3 Leadership vs Management

Nicole Simonson

Learning Objectives

  • Identify key strategies for leadership in nursing practice

  • Identify key strategies for management in nursing practice

  • Distinguish between leadership and management

  • Discuss the benefits of mentoring and precepting

  • Examine interprofessional collaboration strategies within leadership

 

“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”  Margaret Mead

Decision-Making

As a nurse, you are already familiar with aspects of decision-making. You engage in decision-making within daily practice through the use of critical thinking and clinical judgment. As a baccalaureate-prepared nurse, the level of decision-making deepens. Decision-making involves not only identifying a problem but also mapping out several complex pieces within the problem. The map might be straightforward, but it often consists of multiple options leading in multiple directions.  Even though different decisions might be made, the plan to solve the problem may lead to similar outcomes or dead ends. Carefully mapping out a problem and utilizing critical thinking, clinical judgment, and problem-solving can help navigate the nurse through the best possible path for that given situation. Decision-making not only consists of finding a solution but also identifying the root of the problem. The nurse utilizes the nursing process to explore all possibilities that may have contributed to the problem and to strategize to prevent it from reoccurring. An example might be doing a post-fall huddle on an inpatient unit (i.e., after addressing the needs of the patient and ensuring the patient is safe, the team comes together to discuss ways to prevent the patient’s fall in the future along with identifying what went well and could be improved).

There are several ways for a nurse to strengthen their decision-making skills through the following activities: case studies, simulation, and problem-based learning. The Marquis-Huston Model for Teaching Critical Thinking facilitates effective decision-making skills among nurse leaders (Marquis & Huston, 2021). The model discusses four categories that are necessary for nurses to elevate their decision-making skills to those of leadership and management. The four categories include didactic theory, personalized learning, problem-solving, and group process. Each of these categories can be easily translated to your leadership and management course within the RN to BSN completion program.

Marquis-Huston Model for Teaching Critical Thinking

Create an environment that stimulates authentic learning where the learner can practice real-life situations

Didactic Theory

Presentation of material and content for learning

Personalized Learning

Tailor teaching and learning to the individual needs of the learner

Problem-Solving

Ability to critically think in order to determine the solution or best action to a problem

Group Process

Consists of a team of individuals coming together to work on the problem

There are many more theoretical models that guide nurse leaders in the decision-making process, all of which fundamentally contain the nursing process.

Nursing Process

Decision-Making Process

Assess

Assess the situation

Gather the data

Diagnose

Determine the problem

Plan

Develop a plan and possible alternative plans

Implement

Choose a plan and implement the plan

Evaluate

Evaluate the steps within the process and determine whether this plan was successful

Decision-making occurs in several aspects of nursing practice. While determining an action, one must consider the ethical aspects, the role of communication, whether it warrants delegation or supervision, and what type of leadership is involved. Each of these pieces will be discussed in greater detail.

Ethical Considerations

Nurses are positioned to promote a culture and environment that embodies healthy, positive, ethically moral, and holistic behaviors among others in the healthcare arena. It is not only pivotal that nurses identify behaviors that are concerning but role model behaviors that are acceptable in practice. By evaluating ethical considerations within practice, the nurse is engaging in authentic leadership. Authentic nurse leaders are able to self-assess, identify who they are as a nurse and person, and remain true to their values and beliefs in practice (Giordano-Mulligan & Eckardt, 2019). To remain ethically sound, the nurse must possess characteristics of trust, satisfaction, organizational commitment, performance, and a sense of community with fellow team members. Nurses not only role model ethical standards but also are able to discuss these standards with their peers and fellow healthcare professionals. 

By emulating authentic leadership, nurses are seen as positive role models, honest, and actively engaged (Giordano-Mulligan & Eckardt, 2019). Remaining true authentically and upholding ethics is important, but it is also essential to educate others on these attributes. As a nurse leader, it is your role to prepare your team for potential ethical situations and how they might respond or handle these situations.

Role of Communication

Communication is essential in every aspect of nursing. Ineffective communication contributes to medical errors, decreased patient outcomes, and increased patient harm and deaths (Boerner, 2016; Starmer et al., 2014). Additionally, ineffective handoff communication leads to 80% of patient adverse events (The Joint Commission International, 2018). Nurses need to learn the tools to communicate effectively and how to demonstrate these tools in practice. These tools are used in every method of communicating: verbal and nonverbal, face-to-face, written, telephone, etc. Nurses communicate with many different people, including members of the healthcare team and patients and their family members. The delivery of communication is as important as the information that is being relayed. The delivery plays a pivotal role in establishing a rapport with others.

