, P.J. (1995). Role transition to
patient care management. Norwalk, CT: Appleton &
Lange.
Teague, J.B. (1992). The relationship between various
coping styles and burnout among nurses. Dissertation
Abstracts International, 1994.
Trossman, S. (May/June 1999a). When workplace threats
become a reality. The American Nurse, 1, 12.
Trossman, S. (2011b/May/June). Texas Nurses Association
promoting enhanced nurse protection. The American
Nurse, 11.
Tucker, S.J., Weymiller, A.J., Cutshall, S.M., Rhudy, L.M., &
Lohse, C.M. (2012). Stress ratings and health promotion
practices among RNs. Journal of Nursing Administration,
42(5), 282–292.
Tumulty, G., Jernigan, E., & Kohut, G. (1994). The impact
of perceived work environment on job satisfaction of
hospital staff nurses. Applied Nursing Research, 7(2),
84–90.
U.S. Department of Labor (OSHA). (1995). Employee
workplace rights and responsibilities. OSHA, 95–35.
U.S. Department of Labor, Bureau of Labor Statistics.
(2002). Lost-work time injuries and illnesses:
Characteristics and resulting time away from work,
2000. April 10, 2002. Retrieved April 13, 2008, from
ftp://ftp.bls.gov/pub/news.release/History/
osh2.04102002.news.ftp://ftp.bls.gov/pub/news
.release/History/osh2.04102002.news.
Vahey, D., Aiken, L., Sloane, D., Clarke, S., et al. (2004).
Nurse burnout and patient satisfaction. Medical Care,
42(2), II-57–II-66.
Waneka, R., & Spetz, J. (2010). Hospital information
technology systems’ impact on nurses and nursing
care. Journal of Nursing Administration, 40(12),
509–514.
Weng, R-H., Huang, C-Y., Tsai, W-C., Chang, L-P., Lin,
S-E., & Lee, M-Y. (2010). Exploring the impact of
mentoring functions on job satisfaction and
organizational commitment of new staff nurses. BMC
Health Services Research, 10, 240.
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unit 4
Professional Issues
chapter 12 Your Nursing Career
chapter 13 Evolution of Nursing as a Profession
chapter 14 Looking to the Future
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205
chapter 12
Your Nursing Career
OBJECTIVES
After reading this chapter, the student should be able to:
■ Evaluate personal strengths, weaknesses, opportunities, and
threats using a SWOT analysis.
■ Develop a résumé including objectives, qualifications, skills
experience, work history, education, and training.
■ Compose job search letters including cover letter, thank-you
letter, and acceptance and rejection letters.
■ Discuss components of the interview process.
■ Discuss the factors involved in selecting the right position.
■ Explain why the first year is critical to planning a career.
OUTLINE
Getting Started
SWOT Analysis
Strengths
Weaknesses
Opportunities
Threats
Beginning the Search
Researching Your Potential Employer
Writing a Résumé
Essentials of a Résumé
How to Begin
Education
Your Objective
Skills and Experience
Other
Job Search Letters
Cover Letter
Thank-You Letter
Acceptance Letter
Rejection Letter
Using the Internet
The Interview Process
Initial Interview
Answering Questions
Background Questions
Professional Questions
Personal Questions
Additional Points About the Interview
Appearance
Handshake
Eye Contact
Posture and Listening Skills
Asking Questions
After the Interview
The Second Interview
Making the Right Choice
Job Content
Development
Direction
Work Climate
Compensation
I Cannot Find a Job (or I Moved)
The Critical First Year
Attitude and Expectations
Impressions and Relationships
Organizational Savvy
Skills and Knowledge
Advancing Your Career
Conclusion
The National Center for Health Workforce Analy-
sis at the Health Resources and Services Admi-
nistration has projected a growing shortage of
registered nurses (RNs) over the next 15 years,
with a 12% shortage by 2010 and a 20% shortage
by 2015 (http://bhpr.hrsa.gov/healthworkforce/
nursingshortage/tech_report/default.htm). This
continued shortage of RNs will allow you to have
many choices and opportunities as a professional
nurse. By now you have invested considerable time,
expense, and emotion into preparing for your new
career. Your educational preparation, technical and
clinical expertise, interpersonal and management
skills, personal interests and needs, and commit-
ment to the nursing profession will contribute to
meeting your career goals. Successful nurses view
nursing as a lifetime pursuit, not as an occupational
stepping stone.
This chapter deals with the most important
endeavor: finding and keeping your first nur-
sing position. The chapter begins with planning
your initial search; developing a strengths, weak-
nesses, opportunities, and threats (SWOT) analy-
sis; searching for available positions; and researching
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206 unit 4 ■ Professional Issues
organizations. Also included is a section on writing
a résumé and employment-related information
about the interview process and selecting the first
position.
Getting Started
By now at least one person has said to you, “Good
career choice. Nurses are always needed and will
never be out of a job.” This statement is only one
of several career myths. These myths include the
following:
1. “Good workers do not get fired.” They may
not get fired, but many good workers have lost
their positions during restructuring and
downsizing.
2. “Well-paying jobs are available without a
college degree.” Even if entrance into a career
path does not require a college education, the
potential for career advancement is minimal
without that degree. In many health-care
agencies, a baccalaureate degree in nursing is
required for an initial management position,
and due to the Institute of Medicine (IOM)
report (2001), many health-care institutions
are encouraging nurses to return for their BSN
and MSN degrees in order to maintain
employment.
3. “Go to work for a good company, and move up
the career ladder.” This statement assumes that
people move up the career ladder due to
longevity in the organization. In reality, the
responsibility for career advancement rests on
the employee, not the employer.
4. “Find the ‘hot’ industry, and you will always be
in demand.” Nursing is projected to continue to
be one of the “hottest” industries well into the
next decade. However, a nurse who performs
poorly will never be successful, no matter what
the demand.
Many students attending college today are adults
with family, work, and personal responsibilities. On
graduating with an associate degree in nursing, you
may still have student loans and continued respon-
sibilities for supporting a family. Your focus may be
on job security and a steady source of income. The
idea of career planning might not be a thought at
this time; however, this is a strategic process and
requires some thought and personal self-assessment
(Schoessler & Waldo, 2006). The correct goal is to
find a job that fits you. It is also not too early to
begin formal planning of your career. In today’s
dynamic health-care environment, nursing manag-
ers want nurses who consider nursing as a profes-
sion, not a just a job. They look for individuals who
express a commitment to forming partnerships
with the health-care team and institution (Arvids-
son, Skarsater, Oijerval, & Friglund, 2008).
SWOT Analysis
New graduates often secure their first position as a
staff nurse on a medical-surgical floor. They see
themselves as “putting in their year” and then
moving on to their dream position as a critical care
or mother-baby nurse. However, as the health-care
system continues to evolve and reallocate resources,
this may no longer be the automatic first step for
new graduates. Instead, new graduates should focus
on long-term career goals and the different avenues
by which they can be reached. Some of you may
already have determined your career path knowing
that you will need to pursue advanced nursing
degrees to achieve your goal.
Consider your past experiences as they may be
an asset in presenting your abilities for a particular
position. A SWOT analysis, borrowed from the
corporate world, can guide you in discovering your
internal strengths and weaknesses as well as exter-
nal opportunities and threats that may help or
hinder your job search and career planning. The
SWOT analysis is an in-depth look at what will
make you happy in your work. Although you have
already made the decision to pursue nursing,
knowing your strengths and weaknesses can help
you select the work setting that will be satisfying
personally (Christie, 2012). Your SWOT analysis
may include the following factors:
Strengths
■ Relevant work experience
■ Advanced education
■ Product knowledge
■ Good communication and people skills
■ Computer skills
■ Self-managed learning skills
■ Flexibility
Weaknesses
■ Ineffective communication and people skills
■ Inflexibility
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chapter 12 ■ Your Nursing Career 207
■ Lack of interest in further education
■ Difficulty adapting to change
■ Inability to see health care as a business
Opportunities
■ Expanding markets in health care
■ New applications of technology
■ New products and diversification
■ Increasing at-risk populations
■ Nursing shortage
Threats
■ Increased competition among health-care
facilities
■ Changes in government regulation
Take some time to strategically plan your career
and personalize the preceding SWOT analysis.
What are your strengths? What skills do you need
to improve? What weaknesses do you need to mini-
mize, or what strengths do you need to develop as
you begin your job search? What opportunities and
threats exist in the health-care community you are
considering? Doing a SWOT analysis will help you
make an initial assessment of the job market. It can
be used again after you narrow your search for that
first nursing position.
Many graduates find using the SMART ac-
ronym helpful to determine career goals. SMART
represents specific (S), measurable (M), achievable
(A), realistic (R), and timely (T) (www.health
.mo.gov/living/families/wic/wicupdates/. . ./Goal
Setting-SMART ). SMART helps you specify
what you want to accomplish during your career.
