Nursing Leadership and Management

Mike Cowell

NSG 315

National University
 The leader that was studied within a clinical setting was Sarah B. Sarah is a interim manager

on the third floor, east side, at UCSD Thornton Medical Center. She was previously the assistant

manager on that particular unit, but stepped up to cover the managers position until a new floor

manager is hired. The previous floor manager resigned in order to start a new position at Scripps

Mercy. Sarah holds a BSN degree, and has been filling the managers position for approximately

two months. Sarah was selected for this study because it was interesting to see what

leadership/management qualities she possessed as an interim manager. It was interesting to see

her in a new role, and to understand how she filled the void left by the previous manager. How

would she handle the stress of the new position? Would Sarah take the role seriously, being that it

is on a short term basis? How would the staff handle Sarah in her new position, and the change

that came along with it? A lot of questions arose when Sarah was chosen for this study. It seemed

only appropriate that Sarah’s leadership and management style be dissected to understand how

she fills the role.

Characteristics/Qualities

It is important to understand Sarah’s characteristics and qualities that define her as a leader.

Leadership is defined as “the ability to influence other people” (Whitehead et al., 2007). The way

that a leader influences other people depends upon the leadership characteristics and qualities that

they posses. Sarah’s qualities help the staff develop a sense of direction and build commitment to

goals. She also displays the ability to confront the various challenges that arise with being a

leader/manager. Each leader possesses traits that define their leadership style, and Sarah has her

own individual traits that make her an effective leader. Sarah has intelligence. People look to her

for answers to clinical situations, she is well spoken, and she displays the ability to use critical

thinking when necessary. Sarah has integrity. People under her supervision trust her and know
they can depend on her in any situation. Sarah has initiative. She takes it upon herself to find out

the answer to questions that might arise, she isn’t afraid to help out, and she solves disputes

within her unit. Sarah has excellent interpersonal skills in dealing with her staff , patients, and

families. She knows how to relate to people, makes them feel comfortable during conversation,

and is approachable. She displays the ability to be assertive and make decisions. She isn’t afraid

to delegate tasks, tell people what she thinks in a professional manner, or make decisions

regarding staffing. Sarah also displays certain behaviors that are important to have in order to be

an effective leader. These behaviors include solving problems by thinking critically, respect for

people, skillful communication, and the setting of goals.

McGregor’s theories X and Y are used to describe human relations based management.

Theory X states that people do not want to work, and it is the manager’s job to make sure the

work gets done using control, supervision and punishment. Theory Y states that the job itself is

rewarding and motivating, employees do want to do a good job, and the manager uses guidance,

development and reward. In theory Y the manager guides rather than controls, rewards rather

than punishes, and tries to keep satisfied employees committed to the organization. Sarah would

fit under the Theory Y motivation theory. She guides employees in their development, and

generally tries to keep her employees satisfied. She believes that her employees are motivated to

perform well at their jobs and do not need strict supervision and control.

Decision Making Style

Sarah’s leadership style is a mix of authoritarian, democratic and laissez-faire. Authoritarian

because she does have a small degree of control over the group and makes a lot of the decisions

and implements them. Democratic style because she does allow the group input into the decision

making process, she is actively involved in the group, and assumption of responsibility is shared

between her and the group. Laissez-faire style is present because Sarah does allow the group to
have a high degree of freedom. Overall, her leadership style is very efficient. The group functions

independently, but Sarah oversees the unit and intervenes when necessary. The output of the

group is high, and they give patients high quality care. The staff work effectively together and

look to Sarah to solve disputes and answer questions.

One example of Sarah’s authoritarian leadership style is regarding vacation time. Sarah was

receiving complaints that certain employees took to much vacation time, thus taking away

vacation time from other employees and causing scheduling conflicts. Sarah put some thought

into the situation and decided to make a decision based on the fact that it was unfair to other

employees when vacation request were automatically granted. She explained to her staff that each

person deserved equal amount of vacation time, and certain employees should not have schedule

conflicts because of other’s frequent vacations. She made it clear that certain people would have

their vacation request denied, and all future request would need to be pre-approved by her before

they were planned. She was frustrated that employees were planning vacations and just

automatically expected to be given the vacation time. Sarah demonstrated the ability to use her

problem solving skills, and clearly communicate her goal for future situations.

An example of Sarah’s laissez-faire leadership style has to do with how much freedom she

gives her employees. She allows them to do their job, and seek her when a problem arises. She

does not supervise her employees to the point that they are being “watched”, but she does let staff

know when she disagrees with some aspect of their job duties or performance. She has trust in her

staff that they will do their job duties, and perform efficiently. Sarah makes sure to interact with

each employee to see if they have any questions or concerns, and allows them time for feedback.

Change Process / Followers

A recently implemented change involved the change of shift report. JCAHO recommended

that the change of shift report be done at the patients bedside, instead of at the nurses station.
UCSD implemented this recommendation by setting up a protocol for the shift report. The two

nurses would enter the patients room, give report bedside, and then sign off at the bedside

computer that the report was given. The computer sign off screen has specific topics to be

reviewed by the nurses, such as new orders, critical labs and medication review. Sarah was to

oversee and help the staff make this transition. In order for this change to take place, Sarah had to

implement the change, appropriately direct the nursing staff, and influence the way the nurses

were handling the change.

Sarah utilized communication, feedback, and supervision to effectively implement change.

