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AMAZINGRACE • Sally A. Weiss and Ruth M. Tappen • • • • • • • • • • • ••• • ••• • ••• •••••••••• • •••• • • • • • • • • • • • • • • • ••

AMAZINGRACE • Sally A. Weiss and Ruth M. Tappen
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. Essentials of
Nursing Leadership
and Management



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I


••

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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author(s), editors, and publisher are not responsible for errors or omissions or for consequences from appli-
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Library of Congress Control Number: 2014945714

Authorization to photocopy items for internal or personal use, or the internal or personal use of specific
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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 …

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