For example, perhaps you desire to work as a peri-
natal nurse. Many health-care institutions promote
certification as part of a clinical ladder. You would
include obtaining certification as part of your plan
(www. ancc.org).
In addition to completing a SWOT analysis,
there are several other tools that can help you learn
more about yourself. Two of the most common are
the Strong Interest Inventory (SII) and the Myers-
Briggs Type Indicator (MBTI). The SII compares
the individual’s interests with the interests of those
who are successful in a large number of occu-
pational fields in the areas of (1) work styles,
(2) learning environment, (3) leadership style, and
(4) risk-taking/adventure. Completing this inven-
tory can help you discover what work environment
might be best suited to your interests.
The MBTI is a widely used indicator of person-
ality patterns. This self-report inventory provides
information about individual psychological-type
preferences on four dimensions:
1. Extroversion (E) or Introversion (I)
2. Sensing (S) or Intuition (N)
3. Thinking (T) or Feeling (F)
4. Judging ( J) or Perceiving (P)
Although many factors influence behaviors and
attitudes, the MBTI summarizes underlying pat-
terns and behaviors common to most people. Both
tools should be administered and interpreted by a
qualified practitioner. Most university and career
counseling centers are able to administer them.
If you are unsure of where you fit in the work-
place, consider exploring these tests with your
college or university or take the MBTI online at
www.myersbriggs.org/.
Beginning the Search
Even with a nationwide nursing shortage, hospital
mergers, emphasis on increased staff productivity,
budget crises, staffing shifts, and changes in job
market availability affect the numbers and types of
nurses employed in various facilities and agencies.
Instead of focusing on long-term job security, the
career-secure employee focuses on becoming a
career survivalist or developing resilience. Resil-
ience requires that an individual develop the ability
to recover or adapt to changes ( Jackson, Firtko, &
Edinborough, 2007). A career survivalist or resil-
ient individual focuses on the person, not the posi-
tion. Consider the following career survivalist
strategies (Morgan, 2013):
■ Be engaged. Your career belongs to you.
Define your values and determine what
motivates you. Be the lookout for opportunities
to break from the status quo. Opportunities for
nurses are growing every day.
■ Stay informed. Health care is dynamic and
changing daily. Go out there, stay informed,
and start thinking about your options for
riding the waves of change.
■ Learn for employability. Take personal
responsibility for your career success. Continue
to be a “work in progress.” Employability in
health care today means learning technology
tools, job-specific technical skills, and people
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208 unit 4 ■ Professional Issues
skills such as the ability to negotiate, coach,
work in interprofessional teams, and make
presentations.
■ Plan for your financial future. Ask yourself,
“How can I spend less, earn more, and manage
better?” Often, people make job decisions
based on financial decisions, which makes
them feel trapped instead of secure.
■ Develop multiple options. The career
survivalist looks at multiple options constantly.
Moving up is only one option. Being aware of
emerging trends in nursing, adjacent fields,
lateral moves, and special projects presents
other options.
■ Build a safety net. Networking is extremely
important to the career survivalist. Joining
professional organizations, taking time to
build long-term nursing relationships, and
getting to know other career survivalists will
make your career path more enjoyable and
successful.
What do employers think you need to be ready to
work for them? In addition to passing the National
Council Licensure Examination (NCLEX), em-
ployers cite the following skills as desirable in job
candidates (Cazacu, 2010):
■ Oral and written communication skills
■ Responsibility and accountability
■ Integrity
■ Interpersonal skills
■ Proficiency in field of study/technical
competence
■ Teamwork ability
■ Willingness to work hard
■ Leadership abilities
■ Motivation, initiative, and flexibility
■ Critical thinking and analytical skills
■ Self-discipline
■ Organizational skills
In today’s world there are multiple approaches to
looking for a nursing position. The traditional
approaches include looking through newspapers,
professional magazines, and school career place-
ment offices. Newer electronic methods include
career search engines (Kluemper, 2009). Contacting
specific health-care institutions and organizations
and filling out a job application lets employers
know that you are interested in working with them.
Some Internet sites that post nursing opportunities
are:
■ www.careerbuilders.com
■ www.nurse.com
■ www.healthcareersinteraction.com
In recent years, three trends have emerged related
to recruiting. First, employers are being more cre-
ative by using alternative sources to increase the
diversity of employees. They commonly place
advertisements in minority newspapers and maga-
zines and recruit nurses at minority organizations.
Second, employers are using more temporary help
as a way to evaluate potential employees. Nursing
staffing agencies are common in most areas of the
county. Third, the Internet is being used more fre-
quently for advertising and recruitment.
Regardless of where you begin your search,
explore the market vigorously and thoroughly.
Looking only in the classified ads on Sunday
morning is a limited search. Instead, speak to every-
one you know about your job search. Encourage
classmates and colleagues to share contacts with
you, and do the same for them. Also, when possible,
try to speak directly with the person who is looking
for a nurse when you hear of a possible opening.
The people in human resources offices may reject
a candidate on a technicality that a nurse manager
would realize does not affect that person’s ability to
handle the job if he or she is otherwise a good
match for the position. For example, experience in
day surgery prepares a person to work in other
surgery-related settings, but a human resources
interviewer may not know this.
Try to obtain as much information as you can
about the available position. Is there a match
between your skills and interests and the position?
Ask yourself whether you are applying for this posi-
tion because you really want it or just to gain inter-
view experience. Be careful about going through
the interview process and receiving job offers only
to turn them down. Employers may share informa-
tion with one another, and you could end up being
denied the position you really want. Regardless of
where you explore potential opportunities, use
these “pearls of wisdom” from career nurses:
■ Know yourself.
■ Seek out mentors and wise people.
■ Be a risk taker.
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chapter 12 ■ Your Nursing Career 209
■ Never, ever stop learning.
■ Understand the business of health care.
■ Involve yourself in community and professional
organizations.
■ Network.
■ Understand diversity.
■ Be an effective communicator.
■ Set short- and long-term goals, and strive
continually to achieve them.
Researching Your Potential Employer
You have spent time taking a look at yourself and
the climate of the health-care job market. You have
narrowed your choices to the organizations that
really interest you. Now is the time to find out as
much as possible about these organizations.
It is important to evaluate your values and goals
when researching an organization. Ownership of
the company may be public or private, foreign or
American. The company may be local or regional,
a small corporation or a division of a much larger
corporation. Depending on the size and ownership
of the company, information may be obtained from
the public library, chamber of commerce, govern-
ment offices, or company Web site.
Has the organization recently gone through a
merger, a reorganization, or downsizing? Informa-
tion from current and past employees is valuable
and may provide you with more details about
whether the organization might be suitable for you.
Be wary of gossip and half-truths that may emerge,
however, because they may discourage you from
applying to an excellent health-care facility. In
other words, if you hear something negative about
an organization, investigate it for yourself. Often,
individuals jump at work opportunities before
doing a complete assessment of the culture and
politics of the institution.
The first step in assessing the culture is to review
a copy of the company’s mission statement. The
mission statement reflects what the institution con-
siders important to its public image. What are the
core values of the institution?
The department of nursing’s philosophy and
objectives indicate how the department defines
nursing; they identify what the department’s
important goals are for nursing. The nursing phi-
losophy and goals should reflect the mission of the
organization. Where is nursing administration on
the organizational chart of the institution? To
whom does the chief nursing officer report?
Although much of this information may not be
obtained until an interview, a preview of how the
institution views itself and the value it places on
nursing will help you decide if your philosophy of
health care and nursing is compatible with that of
a particular organization. To find out more about a
specific health-care facility, you can (Zedlitz, 2003):
■ Talk to nurses currently employed at the facility.
■ Access the facility’s Web site for information
on its mission, philosophy, and services.
■ Check the library for newspaper and magazine
articles related to the facility.
Writing a Résumé
Your résumé is your personal data sheet and a way
of marketing yourself. It is the first impression the
recruiter or your potential employer has about you.
Consider your résumé your time to shine. The
résumé highlights your skills, talents, and abilities.
You may decide to prepare your own résumé or have
it prepared by a professional service. Regardless of
who prepares it, the purpose of a résumé is to get
a job interview.
Many people dislike the idea of writing a résumé.
After all, how can you sum up your entire career in
a single page? You want to scream at the printed
page, “Hey, I’m bigger than that! Look at all I have
to offer!” However, this one-page summary has to
work well enough to get you the position you want.
Chestnut (1999) summarized résumé writing by
stating, “Lighten up. Although a very important
piece to the puzzle in your job search, a résumé is
not the only ammunition. What’s between your
ears is what will ultimately lead you to your next
career” (p. 28). Box 12-1 summarizes reasons for
preparing a well-considered, up-to-date résumé.