Communication plays a vital role in the process of change. Sarah made clear the proper way to

give the bedside report, and gave an explanation on how to sign off on the computer. Sarah made

it clear to her staff that it was important that each person cooperates and works together to make

this change happen. She made sure to actively listen to questions or concerns from her nursing

staff. Sarah made time to receive feedback from each nurse. She talked to each nurse

individually to understand how they felt about the change, and gave possible solutions to

problems that my have occurred. Sarah also used supervision to implement the new change. She

would make sure that staff were indeed going into the patient rooms, and not just giving the

report at the nurses station. And she would get feedback from the patients on how they felt about

the nurses giving the report at the bedside.

The barrier to change was the nursing staff. Many of the nurses thought it was inappropriate

to give a bedside report because there was certain aspects of the report that the patient should not

hear. Sarah discussed this aspect of the report with the staff, and made it clear that they didn’t

have to include every detail at the bedside, the staff could talk about sensitive topics outside of

the room. The staff also believed that the medical terminology may scare some of the patient’s

and increase their anxiety level. Sarah’s solution to this problem was that the nurses give the
patient an opportunity to ask questions or voice concerns at his time. This way if the patient has a

questions about terminology in the report it gives them an opportunity to ask. Other staff didn’t

like the idea of going into the patients room at seven a.m. and waking the patient up with report,

since it was already difficult to get sleep in the hospital. Sarah made it clear that she was

sympathetic to how difficult it was to get sleep on the unit, but the report did need to be done at

the bedside. Sarah offered the solution that the staff could give the patients more uninterrupted

sleep after the report was given. Another argument was that going into the patient room was time

consuming. Sarah let the staff know that there was really no way around this, she understood that

one shift was trying to go home and the other was trying to get started. However, she made it

clear that they must work together to implement this change, and going into the rooms gave the

nurses a more in depth report on the patients.

A follower is defined as “ a skilled, self directed employee, one who participates actively in

setting the groups direction, invests their time and energy in the work of the group, thinks

critically and advocates for new ideas” (Whitehead et al., 2007). The “followers” on 3 East

would fall under this definition, as most of them are good followers. However, there is always

going to be some sort of resistence to change, not matter how great the followers are. The

resistance Sarah faced in implementing the new bedside report sign-off was both active and

passive. The passive resistance displayed was being too busy to change, refusing to commit to the

change, and agreeing to the change but not implementing it. In terms of active resistance, the

nursing staff attacked the idea, refused to change, argued against the new method, or agreed to

the change but did not follow through. Some of the staff attacked the idea by arguing against the

change and being pessimistic. Other nursing staff outright refused to change, still doing the

reports at the nurses station and signing off at the computers there. And majority of the nurses

agreed to change, but did not actually follow through with their word. This majority would give
the reports outside of the room, and depending, either sign off at the computers in the room or at

the nurses station. It seemed that most of the nurses on the floor were used to just giving verbal

change of shift reports, and they just found it a hassle to go to the patients room and sign off on

the computer. Most of the day nurses would get report, give the night nurse their login code, and

then have the night shift nurse fill out the sign off screen on the computer. Not all of the nurse

were against the change, many of the nurses did follow through with change, and this often

forced the other nurses to give report bedside. It all depended upon the attitude of the nurses who

were giving report. If they both disagreed upon the change, then they would give report outside

of the room, and have one of them sign off on the computer. If both nurses agreed to the change

then they would give the report bedside and sign off together. If one nurse agreed and the other

disagreed, then one of the nurses would compromise.

Environment/Organizational Structure

UCSD Medical Center is a private, coeducational research university hospital. The mission of

the hospital is to take exceptional care of people by; providing excellent and compassionate

patient care, advancing medical discoveries, and educating the healthcare professionals of

tomorrow. UCSD’s vision is clinical excellence through service, innovation, and education.

UCSD has five core values. First is quality; excellence in patient care and other worked

performed. Second is caring; commitment to valuing differences and respecting the well-being

and dignity of each person. The third value is integrity; honesty and trustworthiness. Fourth is

creativity; enhancing knowledge, discovering and sharing new ways to do things. And the last

value is teamwork; commitment to working together to achieve goals.

The organizational structure of UCSD traditional, or vertical. In this structure a top to bottom

line of authority is used and decision making is centralized. There is also a span of control,

meaning that there are only a certain number of individuals that Sarah supervises. The
organizational structure of UCSD does have an impact on the way Sarah and the staff nurses do

their job. However, in the scheme of things each individual is accountable for their actions. Sarah

must answer to the nursing manager, and the nursing manager must answer to the person above

them. But what does this really mean in the whole picture? Sarah is always going to feel pressure

from her supervisors, and in turn her staff nurses will always feel pressure from Sarah. However,

the nurses don’t look at the organizational structure, mission, vision, or values and take them into

account in their job duties. They are there to take care of their patients and advocate for them. It

is up to Sarah to implement change and make sure that the nursing staff is conforming, and being

that she is good leader the staff will eventually comply. It is important for Sarah and the staff

nurses to understand how the organizational structure works, but how much it really affects their

job duties or performance is not seen. Sarah is a good manager, the staff listen to what she has to

say and they respect her position. The group works together as a cohesive unit, and for that the

patients receive quality care. Change is going to take place, and sometimes it is difficult for

individuals to change. However, because this group works so well together, they will find a way

to implement change in the workplace.

References
Whitehead, D. K., Weiss, S.A. & Tappen, R.M. (2007). Essentials of Nursing Leadership and
Management (4th ed.). Philadelphia: F.A. Devis Company.

http://health.ucsd.edu/about/mission.htm?intcmp=hh_mission