Delegation vs. Supervision

Nurses make use of both delegation and supervision regularly in practice. As a practicing nurse, you are more than likely familiar with both skills. Do you feel comfortable and competent when delegating to and supervising others? Do you feel ready to delegate to peers and be a nurse leader? If not, it is okay. Let’s elevate your delegation and supervision skills.

Delegation can be defined in various ways. The American Nurses Association (2012) states that delegation involves assigning tasks to others while holding accountability for the outcome. Ultimately, you are still responsible for what happens. The five rights of delegation must be considered when assigning a task: right task, right circumstance, right person, right direction/communication, and right level of supervision. Nurse leaders may also delegate to those they lead, whether in the capacity of charge nurse, supervisor, manager, or another role. Delegating allows the nurse leader to address more complex and higher-level tasks within the scope of the job. For instance, a nurse leader may delegate post-fall chart audits to a nurse who is experienced with post-fall investigations.

Supervision involves observing and watching others while they are performing tasks. This may occur to determine the individual’s level of comprehension and competency, such as during orientation, skills check-off, and rollout of new practices. Supervision may be required when there are concerns over one’s ability to carry out certain aspects of their role.

Leadership vs. Followership

Nurses can be seen both as leaders and followers. There is a time and place for both. As a nurse leader, there may be times when it is important to follow the lead of others. Examples of following the lead include following higher-up leadership, modeling the way with new initiatives, and allowing others the opportunity to lead. Even a nurse leader can model what it means to follow versus lead. Both roles are equally important in order to ensure safety and quality outcomes.

Roxanne has been inspired by her continuing education for her RN to BSN and wants to engage further in a leadership capacity. A position for shift supervisor opens up, and Roxanne is well prepared to fill the role. She is able to put several of her new learnings into practice.

 At the start of Roxanne’s shift, Mr. Carpenter is found down in his bathroom. The staff assesses Mr. Carpenter per the fall policy and assists in getting him up and back into bed. After Mr. Carpenter is settled, the call light is in place, and the proper safety precautions are employed, Roxanne leads a post-fall huddle with the team. The team discusses what has happened with Mr. Carpenter, what his fall risk score was, whether fall precautions were followed, and what could have gone better or been done differently.Steps to cover a post fall huddle

During the post-fall huddle, blame is not placed on any one individual. Roxanne takes this as an opportunity to learn. Normally, Mr. Carpenter gets up with stand-by assistance and his wheeled walker. Before the incident, Cameron, the CNA, had assisted Mr. Carpenter to the bathroom and provided him with the call light to notify staff when he was done. Cameron had left the room to continue with his other work. When Mr. Carpenter was finished, he didn’t want to bother Cameron, so he got up rather quickly by himself and began to feel lightheaded. This was new for Mr. Carpenter; he lost his balance and lowered himself to the floor and pulled the call light. Fortunately, Mr. Carpenter was not injured. The team obtained his vital signs and blood glucose. The team found that Mr. Carpenter’s blood pressure was lower than normal and may have contributed to his feeling lightheaded and off-balance. Roxanne prompted the primary nurse to investigate the reasons that this may have occurred and to notify the physician about the fall per policy. The team also decided it would be important to supervise Mr. Carpenter whenever he was ambulating or in the bathroom until it was determined why he experienced these symptoms. Roxanne wrote up the incident, what had occurred, and provided the information to her manager.

Informal Leadership

Leadership can take on many different forms. It can be in formal roles such as charge nurse, nurse manager, director of nursing, etc. It can also take on informal roles; all nurses possess some level of leadership. The amount of leadership a nurse exhibits can be based on several factors such as degree, experience, and intrinsic and extrinsic motivators. The ANA’s Nursing: Scope and Standards of Practice (2021) outlines in Standard 12 that leadership consists of 10 competencies that a nurse should possess regarding leadership. These standards provide the framework in which nursing practice provides quality patient care. As a BSN-prepared nurse, it is important to demonstrate each of the competencies in order to be able to support other nurses in developing their own nursing practice.

These competencies promote leadership and encourage nurses to initiate various actions such as leading change, mentoring, appropriately delegating, engaging in professional activities and organizations, etc. (ANA, 2021). Our discussion regarding informal leadership will focus on three areas: taking the lead, role modeling, and accountability.