Although you might labor intensively over pre-
paring your résumé, most job applications live or
die within 10–30 seconds as the receptionist or
applications examiner decides whether your résumé
should be forwarded to the next step or rejected. In
many places, nonnursing personnel first screen your
résumé. Some beginning helpful tips include the
following (Ervin, Bickes, & Schim, 2006).
■ Keep the résumé to one or two pages. Do not
use smaller fonts to cram more information on
the page. Proofread, proofread, proofread.
Typing errors, misspelled words, and poor
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210 unit 4 ■ Professional Issues
grammar act as red flags. Use action verbs
when possible. Do not substitute quantity of
words for quality.
■ Itemize your educational experiences on your
résumé. Also include any certifications you
may have. As a new graduate, it may be helpful
to highlight specific clinical experiences as
they relate to the position you wish to obtain.
■ State your objective. Although you know very
well what position you are seeking, the
individual conducting the initial screening does
not want to take the time to determine this.
Tailor your résumé to the institution and
position to which you are applying.
■ Employers care about what you can do for
them and your potential for future success with
their company. Your résumé must answer those
questions.
Essentials of a Résumé
Most résumés follow one of four formats: standard,
chronological, functional, or a combination. There
are several Web sites on resume writing. Many of
these offer free templates to assist you with this
skill. Regardless of the type of résumé, basic ele-
ments of personal information, education, work
experience, qualifications for the position, and ref-
erences should be included (Marino, 2000; Zedlitz,
2003):
■ Standard. The standard résumé is organized
by categories. By clearly stating your personal
information, job objective, work experience,
education and work skills, memberships,
honors, and special skills, you give the
employer a “snapshot” of the person requesting
entrance into the workforce. This is a useful
résumé for first-time employees or recent
graduates.
■ Chronological. The chronological résumé lists
work experiences in order of time, with the
most recent experience listed first. This style is
useful in showing stable employment without
gaps or many job changes. The objective and
qualifications are listed at the top.
■ Functional. The functional résumé also lists
work experience but in order of importance to
your job objective. List the most important
work-related experience first. This is a useful
format when you have gaps in employment or
lack direct experience related to your objective.
■ Combination. The combination résumé is a
popular format, listing work experience directly
related to the position but in a chronological
order.
Most professional recruiters and placement services
agree on the following tips in preparing a résumé
(Korkki, 2010):
■ Make sure your résumé is readable. Is the type
large enough for easy reading? Are paragraphs
indented or bullets used to set off information,
or does the entire page look like a gray blur?
Using bold headings and appropriate spacing
can offer relief from lines of gray type, but be
careful not to get so carried away with graphics
that your résumé becomes a new art form. The
latest trends in résumé writing are using fonts
such as Arial or Century New Gothic over the
standard Times New Roman ( James, 2003).
The paper should be an appropriate color such
as cream, white, or off-white. Use easily
readable fonts and a laser printer. If a good
computer and printer are not available, most
printing services prepare résumés at a
reasonable cost. Résumés may also be sent
electronically. Some organizations require
applicants to upload their resumes into their
application system. Another way is to attach a
resume to an introductory e-mail. It is often
recommended that you convert your resume to
a portable document format (PDF). This
format is readable by most systems and also
allows for greater protection, as word
processing documents (Microsoft Word,
WordPerfect) are easily altered.
Assists in completing an employment application quickly
and accurately
Demonstrates your potential
Focuses on your strongest points
Gives you credit for all your achievements
Identifies you as organized, prepared, and serious about
the job search
Serves as a reminder and adds to your self-confidence
during the interview
Provides initial introduction to potential employers in
seeking the interview
Serves as a guide for the interviewer
Functions as a tool to distribute to others who are willing
to assist you in a job search
box 12-1
Reasons for Preparing a Résumé
Adapted from Marino, K. (2000). Resumes for the health care
professional. New York: John Wiley & Sons; and Zedlitz, R. (2003).
How to get a job in health care. New York: Delmar Learning.
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chapter 12 ■ Your Nursing Career 211
■ Make sure the important facts are easy to spot.
Education, current employment,
responsibilities, and facts to support the
experience you have gained from previous
positions are important. Put the strongest
statements at the beginning. Avoid excessive
use of the word “I.” If you are a new nursing
graduate and have little or no job experience,
list your educational background first.
Remember that positions you held before you
entered nursing might support experience that
will be relevant in your nursing career. Be sure
to let your prospective employer know how to
contact you.
■ Do a spelling and grammar check. Use simple
terms, action verbs, and descriptive words.
Check your finished résumé for spelling, style,
and grammar errors. If you are not sure if the
grammar or style is correct, get another opinion.
■ Follow the do nots. Do not include pictures, fancy
binders, salary information, or hobbies (unless
they have contributed to your work experience).
Do not include personal information such as
weight, marital status, and number of children.
Do not repeat information just to make the
résumé longer. A good résumé is concise and
focuses on your strengths and accomplishments.
No matter which format you use, it is essential to
include the following:
■ A clearly stated job objective
■ Highlighted qualifications
■ Directly relevant skills and experience
■ Chronological work history
■ Relevant education and training
How to Begin
Start by writing down every applicable point you
can think of in the preceding five categories. Work
history is usually the easiest place to begin. Arrange
your work history in reverse chronological order,
listing your current job first. Account for all your
employable years. Short lapses in employment are
acceptable, but give a brief explanation for longer
periods (e.g., “maternity leave”). Include employer,
dates worked (years only, e.g., 2001–2002), city, and
state for each employer you list. Briefly describe the
duties and responsibilities of each position. Empha-
size your accomplishments, any special techniques
you learned, or changes you implemented. Use
action verbs, such as those listed in Table 12-1, to
describe your accomplishments. Also cite any
special awards or committee chairs. If a previous
position was not in the health field, try to relate
your duties and accomplishments to the position
you are seeking.
Education
Next, focus on your education. Include the name
and location of every educational institution you
attended; the dates you attended; and the degree,
diploma, or certification attained. Start with your
most recent degree. It is not necessary to include
your license number because you will give a copy of
the license when you begin employment. If you are
table 12-1
Action Verbs
Management Skills Communication Skills Accomplishments Helping Skills
Attained Collaborated Achieved Assessed
Developed Convinced Adapted Assisted
Improved Developed Coordinated Clarified
Increased Enlisted Developed Demonstrated
Organized Formulated Expanded Diagnosed
Planned Negotiated Facilitated Expedited
Recommended Promoted Implemented Facilitated
Strengthened Reconciled Improved Motivated
Supervised Recruited Instructed Represented
Reduced (losses)
Resolved
(problems)
Restored
Source: Adapted from Parker, Y. (1989). The Damn Good Résumé Guide. Berkeley, CA: Ten Speed Press.
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212 unit 4 ■ Professional Issues
still waiting to take the National Council Licensure
Examination (NCLEX), you need to indicate when
you are scheduled for the examination. If you are
seeking additional training, such as for intravenous
certification, include only what is relevant to your
job objective.
Your Objective
It is now time to write your job objective. Write a
clear, brief job objective. To accomplish this, ask
yourself: What do I want to do? For or with whom?
When? At what level of responsibility? For example
(Parker, 1989; Hart, 2006):
■ What: RN
■ For whom: Pediatric patients
■ Where: Large metropolitan hospital
■ At what level: Staff
A new graduate’s objective might read: “Position as
staff nurse on a pediatric unit” or “Graduate nurse
position on a pediatric unit.” Do not include phrases
such as “advancing to neonatal intensive care unit.”
Employers are trying to fill current openings and
do not want to be considered a stepping stone in
your career.
Skills and Experience
Relevant skills and experience are included in your
résumé not to describe your past but to present a
“word picture of you in your proposed new job,
created out of the best of your past experience”
(Parker, 1989, p. 13; Impollonia, 2004). Begin by
jotting down the major skills required for the posi-
tion you are seeking. Include five or six major skills
such as:
■ Administration/management
■ Teamwork/problem solving
■ Patient relations
■ Specialty proficiency
■ Technical skills
Other
Academic honors, publications, research, and mem-
bership in professional organizations may be
included. Were you active in your school’s student
nurses association, or in a church or community
organization? Were you on the dean’s list? What if
you were “just a housewife” for many years? First,
do an attitude adjustment: you were not “just a
housewife” but a family manager. Explore your role
in work-related terms such as community volunteer,
personal relations, fund-raising, counseling, or teach-
ing. A college career office, women’s center, or pro-
fessional résumé service can offer you assistance
with analyzing the skills and talents you shared
with your family and community. A student who
lacks work experience has options as well. Exam-
ples of nonwork experiences that show marketable
skills include (Eubanks, 1991; Parker, 1989):
■ Working on the school paper or yearbook
■ Serving in the student government
■ Leadership positions in clubs, bands, or church
activities
■ Community volunteer
■ Coaching sports or tutoring children in
academic areas
After you have jotted down everything relevant
about yourself, develop the highlights of your quali-
fications. This area could also be called the Summary
of Qualif ications, or just Summary. The highlights
should be immodest one-liners designed to let your
prospective employer know that you are qualified
and talented and the best choice for the position.
A typical group of highlights might include (Parker,
1989):
■ Relevant experience
■ Formal training and credentials, if relevant
■ Significant accomplishments, very briefly
stated
■ One or two outstanding skills or abilities
■ A reference to your values, commitment, or
philosophy, if appropriate
A new graduate’s highlights could read:
■ Five years of experience as a licensed practical
nurse in a large nursing home
■ Excellent patient/family relationship skills
■ Experience with chronic psychiatric patients
■ Strong teamwork and communication skills
■ Special certification in rehabilitation and
reambulation strategies
Tailor the résumé to the job you are seeking. Include
only relevant information, such as internships,
summer jobs, inter-semester experiences, and vol-
unteer work. Even if your previous work experience
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chapter 12 ■ Your Nursing Career 213
is not directly related to nursing, it can show trans-
ferable skills, motivation, and your potential to be
a great employee.
Regardless of how wonderful you sound on
paper, if the résumé itself is not high quality, it may
end up in a trash can. Also let your prospective
employer know whether you wish to have a response
on an answering machine or fax.
Job Search Letters
The most common job search letters are the cover
letter, thank-you letter, and acceptance letter. Job
search letters should be linked to your SWOT
analysis. Regardless of their specific purpose, letters
should follow basic writing principles (Banis, 1994):
■ State the purpose of your letter.
■ State the most important items first, and
support them with facts.
■ Keep the letter organized.
■ Group similar items together in a paragraph,
and then organize the paragraphs to flow
logically.
Business letters are formal, but they can also be
personal and warm but professional.
■ Avoid sending an identical form letter to
everyone. Instead, personalize each letter to fit
each individual situation.
■ As you write the letter, keep it work-centered
and employment-centered, not self-centered.
■ Be direct and brief. Keep your letter to one
page.
■ Use the active voice and action verbs and have
a positive, optimistic tone.
■ If possible, address your letters to a specific
individual, using the correct title and business
address. Letters addressed to “To Whom It
May Concern” do not indicate much research
or interest in your prospective employer.
■ A timely (rapid) response demonstrates your
knowledge of how to do business.
■ Be honest. Use specific examples and evidence
from your experience to support your claims.
Cover Letter
You have spent time carefully preparing the résumé
that best sells you to your prospective employer.
The cover letter will be your introduction. If it is
true that first impressions are lasting ones, the cover
letter will have a significant impact on your pro-
spective employer. The purposes of the cover letter
include (Beatty, 1989):
■ Acting as a transmittal letter for your résumé
■ Presenting you and your credentials to the
prospective employer
■ Generating interest in interviewing you
Regardless of whether your cover letter will be read
first by human resources personnel or by the indi-
vidual nurse manager, its effectiveness cannot be
overemphasized. A poor cover letter can eliminate
you from the selection process before you even have
an opportunity to compete. A sloppy, disorganized
cover letter and résumé may suggest you are sloppy
and disorganized at work. A lengthy, wordy cover
letter may suggest a verbose, unfocused individual
(Beatty, 1991). Your cover letter should do the fol-
lowing (Anderson, 1992):
■ State your purpose in applying and your
interest in a specific position. Also identify
how you learned about the position.
■ Emphasize your strongest qualifications that
match the requirements for the position.
Provide evidence of experience and
accomplishments that relate to the available
position, and refer to your enclosed résumé.
■ Sell yourself. Convince this employer that you
have the qualifications and motivation to
perform in this position.
■ Express appreciation to the reader for
consideration.
If possible, address your cover letter to a specific
person. If you do not have a name, call the health-
care facility and obtain the name of the human
resources supervisor. If you still can’t get a name,
create a greeting that includes the word mana-
ger: for example, Dear Human Resources Mana-
ger or Dear Personnel Manager (Zedlitz, 2003,
p. 19).
Thank-You Letter
Thank-you letters are important but seldom used
tools in a job search. You should send a thank-you
letter to everyone who has helped in any way in
your job search. As stated earlier, promptness is
important. Thank-you letters should be sent within
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214 unit 4 ■ Professional Issues
24 hours to anyone who has interviewed you. The
letter (Banis, 1994, p. 4) should:
■ Express appreciation
■ Reemphasize your qualifications and the
match between your qualifications and the
available position
■ Restate your interest in the position
■ Provide any supplemental information not
previously stated
Acceptance Letter
Write an acceptance letter to accept an offered
position; confirm the terms of employment, such as
salary and starting date; and reiterate the employer’s
decision to hire you. The acceptance letter often
follows a telephone conversation in which the
terms of employment are discussed.
Rejection Letter
Although not as common as the first three job
search letters, you should send a rejection letter if
you are declining an employment offer. When
rejecting an employment offer, indicate that you
have given the offer careful consideration but have
decided that the position does not fit your career
objectives and interests at this time. As with your
other letters, thank the employer for his or her
consideration and offer.
Using the Internet
Performing Internet searches for positions offers
greater opportunities and the ability to see what
types of jobs are available. Numerous sites either
post positions or assist potential employees in
matching their skills with available employment.
More and more corporations are using the Inter-
net to reach wider audiences. If you use the Inter-
net in your search, it is always wise to follow up
with a hard copy of your résumé if an address is
listed. Mention in your cover letter that you sent
your résumé via the Internet and the date you did
so. If you are using an Internet-based service, follow
up with an e-mail to ensure that your résumé was
received. Table 12-2 summarizes the major “do’s
and don’ts” when using the Internet to job search.
The Interview Process
Initial Interview
Your first interview may be with the nurse manager,
someone in the human resources office, or an inter-
viewer at a job fair or even over the telephone.
Regardless of with whom or where you interview,
preparation is the key to success.
You began the first step in the preparation
process with your SWOT analysis. If you did not
obtain any of the following information regard-
table 12-2
Do’s and Don’ts of Internet Job Searching
Do Don’t
Focus on selling yourself: “My clinical practicum in the ICU at a
major health center and my strong organizational skills fit with
the entry-level ICU position posted in Nursing Spectrum.”
Use many “I”s in the message: “I saw your job posting in
Nursing Spectrum, and I have attached my résumé.”
Use short paragraphs; keep the message short. Long messages probably will not even be read.
Use highlighting and bullets. Forget to format for e-mail.
Use an appropriate e-mail address: DKWhitehead431@. . .. Use a silly or inappropriate e-mail: smartypants@. . . or
partyanimal@. . .
Use an effective subject: ICU RN position. Use subjects used by computer viruses or junk e-mailers:
Hi, Important, Information.
Send your message to the correct e-mail address. Assume; if the address is not indicated, call to see what
person/address is appropriate.
Send messages individually. Send a blast message to many recipients; it may be
discarded as junk mail.
Treat e-mail with the same care you treat a traditional business
application.
Slip into informality—remember spelling and grammar
checks.
Keep your résumé “cyber-safe.” Remove your standard contact information and replace it
with your e-mail address.
Change the format of your resume: save your Word document
as an HTML file or an ASCII text file.
Assume that everyone is using the same word processing
program.
Source: Adapted from Job Hunt: The Online Job Search Guide. Retrieved October 1, 2013, from www.job-hunt.org/
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chapter 12 ■ Your Nursing Career 215
ing your prospective employer at that time, it is
imperative that you do it now (Impollonia, 2004):
■ Key people in the organization
■ Number of patients and employees
■ Types of services provided
■ Reputation in the community
■ Recent mergers and acquisitions
■ Other recent news
Much of this information will be available on the
prospective employer’s Web site. Other potential
sources of information are local newspapers and
magazines, either in print or on the publications;
websites.
You also need to review your qualifications for
the position. What does your interviewer want to
know about you? Consider the following:
■ Why should I hire you?
■ What kind of employee will you be?
■ Will you get things done?
■ How much will you cost the company?
■ How long will you stay?
■ What have you not told us about your
weaknesses?
Answering Questions
The interviewer may ask background questions,
professional questions, and personal questions. If
you are especially nervous about interviewing, role-
play your interview with a friend or family member
acting as the interviewer. Have this person help you
evaluate not just what you say but how you say it.
Voice inflection, eye contact, and friendliness are
demonstrations of your enthusiasm for the position
(Costlow, 1999).