Taking the Lead

Taking the lead can occur in many ways. Nurses can take the lead by identifying issues or concerns and proposing ways to make improvements to address those issues. Likewise, nurses can take the lead in providing recognition to fellow nurses and healthcare professionals. Recognizing staff for doing a job well done, especially during a difficult or challenging situation helps establish comradery and sets the tone for the team. Another way can be by volunteering for new and challenging situations. Taking the lead can also mean doing what is right when others are not (such as following a new policy that was just implemented even if you’re resistant to it).

Role Modeling

Taking the lead can look much like role modeling. In many instances, they are one and the same. As a leader, a nurse must role model desired behaviors and actions for the team, especially when situations are challenging and morale might be low. As nurse leader, you may also be role modeling what it looks like to be a leader both informally and formally. Whether you realize it or not, there are members of your team who are looking to you to set an example they can learn from. These team members might be the new nurse who is trying to find their way, a CNA who is unsure of some of the tasks delegated to them, the social worker who is nervous to engage in difficult conversations, etc. Other areas in which nurses can model behaviors include promoting a culture of diversity, equity, and inclusion (National Academy of Sciences, 2021).

Accountability

As nurses, we are responsible and accountable for many things. Taking ownership of what we are responsible for is a characteristic of a nurse leader. Accountability involves taking ownership of the consequences of one’s actions. These actions could be a lack of action as well. One can take ownership for consequences that have both positive and negative outcomes. It is important that nurses and leaders exemplify accountability in their profession. An example of this may be acknowledging medical errors that occur whether the error solely lies upon oneself or involves multiple members of the healthcare team. In this case, you should not only acknowledge the error but take it to the next step by completing a report as outlined by your facility’s policies and procedures.

Roxanne has been in the shift supervisor role for a few months now. She recognizes that it was a bit of a transition with the team—Roxanne going from a peer to someone in charge. Roxanne is orienting another nurse, Max, to shift supervisor. She recognizes that it can be difficult to transition from peer to leader within the team. Sometimes other nurses may take advantage of friendships or previous relationships.

 Roxanne describes how a fellow nurse thought that she would be treated differently since she and Roxanne were friends. Roxanne explains to Max, “It is important to be consistent with the team, maintain a standard as a leader, and ensure that everyone, even us, are following the policies and procedures outlined. It is not easy to avoid favoring staff, but we must role model professional behaviors and standards of practice.” Roxanne acknowledges, “Now that I have been in this role for a few months, the team has gotten familiar with me as a supervisor and my leadership style.” Additionally, Roxanne tells Max, “It is important that we role model standards of practice, even when we are not in the supervisor role. Others watch us and look to us to set the example.”

Creating Relationships

Creating relationships is an important and natural part of any job. It is equally important to determine the type of relationship. Role modeling the type of professional relationship one has with team members, patients, and family members is very important as well. As a baccalaureate-prepared nurse and leader, there are other ways to build relationships that will enhance your role as a nurse leader. A few examples include mentoring, precepting, and networking. As a mentor and preceptor, you are recognized by others for your leadership, experience, and practice as a nurse.

Mentoring and precepting are often perceived as one and the same. There are both similarities and differences between the two. Both have an individual who takes on the role of the more experienced and knowledgeable nurse who provides guidance to a less experienced and knowledgeable nurse.

Mentoring

The mentor tends to be a nurse who has been asked by the mentee to volunteer as a mentor. The mentor establishes a relationship with the mentee who tends to have less experience. The relationship of the mentor and mentee oftentimes is reciprocal in nature, as both individuals may benefit from mentoring. The relationship between the two may also last much longer than that with a preceptor.

Precepting

A preceptor may possess similar characteristics as a mentor but are assigned to new nurses or nurses of lesser experience to orient and acclimate the preceptee to the role and work environment. Some facilities may require preceptors to take a formal course on being a preceptor as a prerequisite. The preceptor and preceptee work one-on-one for a specified period. Something to consider once you have completed your BSN is to be a preceptor for other ADNs pursuing their bachelor’s degrees.