Whatever the questions, know your key points
and be able to explain in the interview why the
company will be glad it hired you, say, 4 years
from now. Never criticize your current employer
before you leave. Personal and professional integ-
rity will follow you from position to position. Many
companies count on personal references when
hiring, including those of faculty and administra-
tors from your nursing program. When leaving
positions you held during school or on graduating
from your program, it is wise not to take parting
shots at someone. Doing a professional program
evaluation is fine, but “taking cheap shots” at
faculty or other employees is unacceptable (Costlow,
1999).
Background Questions
Background questions usually relate to information
on your résumé. If you have no nursing experience,
relate your prior school and work experience and
other accomplishments in relevant ways to the
position you are seeking without going through
your entire autobiography with the interviewer. You
may be asked to expand on the information in your
résumé about your formal nursing education. Here
is your opportunity to relate specific courses or
clinical experiences you enjoyed, academic honors
you received, and extracurricular activities or
research projects you pursued. The background
questions are an invitation for employers to get to
know you. Be careful not to appear inconsistent
with this information and what you say later.
Professional Questions
Many recruiters are looking for specifics, especially
those related to skills and knowledge needed in the
position available. They may start with questions
related to your education, career goals, strengths,
weaknesses, nursing philosophy, style, and abilities.
Interviewers often open their questioning with
phrases such as “review,” “tell me,” “explain,” and
“describe,” followed by “How did you do it?” or
“Why did you do it that way?” (Mascolini &
Supnick, 1993). How successful will you be with
these types of questions?
When answering “how would you describe”
questions, it is especially important that you remain
specific. Cite your own experiences, and relate these
behaviors to a demonstrated skill or strength.
Examples of questions in this area include the fol-
lowing (Bischof, 1993):
■ What is your philosophy of nursing? This
question is asked frequently. Your response
should relate to the position you are seeking.
■ What is your greatest weakness? Your
greatest strength? Do not be afraid to present
a weakness, but present it to your best
advantage, making it sound like a desirable
characteristic. Even better, discuss a weakness
that is already apparent, such as lack of nursing
experience, stating that you recognize your lack
of nursing experience but that your own work
or management experience has taught you
skills that will assist you in this position. These
skills might include organization, time
management, team spirit, and communication.
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If you are asked for both strengths and
weaknesses, start with your weaknesses and
end on a positive note with your strengths. Do
not be too modest, but do not exaggerate.
Relate your strengths to the prospective
position. Skills such as interpersonal
relationships, organization, and leadership are
usually broad enough to fit most positions.
■ Where do you see yourself in 5 years? Most
interviewers want to gain insight into your
long-term goals as well as some idea whether
you are likely to use this position as a brief
stop on the path to another job. It is helpful
for you to know some of the history regarding
the position. For example, how long have
others usually remained in that job? Your
career planning should be consistent with the
organization’s needs.
■ What are your educational goals? Be honest
and specific. Include both professional
education, such as RN or bachelor of science
in nursing, and continuing education courses.
If you want to pursue further education in
related areas, such as a foreign language or
computers, include this as a goal. Indicate
schools to which you have applied or in which
you are already enrolled.
■ Describe your leadership style. Be prepared to
discuss your style in terms of how effectively
you work with others, and give examples of
how you have implemented your leadership in
the past.
■ What can you contribute to this position?
What unique skill set do you offer? Review
your SWOT analysis as well as the job
description for the position before the
interview. Be specific in relating your
contributions to the position. Emphasize
your accomplishments. Be specific and
convey that, even as a new graduate, you
are unique.
■ What are your salary requirements? You may
be asked about a minimum salary range. Try to
find out the prospective employer’s salary range
before this question comes up. Be honest about
your expectations but make it clear that you
are willing to negotiate.
■ What-if questions. Prospective employers are
increasingly using competency-based interview
questions to determine people’s preparation for
a job. There is often no single correct answer
to these questions. The interviewer may be
assessing your clinical decision-making and
leadership skills. Again, be concise and specific,
aligning your answer with the organizational
philosophy and goals. If you do not know the
answer, tell the interviewer how you would go
about finding the answer. You cannot be
expected to have all the answers before you
begin a job, but you can be expected to know
how to obtain answers once you are in the
position.
Personal Questions
Personal questions deal with your personality
and motivation. Common questions include the
following:
■ How would you describe yourself? This is a
standard question. Most people find it helpful
to think about an answer in advance. You can
repeat some of what you said in your résumé
and cover letter, but do not provide an
in-depth analysis of your personality.
■ How would your peers describe you? Ask
them. Again, be brief, describing several
strengths. Do not discuss your weaknesses
unless you are asked about them.
■ What would make you happy with this
position? Be prepared to discuss your needs
related to your work environment. Do you
enjoy self-direction, flexible hours, and strong
leadership support? Now is the time to cite
specifics related to your ideal work
environment.
■ Describe your ideal work environment. Give
this question some thought before the
interview. Be specific but realistic. If the norm
in your community is two RNs to a floor with
licensed practical nurses and other ancillary
support, do not say that you believe a staff
consisting only of RNs is needed for good
patient care.
■ Describe hobbies, community activities, and
recreation. Again, brevity is important. Many
times this question is used to further observe
the interviewee’s communication and
interpersonal skills.
Never pretend to be someone other than who you
are. If pretending is necessary to obtain the posi-
tion, then the position is not right for you.
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Additional Points About the Interview
Federal, state, and local laws govern employment-
related questions. Questions asked on the job app-
lication and in the interview must be related to the
position advertised. Questions or statements that
may lead to discrimination on the basis of age,
gender, race, color, religion, or ethnicity are illegal.
If you are asked a question that appears to be illegal,
you may wish to take one of several approaches:
■ You may answer the question, realizing that it
is not a job-related question. Make it clear to
the interviewer that you will answer the
question even though you know it is not
job-related.
■ You may refuse to answer. You are within your
rights but may be seen as uncooperative or
confrontational.
■ Examine the intent of the question and relate
it to the job.
Just as important as the verbal exchanges of the
interview are the nonverbal aspects. These include
appearance, handshake, eye contact, posture, and
listening skills.
Appearance
Dress in business attire. For women, a skirted suit,
pants suit, or tailored jacket dress is appropriate.
Men should wear a classic suit, light-colored shirt,
and conservative tie. For both men and women,
gray or navy blue clothing is rarely wrong. Shoes
should be polished, with appropriate heels. Nails
and hair for both men and women should reflect
cleanliness, good grooming, and willingness to
work. The 2-inch red dagger nails worn on prom
night will not support an image of the professional
nurse. In many institutions, even clear, acrylic nails
are not allowed. Paint stains on the hands from a
weekend of house maintenance are equally unsuit-
able for presenting a professional image.
Handshake
Arrive at the interview 10 minutes before your
scheduled time. (Allow yourself extra time to find
the place if you have not previously been there.)
Introduce yourself courteously to the receptionist.
Stand when your name is called, smile, and shake
hands firmly. If you perspire easily, wipe your palms
just before handshake time.
Eye Contact
During the interview, use the interviewer’s title and
last name as you speak. Never use the interviewer’s
first name unless specifically requested to do so. Use
good listening skills (all those leadership skills you
have learned). Smile and nod occasionally, making
frequent eye contact. Do not fold your arms across
your chest, but keep your hands at your sides or
in your lap. Pay attention, and sound sure of
yourself.
Posture and Listening Skills
Phrase your questions appropriately and relate
them to yourself as a candidate: “What would be
my responsibility?” instead of “What are the respon-
sibilities of the job?” Use appropriate grammar and
diction. Words or phrases such as “yeah,” “uh-huh,”
“uh,” “you know,” or “like” are too casual for an
interview.
Do not say “I guess” or “I feel” about anything.
These words make you sound indecisive. Remem-
ber your action verbs—I analyzed, organized,
developed. Do not evaluate your achievements as
mediocre or unimpressive.
Asking Questions
At some point in the interview, you will be asked
if you have any questions. Knowing what questions
you want to ask is just as important as having pre-
pared answers for the interviewer’s questions. The
interview is as much a time for you to learn the
details of the job as it is for your potential employer
to find out about you. You will need to obtain spe-
cific information about the job, including the type
of patients for whom you would care, the people
with whom you would work, the salary and benefits,
and your potential employer’s expectations of you.
Be prepared for the interviewer to say, “Is there
anything else I can tell you about the job?” Jot down
a few questions on an index card before going for
the interview. You may want to ask a few questions
based on your research, demonstrating knowledge
about and interest in the company. In addition, you
may want to ask questions similar to the ones listed
next. Above all, be honest and sincere (Bhasin,
1998; Bischof, 1993; Johnson, 1999).
■ What is this position’s key responsibility?
■ What kind of person are you looking for?
■ What are the challenges of the position?
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218 unit 4 ■ Professional Issues
■ Why is this position open?
■ To whom would I report directly?
■ Why did the previous person leave this
position?
■ What is the salary for this position?
■ What are the opportunities for advancement?
■ What kind of opportunities are there for
continuing education?
■ What are your expectations of me as an
employee?
■ How, when, and by whom are evaluations
done?
■ What other opportunities for professional
growth are available here?
■ How are promotion and advancement handled
within the organization?
The following are a few additional tips about asking
questions during a job interview:
■ Do not begin with questions about vacations,
benefits, or sick time. This gives the impression
that these are the most important part of the
job to you, rather than the work itself.
■ Do begin with questions about the employer’s
expectations of you. This gives the impression
that you want to know how you can contribute
to the organization.
■ Do be sure you know enough about the
position to make a reasonable decision about
accepting an offer if one is made.
■ Do ask questions about the organization as a
whole. The information is useful to you and
demonstrates that you are able to see the big
picture.
■ Do bring a list of important points to discuss
as an aid to you if you are nervous.
During the interview process, there are a few red
flags to be alert for (Tyler, 1990):
■ Much turnover in the position
■ A newly created position without a clear
purpose
■ An organization in transition
■ A position that is not feasible for a new
graduate
■ A “gut feeling” that things are not what they
seem
The exchange of information between you and the
interviewer will go more smoothly if you review
Box 12-2 before the interview.
After the Interview
If the interviewer does not offer the information,
ask about the next step in the process. Thank the
interviewer, shake hands, and exit. If the reception-
ist is still there, you may quickly smile and say thank
you and good-bye. Do not linger and chat, and do
not forget to send your thank-you letter.
Adapted from Bischof, J. (1993). Preparing for job interview questions. Critical Care Nurse, 13(4), 97–100; Krannich, C., & Krannich, R. (1993).
Interview for success. New York: Impact Publications; Mascolini, M., & Supnick, R. (1993). Preparing students for the behavioral job interview.
Journal of Business and Technical Communication, 7(4), 482–488; and Zedlitz, R. (2003). How to get a job in health care. New York: Delmar
Learning.
Do:
Shake the interviewer’s hand firmly, and introduce yourself.
Know the interviewer’s name in advance, and use it in
conversation.
Remain standing until invited to sit.
Use eye contact.
Let the interviewer take the lead in the conversation.
Talk in specific terms, relating everything to the position.
Support responses in terms of personal experience and
specific examples.
Make connections for the interviewer. Relate your responses
to the needs of the individual organization.
Show interest in the facility.
Ask questions about the position and the facility.
Come across as sincere in your goals and committed to
the profession.
Indicate a willingness to start at the bottom.
Take any examinations requested.
Express your appreciation for the time.
Do Not:
Place your purse, briefcase, papers, etc., on the
interviewer’s desk. Keep them in your lap or on the floor.
Slouch in the chair.
Play with your clothing, jewelry, or hair.
Chew gum or smoke, even if the interviewer does.
Be evasive, interrupt, brag, or mumble.
Gossip about or criticize former agencies, schools, or
employees.
box 12-2
Do’s and Don’ts for Interviewing
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The Second Interview
Being invited for a second interview means that the
first interview went well and that you made a favor-
able impression. Second visits may include a tour
of the facility and meetings with a higher-level
executive or a supervisor in the department in
which the job opening exists and perhaps several
colleagues. In preparation for the second interview,
review the information about the organization
and your own strengths. It does not hurt to have
a few résumés and potential references available.
Pointers to make your second visit successful
include the following (Knight, 2005; Muha &
Orgiefsky, 1994):
■ Dress professionally. Do not wear “trendy”
outfits, sandals, or open-toed shoes. Minimize
jewelry and makeup.
■ Be professional and pleasant with everyone,
including administrative assistants and
housekeeping and maintenance personnel.
■ Do not smoke.
■ Remember your manners.
■ Avoid controversial topics for small talk.
■ Obtain answers to questions you might have
considered since your first visit.
In most instances, the personnel director or nurse
manager will let you know how long it will be
before you are contacted again. It is appropriate to
ask for this information before you leave the second
interview. If you do receive an offer during this visit,
graciously say “thank you” and ask for a little time
to consider the offer (even if this is the offer you
have anxiously been awaiting).
If the organization does not contact you by the
expected date, do not panic. It is appropriate to call
your contact person, state your continued interest,
and tactfully express the need to know the status of
your application so that you can respond to other
deadlines.
Making the Right Choice
You have interviewed well, and now you have to
decide among several job offers. Your choice will
not only affect your immediate work but also influ-
ence your future career opportunities. The nursing
shortage has led to greatly enhanced workplace
enrichment programs and nurse residencies as a
recruitment and retention strategy. Career ladders,
shared governance, participatory management, staff
nurse presence on major hospital committees,
decentralization of operations, and a focus on
quality interpersonal relationships are among some
of these features. Be sure to inquire about the com-
ponents of the professional practice environment
( Joel, 2003). There are several additional factors to
consider.
Job Content
The immediate work you will be doing should be
a good match with your skills and interests.
Although your work may be personally challenging
and satisfying this year, what are the opportunities
for growth? How will your desire for continued
growth and challenge be satisfied?
Development
You should have learned from your interviews
whether your initial training and orientation seem
sufficient. Inquire about continuing education to
keep you current in your field. Is tuition reimburse-
ment available for further education? Is manage-
ment training provided, or are supervisory skills
learned on the job?
Direction
Good supervision and mentors are especially
important in your first position. You may be able to
judge prospective supervisors throughout the inter-
view process, but you should also try to get a broader
view of the overall philosophy of supervision. You
may not be working for the same supervisor in a
year, but the overall management philosophy is
likely to remain consistent.
Work Climate
The daily work climate must make you feel com-
fortable. Your preference may be formal or casual,
structured or unstructured, complex or simple. It is
easy to observe the way people dress, the layout of
the unit, and lines of communication. It is more
difficult to observe company values, factors that will
affect your work comfort and satisfaction over the
long term. Try to look beyond the work environ-
ment to get an idea of values. What is the unwritten
message? Is there an open-door policy sending a
message that “everyone is equal and important,” or
does the nurse manager appear too busy to be con-
cerned with the needs of the employees? Is your
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220 unit 4 ■ Professional Issues
supervisor the kind of person for whom you could
work easily?
Compensation
In evaluating the compensation package, starting
salary should be less important than the organiza-
tion’s philosophy on future compensation. What
is the potential for salary growth? How are in-
dividual increases determined? Can you live on
the wages being offered? Also review the organi-
zation’s package regarding retirement and health
insurance.
I Cannot Find a Job (or I Moved)
It is often said that finding the first job is the
hardest. Many employers prefer to hire seasoned
nurses who do not require a long orientation and
mentoring, particularly in specialty areas. Some
require new graduates to do postgraduate intern-
ships. Changes in skill mix with the implementa-
tion of various types of care delivery influence the
market for the professional nurse. The new gradu-
ate may need to be armed with a variety of skills,
such as intravenous certification, home assessment,
advanced rehabilitation skills, and various respira-
tory modalities, to even warrant an initial interview.
Keep informed about the demands of the market
in your area, and be prepared to be flexible in
seeking your first position. Even with the continu-
ing nursing shortage, hiring you as a new graduate
will depend on you selling yourself.
After all this searching and hard work, you still
may not have found the position you want. You may
be focusing on work arrangements or benefits
rather than on the job description. Your lack of
direction may come through in your résumé, cover
letter, and personal presentation. As a new graduate,
you may also have unrealistic expectations or be
trying to cut corners, ignoring the basic rules of
marketing yourself discussed in this chapter. Go
back to your SWOT analysis. Take another look at
your résumé and cover letter. Become more asser-
tive as you start again.
The Critical First Year
Why a section on the “first year”? Working hard is
important; however, some of the behaviors that
were rewarded in school are not rewarded on the
job. There are no syllabi, study questions, or extra-
credit points. Only As are acceptable, and there do
not appear to be many completely correct answers.
Quality is the expectation with little room for error.
Discovering this has been called “reality shock”
(Kramer, 1974). Voluminous concept maps and
meticulous medication cards are out; multiple
responsibilities and thinking on your feet are in.
What is the new graduate to do?
Your first year will be a transition year. You are
no longer a college student. You are a novice nurse.
You are “the new kid on the block,” and people will
respond to you differently and judge you differently
than when you were a student. To be successful, you
have to respond differently. You may be thinking,
“Oh, they always need nurses—it doesn’t matter.”
Yes, it does matter. Many of your career opportuni-
ties will be influenced by the early impressions you
make. The following section addresses what you
can do to help ensure first-year success.