Role of Mentor and Preceptor

Both roles of mentor and preceptor can be something that you as a nurse may take on, but there may be times when you are also in the role of mentee and preceptee. You may remember being a preceptee as a new graduate nurse, starting a new job, and in your clinical capstone course. You may want to consider whether in the future being a preceptor would be a good stepping-stone as a leader in your department. Discuss with your manager or direct leader what steps would be involved in taking on this role. Likewise, you may also find yourself in the position of mentor or mentee. As a more experienced nurse, you might be asked to guide less experienced nurses on their journey as a mentor or coach. Additionally, as a new baccalaureate-prepared nurse, you may be seeking out the next steps in your professional journey and might want to have a mentor.

Selecting your own mentor is equally as important as being a mentor. You might select a mentor for a specific growth and development opportunity, or you might select an individual you find to be a role model. Consider someone that embodies the characteristics and role that you wish you possess. For instance, if you want to elevate your leadership skills, you may seek a mentor who exhibits exemplary qualities of a leader. Additionally, you may also want to consider the role or title of the potential mentor. For example, if you are looking to become a nurse educator, perhaps you connect with someone in this role.

 

Networking

Another way to establish relationships within nursing and the healthcare professional arena is through networking. Networking can occur organically or deliberately in nature. For instance, networking might naturally occur through your workplace or relationships established through nursing school. More intentional ways to network might be through social media platforms, professional nursing organizations, and participation in committees at the workplace. As discussed in Chapter 2, professional organizations offer a multitude of benefits not only regarding certifications and professional development but also the ability to network with fellow nurses on a given specialty, topic, or cause. You may be drawn to one or more professional organizations depending on your interests; you might choose one for professional development and another for networking. You have the opportunity to carry out interactions that fit your needs.

Many of these professional organizations are also visible on social media platforms. Additionally, social media may be a good forum to establish a community with those like you or to voice your thoughts on a specific topic. When interacting on social media platforms, one must remain professional in their communication with consideration for HIPAA violations and any workplace-related social media policies that may exist.

Networking

Type

Social Media

Professional Organizations

Workplace Activities

Unit-based committees

Hospital-wide committees

Quality improvement initiatives

Other Forms of Networking

Roxanne is currently enrolled in the leadership course for the RN to BSN program. She was reading about the importance of networking and forging relationships as a nursing professional and leader. She shares what she has learned with her manager: “I had not realized how many different ways that nurses create and maintain relationships in both a professional and personal capacity.” Roxanne says that professional relationships in the workplace are equally as important as the ones made with preceptors, mentors, and professional organizations.

She goes on to say, “It is easy to establish relationships on social media platforms as one can engage passively, but it takes more effort to engage in other relationships.” Roxanne tells her manager, “I would like to be on a committee here to help with process improvements and be actively involved in making positive changes.” Roxanne’s manager Keri says there are monthly meetings for the QI committee and the practice council and that one of these would be a viable option. Kerri also mentions that Roxanne should join a professional organization such as the American Health Care Association (AHCA), https://www.ahcancal.org/Pages/default.aspx, or the American Association of Post-Acute Care Nursing (AAPACN), https://www.aapacn.org/, geared specifically toward care provided in long-term settings. Kerri proceeds to say, “There is an organization in healthcare and nursing for just about any topic. You can gain additional knowledge as well as network with those who work in the same practice setting as you.”

Interprofessional Collaboration

Collaboration is an instrumental part of providing safe, quality patient care. It occurs among two or more individuals, such as nurses, healthcare professionals, and patients. The Institute of Medicine (IOM) created a series of reports that illustrate the importance of collaboration, including To Err is Human Building a Safer Health System (2000), Crossing the Quality Chasm: A New Health System for the 21st Century (1999), and The Bridge to Quality: Health Professions Education (2001). These reports have been a driving force in nursing, healthcare, and educational settings. Additionally, collaboration occurs in the forms of communication and coordination of care.

Interprofessional collaboration encompasses collaboration, communication, and coordination of care (Foronda, MacWilliams, & McArthur, 2016). It is a patient-centered approach inclusive of key healthcare professionals, patients, and families as equal contributors to the plan of care (Golom & Schreck, 2018). The team creates an environment that promotes shared decision-making consisting of collegiality, respect, trust, and support (Rose, 2011). By forming an interprofessional team, this approach allows for efficient collaboration and communication leading to improved patient safety and outcomes. It is important for the nurse to lead or guide interprofessional efforts because the nurse is often the most familiar with the patient and can readily advocate for the patient’s needs. As a baccalaureate-prepared nurse, you are equipped with knowledge from the National Academy of Medicine (NAM) and the ANA’s Scope and Standards of Practice, which articulate the following competencies for healthcare professionals: patient-centered care, interprofessional teamwork, evidence-based practice, quality improvement, and informatics (Institute of Medicine, 2010). The primary nurse can help foster effective teamwork among the interprofessional team by identifying purpose, establishing social rapport, fostering a supportive environment, and leading collaboration (Smith et al., 2018).