Attitude and Expectations
Adopt the right attitudes, and adjust your expectations.
Now is the time to learn the art of being new. You
felt like the most important, special person during
the recruitment process. Now, in the real world,
neither you nor the position may be as glamorous
as you once thought. In addition, although you
thought you learned much in school, your decisions
and daily performance do not always warrant an A.
Above all, people shed the company manners they
displayed when you were interviewing, and organi-
zational politics eventually surface. Your leadership
skills and commitment to teamwork will get you
through this transition period.
Impressions and Relationships
Manage a good impression, and build effective rela-
tionships. Remember, you are being watched: by
peers, subordinates, and superiors. Because you as
yet have no track record, first impressions are mag-
nified. Although every organization is different,
most are looking for someone with good judgment,
a willingness to learn, a readiness to adapt, and a
respect for the expertise of more experienced
employees. Most people expect you to “pay your
dues” to earn respect from them.
Organizational Savvy
Develop organizational savvy. An important person
in this first year is your immediate supervisor.
Support this person. Find out what is important to
your supervisor and what he or she needs and
expects from the team. Become a team player.
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chapter 12 ■ Your Nursing Career 221
When confronted with an issue, present solutions,
not problems, as often as you can. You want to be
a good leader someday; learn first to be a good fol-
lower. Finding a mentor is another important goal
of your first year. Mentors are role models and
guides who encourage, counsel, teach, and advocate
for their mentee. In these relationships, both the
mentor and mentee receive support and encourage-
ment (Klein & Dickenson-Hazard, 2000).
The spark that ignites a mentoring relationship
may come from either the protégé or the mentor.
Protégés often view mentors as founts of success,
a bastion of life skills they wish to learn and
emulate. Mentors often see the future that is hid-
den in another’s personality and abilities (Klein &
Dickenson-Hazard, 2000, pp. 20–21).
Skills and Knowledge
Master the skills and knowledge of the position. Tech-
nology is constantly changing, and contrary to
popular belief, you did not learn everything in
school. Be prepared to seek out new knowledge and
skills on your own. This may entail extra hours of
preparation and study, but no one ever said learning
stops after graduation. Lifelong learning is key to
being a successful nurse.
Advancing Your Career
Many of the ideas presented in this chapter will
continue to be helpful as you advance in your
nursing career. Continuing to develop your leader-
ship and patient care skills through practice, and
further education will be the keys to your profes-
sional growth. The RN is expected to develop and
provide leadership to other members of the health-
care team while providing safe, effective, and quality
care to patients. According to the Health Resources
and Services Administration (HRSA) (2010), the
number of licensed RNs in the United States
increased to a record high level. This increase
reflects a larger number of younger nurses entering
the workforce along with older experienced nurses.
Getting your first job within this environment due
to the increased demand for nurses may not be so
difficult, but you hold the responsibility for advanc-
ing your career.
Conclusion
Finding your first position is more than being in
the right place at the right time. It is a complex
combination of learning about yourself and the
organizations you are interested in and presenting
your strengths and weaknesses in the most posi-
tive manner possible. Keeping the first position
and using the position to grow and learn are also
part of a planning process. Recognize that the inde-
pendence you enjoyed through college may not be
the skill you need to keep your first position. There
is an important lesson to be learned: becoming a
team player and being savvy about organizational
politics are as important as becoming proficient in
nursing skills. Take the first step toward finding a
mentor—before you know it, you will become one
yourself.
Study Questions
1. Using the SWOT analysis worksheet developed for this chapter, how will you articulate your
strengths and weaknesses during an interview?
2. Design a one- to two-page résumé to use in seeking your first position. Are you able to “sell
yourself ” in one or two pages? If not, what adjustments are you going to make? Develop a cover
letter, thank-you letter, acceptance letter, and rejection letter that you can use during the
interview process.
3. Using the interview preparation worksheet developed for this chapter, formulate responses to
the questions. How comfortable do you feel answering these questions? Share your responses
with other classmates to get additional ideas.
4. Evaluate the job prospects in the community where you now live. What areas could you explore
in seeking your first position?
5. What plans do you have for advancing your career? What plans do you have for finding a
mentor?
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222 unit 4 ■ Professional Issues
Case Study to Promote Critical Reasoning
Paul Delane is interviewing for his first nursing position after obtaining his RN license. He has
been interviewed by the nurse recruiter and is now being interviewed by the nurse manager on the
pediatric floor. After a few minutes of social conversation, the nurse manager begins to ask some
specific nursing-oriented questions: How would you respond if a mother of a seriously ill child
asks you if her child will die? What attempts do you make to understand different cultural beliefs
and their importance in health care when planning nursing care? How does your philosophy of
nursing affect your ability to deliver care to children whose mothers are HIV-positive?
Paul is very flustered by these questions and responds with “it depends on the situation,” “it
depends on the culture,” and “I don’t ever discriminate.”
1. What responses would have been more appropriate in this interview?
2. How could Paul have used these questions to demonstrate his strengths, experiences, and skills?
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chapter 12 ■ Your Nursing Career 223
References
Anderson, J. (1992). Tips on résumé writing. Imprint, 39(1),
30–31.
Arvidsson, B., Skarsater, I., Oijervall, J., & Friglund, B.
(2008). Process-oriented group supervision during
nursing education: Nurses’ conception one year after
their nursing degree. Journal of Nursing Management,
16(7), 868–875.
Banis, W. (1994). The art of writing job-search letters. In
College Placement Council, Inc. (ed.), Planning Job
Choices. Philadelphia: College Placement Council,
44–51.
Beatty, R. (1991). Get the right job in 60 days or less.
New York: John Wiley & Sons.
Beatty, R. (1989). The Perfect cover letter. New York: John
Wiley & Sons.
Bhasin, R. (1998). Do’s and don’ts of job interviews. Pulp &
Paper, 72(2), 37.
Bischof, J. (1993). Preparing for job interview questions.
Critical Care Nurse, 13(4), 97–100.
Cazacu, A. (2010). What are employers looking for in a
candidate? Retrieved on October 1, 2013, from http://
ezinearticles.com/?What-Are-Employers-Looking-For-in
-a-Candidate?&id=4738932
Chestnut, T. (1999). Some tips on taking the fear
out of résumé writing. Phoenix Business Journal,
19(47), 28.
Christie, I. (2012). Analyze your career with a personal
SWOT. Retrieved on October 1, 2013, from http://
career-advice.monster.com
Costlow, T. (1999). How not to create a good first
impression. Fairfield County Business Journal, 38(32),
17.
Ervin, E.E., Bickes, J.T., & Schim, S.M. (2006).
Environments of care: A curriculum model for preparing
a new generation of nurses. Journal of Nursing
Education, 45(2). 75–80.
Eubanks, P. (1991). Experts: Making your résumé an asset.
Hospitals, 5(20), 74.
Goal setting using the SMART acronym (n.d.). Retrieved
October 1, 2013, from health.mo.gov/living/families/
wic/wicupdates/. . ./GoalSetting-SMART
Hart, K. (2006). Student extra: The employment
interview: Tips for success selecting an employer for
the perfect fit. American Journal of Nursing, 106(4),
72AAA–72CCC.
Health Resources and Services Administration. (HRSA).
(2010). HRSA study finds nursing workforce is growing.
Retrieved on October 1, 2013, from www.hrsa.gov/
about/news/pressreleases/2010/100922/
nursingworkforce
Impollonia, M. (2004), How to impress nursing recruiters to
get the job you want. Imprint, March.
Institute of Medicine. (2001). Crossing the quality chasm: A
new health system for the 21st century. National
Academies Press.
Jackson, D., Firtko, A., & Edinborough, M. (2007). Personal
resilience as a strategy for surviving and thriving in the
face of workplace diversity: A literature review. Journal
of Advanced Nursing, 60(1), 1–9.
James, L. (2003). Vitae statistics. Travel Weekly, 1695,
70.
Job Hunt: The online job search guide. Retrieved October
1, 2013, from www.job-hunt.org/
Joel, L. (2003). The role of the workplace in your transition
from student to nurse. Imprint, April.
Johnson, K. (1999). Interview success demands research,
practice, preparation. Houston Business Journal, 30(23),
38.
Klein, E., & Dickenson-Hazard, N. (2000). The spirit of
mentoring. Reflections on Nursing Leadership, 26(3),
18–22.
Kluemper, D.H. (2009) Future employment selection
methods: Evaluating social networking web sites. Journal
of Managerial Psycholog,. 24(6), 567–580.
Knight, K. (2005). New grad? Be prepared to look great.
Imprint, January.
Kramer, M. (1974). Reality shock: Why nurses leave
nursing. St. Louis: C.V. Mosby.
Krannich, C., & Krannich, R. (1993). Interview for success.
New York: Impact Publications.
Korkki, P. (2010). Writing a résumé that shouts ‘Hire Me.’
New York Times. February 27, 2010.
Marino, K. (2000). Resumes for the health care
professional. New York: John Wiley & Sons.
Mascolini, M., & Supnick, R. (1993). Preparing students for
the behavioral job interview. Journal of Business and
Technical Communication, 7(4), 482–488.
Morgan, H. (2013). The 8 new rules of a career survivalist.
U.S. News and World Report, June 26, 2013.
Retrieved October 1, 2013, from http://money
.usnews.com/money/blogs/outside-voices-careers/
2013/06/26/the-8-new-rules-of-a-career-survivalist
Muha, D., & Orgiefsky, R. (1994). The 2nd interview: The
plant or office visit. In College placement council, inc.
(ed.), Planning Job Choices. Philadelphia: College
Placement Council, 58–60.
Parker, Y. (1989). The damn good résumé guide. Berkeley,
CA: Ten Speed Press.
Schoessler, M., & Waldo, M. (2006). The first 18 months
in practice: A development transition model for the
newly graduated nurse. Journal of Nurses in Staff
Development, 22(2), 47–52.
Tyler, L. (1990). Watch out for “red flags” on a job
interview. Hospitals, 64(14), 46–47.
Zedlitz, R. (2003). How to get a job in health care. New
York: Delmar Learning.
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225
chapter 13
Evolution of Nursing as a Profession
OBJECTIVES
After reading this chapter, the student should be able to:
■ Compare and contrast historical and current definitions of
nursing.
■ Summarize the relationship between social change and the
advance of nursing as a profession.
■ Discuss some of the issues faced by the nursing profession.
■ Explain current changes impacting nursing’s future.
OUTLINE
Introduction
Nursing Defined
Early and Modern Nurse Leaders
The 19th and 20th Centuries
Nurse Leaders in the 21st Century
Linda Aiken
Dr. Beverly Malone
Dr. Tim Porter-O’Grady
Political Influences and the Advance of
Nursing as a Profession
Nursing and Health-Care Reform
Nursing Today
Health Care in the Future
Conclusion
Introduction
It is often said that you do not know where you are
going until you know where you have been. Over
40 years ago, Beletz (1974) wrote that most people
thought of nurses in gender-linked, task-oriented
terms: “a female who performs unpleasant technical
jobs and functions as an assistant to the physician”
(p. 432). Interestingly, physicians in the 1800s
viewed nursing as a complement to medicine.
According to Warrington (1839), “. . . the prescrip-
tions of the best physician are useless unless they
be timely and properly administered and attended
to by the nurse” (p. iv).
In its earliest years, most nursing care occurred
at home. Even in 1791 when the first hospital
opened in Philadelphia, nurses continued to care
for patients in their own home settings. It took
almost another century before nursing moved into
hospitals. These institutions, mostly dominated by
male physicians, promoted the idea that nurses
acted as the “handmaidens” to the better educated,
more capable men in the medical field.
The level of care differed greatly in these early
health-care institutions. Those operated by the reli-
gious nursing orders gave high-quality care to
patients. In others, care varied greatly from good to
almost none at all. Although the image of nurses
and nursing has advanced considerably since then,
some still think of nurses as helpers who carry out
the physician’s orders.
Throughout its history, the nursing profession
provided many great leaders who participated in
social change and health-care reform. These nurse
leaders initiated change within the social environ-
ment of the time, using the strategies of change and
conflict resolution discussed earlier in the text.
It comes as no surprise that nursing and health
care have converged and reached a crossing point.
Nurses face a new age for human experience; the
very foundations of health practices and therapeu-
tic interventions continue to be dramatically altered
by significantly transformed scientific, technologi-
cal, cultural, political, and social realities (Porter-
O’Grady, 2003). The global environment needs
nurses more than ever to meet the health-care
needs of all. This chapter discusses nurse leaders of
the past and present and how nursing itself has
changed. Chapter 14 discusses changes to the
overall health-care system and their implications
for nurses.
Nursing Defined
The changes that have occurred in nursing are
reflected in the definitions of nursing that have
developed over time. In 1859, Florence Nightingale
defined the goal of nursing as putting the client “in
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226 unit 4 ■ Professional Issues
the best possible condition for nature to act upon
him” (Nightingale, 1859, p. 79). In 1966, Virginia
Henderson focused her definition on the unique-
ness of nursing:
The unique function of the nurse is to assist the
individual, sick or well, in the performance of those
activities contributing to health or its recovery (or
to peaceful death) that he would perform unaided if
he had the necessary strength, will or knowledge.
And to do this in such a way as to help him gain
independence as rapidly as possible (Henderson,
1966, p. 21).
Martha Rogers defined nursing practice as “the
process by which this body of knowledge, nursing
science, is used for the purpose of assisting human
beings to achieve maximum health within the
potential of each person” (Rogers, 1988, p. 100).
Rogers emphasized that nursing is concerned with
all people, only some of whom are ill.
In the modern nursing era, nurses are viewed as
collaborative members of the health-care team.
Nursing has emerged as a strong field of its own in
which nurses have a wide range of obligations,
responsibilities, and accountability. Recent polls
show that nurses are considered the most trusted
group of professionals because of their knowl-
edge, expertise, and ability to care for diverse
populations.
Early and Modern Nurse Leaders
The 19th and 20th Centuries
Florence Nightingale, immortalized by Henry Wads-
worth Longfellow in his poem The Lady with the
Lamp (Longfellow, 1868), remains the best known
of the historic nursing leaders and is considered the
founder of modern nursing. Nightingale brought
about changes in the care of soldiers, the keeping
of hospital records, the status of nurses, and even
the profession itself. On her return home after the
Crimean War she had two goals: to reform military
health care and to establish an official training
school for nurses. The British public contributed
more than $220,000 (a great sum of money at that
time) to the Nightingale Fund for the purpose of
establishing the school.
Nightingale’s concepts of nursing care became
the basis of modern theory development and, in
today’s language, used evidence-based practice to
promote nursing. Her book Notes on Nursing:
What It Is and What It Is Not laid the founda-
tion for modern nursing education and practice.
Many nursing theorists have used Nightingale’s
thoughts as a basis for constructing their view of
nursing.
Nightingale believed that schools of nursing
must be independent institutions and that women
who were selected to attend the schools should be
from the higher levels of society. Many of Night-
ingale’s beliefs about nursing education are still
applicable, particularly those involved with the
progress of students, the use of diaries kept by stu-
dents, and the need for integrating theory into
clinical practice (Roberts, 1937).
The Nightingale school served as a model for
nursing education. Its graduates were sought world-
wide. Many of them established schools and became
matrons (superintendents) in hospitals in other
parts of England, the British Commonwealth, and
the United States. However, very few schools were
able to remain financially independent of the hos-
pitals and thus lost much of their autonomy. This
was in contradiction to Nightingale’s philosophy
that the training schools were educational institu-
tions, not part of any service agency.
Other well-known nurse leaders include the fol-
lowing people:
Lillian Wald, who founded the Henry Street
Settlement, provided a role model for contempo-
rary community health nursing. She developed a
system for bringing health care back to people
within their homes, schools, and neighborhoods.
She focused on health teaching and health promo-
tion for families, particularly women and children.
Wald and her colleagues brought basic nursing
care to the people in their home environment.
These nurses were independent practitioners who
made their own decisions and followed up on their
own assessments of families’ needs. Like Nightin-
gale, they were very aware of the effect of the envi-
ronment on the health of their clients and worked
hard to improve their clients’ surroundings.
Wald was convinced that many illnesses resulted
from causes outside individual control and that
treatment needed to be holistic. She said she chose
the title public health nurse to emphasize the value
of the nurse whose work was built on an under-
standing of the social and economic problems that
inevitably accompanied the clients’ ills (Bueheler-
Wilkerson, 1993). The success of the nurses of the
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chapter 13 ■ Evolution of Nursing as a Profession 227
Henry Street Settlement laid the groundwork for
school nurses placed in the New York City school
system (www.henrystreet.org/about/history/).
Margaret Sanger, a political activist like many of
the others, is best known for her courageous fight
to make birth control information available to
everyone who needed or wanted it. She had a tre-
mendous impact on contemporary society. Through
enabling women to control their fertility and giving
them access to contraception, as advocated by
Sanger, it is possible for women to have a broader
set of life options, particularly in the areas of educa-
tion and employment (Malveaux, 2013).
Sanger was very concerned about the working
conditions faced by people living in poverty. Her
fight to make Congress aware of the plight of chil-
dren in the labor force is less well known but led
to important changes in the child labor laws. A
major strike of industrial workers in Lawrence,
Massachusetts, marked the beginning