Interprofessional collaboration can take on many forms. It should ideally be integrated into the education of healthcare professionals. However, in practice, it should be performed with handoff communication, whether a bedside report or providing updates on patient status to another healthcare professional. Handoff communication should include not only the key healthcare professionals but also the patient and their family. Interprofessional rounding is another way that healthcare professionals and patients can engage in collaboration. Interprofessional rounding brings the team together for daily rounds on patients to discuss patient status, needs, and goals (Verhaegh et al., 2017). Another type of collaboration is interprofessional bedside rounding, where the healthcare team goes to the patient bedside to discuss patient status, needs, and goals. The rounds consist of a standardized communication tool to ensure all disciplines are contributing to the shared decision-making process (Henkin et al., 2016).

End of Chapter Activities

Click on the slide to see 6 end of the chapter activities that may help you put the pieces of this chapter together.

 

References

American Nurses Association. (2021). Nursing: Scope and standards of practice. (4th ed.).

American Nurses Association. (2012). ANA’s principles for delegation by registered nurses to unlicensed assistive personnel (UAP). Nursebooks.org. https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principlesofdelegation.pdf

Boerner, H. (2016). Eliminating harm: How hospital systems are working to reverse medical errors. Physician Leadership Journal, 3(2), 30–32.

Foronda, C., MacWilliams, B., & McArthur, E. (2016). Interprofessional communication in healthcare: An integrative review. Nurse Education in Practice, 19, 36–40. doi: http://dx.doi.org/10.1016/j.nepr.2016.04.005

Giordano-Mulligan, M. & Eckardt, S. (2019). Authentic nurse leadership conceptual framework: Nurses’ perception of authentic nurse leader attributes. Nurse Administration Quarterly, 43(2), 164–174.

Henkin, S., Chon, T. Y., Christopherson, M. L., Halvorsen, A. J., Worden, L. M., & Ratelle, J. T. (2016). Improving nurse-physician teamwork through interprofessional bedside rounding. Journal of Multidisciplinary Healthcare, 2016(9), 201–205. doi: 10.2147/JMDH.S106644

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. The National Academies Press. https://doi.org/10.17226/12956

The Joint Commission International. (2018). Communicating clearly and effectively to patients [White paper]. Joint Commission International. https://store.jointcommissioninternational.org/assets/3/7/jci-wp-communicating-clearly-final_(1).pdf

Marquis, B. L., & Huston, C. J. (2021). Leadership roles and management functions in nursing: Theory and application (10th ed.). Wolters Kluwer.

National Academies of Sciences, Engineering, and Medicine. (2021). The future of nursing 2020-2030: Charting a path to achieve health equity. The National Academies Press. https://doi.org/10.17226/25982

Rose, L. (2011). Interprofessional collaboration in the ICU: How to define? Nursing in Critical Care, 16, 5–10. https://doi.org/10.1111/j.1478-5153.2010.00398.x

Smith, C. D., Balatbat, C., Corbridge, S., Dopp, A. L., Fried, J., Harter, R., Landefeld, S., Martin, C. Y., Opelka, F., Sandy, L., Sato, L., & Sinsky, C. (2018). Implementing optimal team-based care to reduce clinician burnout. NAM Perspectives. https://doi.org/10.31478/201809c

Starmer, A. J., Spector, N. D., Srivastava, R., & West, D. C. (2014). Changes in medical errors after implementation of a handoff program. New England Journal of Medicine, 371, 1803–1812. DOI: 10.1056/NEJMsa1405556

Verhaegh, K. J., Seller-Boersma, A., Simons, R., Steenbruggen, J., Geerlings, S. E., de Rooij, S. E., & Burrman, B. M. (2017). An exploratory study of healthcare professionals’ perceptions of interprofessional communication and collaboration. Journal of Interprofessional Care, 31(3), 397–400. https://doi.org/10.1080/13561820.2017.1289158

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Opening Doors to Your Future: A Handbook for RN-BSN Students Copyright © 2022 by Nicole Simonson; Jessica Hertig; Jill Saxton; and Amy Driscoll. All Rights Reserved.

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