TEST BANK for Leading and Managing in Nursing 6th Edition by Patricia Yoder-Wise

Chapter 01: Leading, Managing, and Following MULTIPLE CHOICE 1. A nurse manager of a 20-bed medical unit finds that 80% of the patients are older adults. She is asked to assess and adapt the unit to better meet the unique needs of the older adult patient. Using complexity principles, what would be the best approach to take in making this change? a. Leverage the hierarchical management position to get unit staff involved in assessment and planning. b. Engage involved staff at all levels in the decision-making process. c. Focus the assessment on the unit, and omit the hospital and community environment. d. Hire a geriatric specialist to oversee and control the project.

ANS: B Complexity theory suggests that systems interact and adapt and that decision making occurs throughout the systems, as opposed to being held in a hierarchy. In complexity theory, every voice counts, and therefore, all levels of staff would be involved in decision making.

2. A unit manager of a 25-bed medical/surgical area receives a phone call from a nurse who has called in sick five times in the past month. He tells the manager that he very much wants to come to work when scheduled but must often care for his wife, who is undergoing treatment for breast cancer.

According to Maslow’s need hierarchy theory, what would be the best approach to satisfying the needs of this nurse, other staff, and patients? a. Line up agency nurses who can be called in to work on short notice. b. Place the nurse on unpaid leave for the remainder of his wife’s treatment. c. Sympathize with the nurse’s dilemma and let the charge nurse know that this nurse may be calling in frequently in the future. d. Work with the nurse, staffing office, and other nurses to arrange his scheduled days off around his wife’s treatments.

ANS: D Placing the nurse on unpaid leave may threaten the nurse’s capacity to meet physiologic needs and demotivate the nurse. Unsatisfactory coverage of shifts on short notice could affect patient care and threaten the needs of staff to feel competent. Arranging the schedule around the wife’s needs meets the needs of the staff and of patients while satisfying the nurse’s need for affiliation.

3. A grievance brought by a staff nurse against the unit manager requires mediation. At the first mediation session, the staff nurse repeatedly calls the unit manager’s actions unfair, and the unit manager continues to reiterate the reasons for her actions. What would be the best course of action at this time? a. Send the two disputants away to reach their own resolution. b. Involve another staff nurse in the discussion so as to clarify issues. c. Ask each party to examine her own motives and issues in the conflict. d. Continue to listen as the parties repeat their thoughts and feelings about the conflict.

ANS: C Ury, Brett, and Goldberg outline steps to restoring unity, the first of which is to address the interests and involvement of participants in the conflict by examining the real issues of all parties.

4. At a second negotiation session, the unit manager and staff nurse are unable to reach a resolution. It would now be best to: a. Arrange another meeting in a week’s time so as to allow a cooling-off period. b. Turn the dispute over to the director of nursing. c. Insist that participants continue to talk until a resolution has been reached. d. Back the unit manager’s actions and end the dispute.

ANS: B According to the principles outlined by Ury, Brett, and Goldberg, a “coolingoff” period is recommended if resolution fails.

5. The manager of a surgical area has a vision for the future that requires the addition of RN assistants or unlicensed persons to feed, bathe, and walk patients. The RNs on the staff have always practiced in a primary nursing– delivery system and are very resistant to this idea. The best initial strategy in this situation would include: a. Exploring the values and feelings of the RN group in relationship to this change. b. Leaving the RNs alone for a time so they can think about the change before it is implemented. c. Dropping the idea and trying for the change in a year or so when some of the present RNs have retired. d. Hiring the assistants and allowing the RNs to see what good additions they are.

ANS: A

Influencing others requires emotional intelligence in domains such as empathy, handling relationships, deepening self-awareness in self and others, motivating others, and managing emotions. Motivating others recognizes that values are powerful forces that influence acceptance of change. Leaving the RNs alone for a period of time before implementation does not provide opportunity to explore different perspectives and values. Avoiding discussion until the team changes may not promote adoption of the change until there is opportunity to explore perspectives and values related to the change. Hiring of the assistants demonstrates lack of empathy for the perspectives of the RN staff.

6. As the RN charge nurse on the night shift in a small long-term care facility, you’ve found that there is little turnover among your LPN and nursing assistant (NA) staff members, but they are not very motivated to go beyond their job descriptions in their work. Which of the following strategies might motivate the staff and lead to greater job satisfaction? a. Ask the director of nursing to offer higher wages and bonuses for extra work for the night LPNs and NAs. b. Allow the LPNs and NAs greater decision-making power within the scope of their positions in the institution. c. Hire additional staff so that there are more staff available for enhanced care and individual workloads are lessened. d. Ask the director of nursing to increase job security for night staff by having them sign contracts that guarantee work.

ANS: B Hygiene factors such as salary, working conditions, and security are consistent with Herzberg’s two-factor theory of motivation; meeting these needs avoids job dissatisfaction. Motivator factors such as recognition and satisfaction with work promote a satisfying and enriched work environment.

Transformational leaders use motivator factors liberally to inspire work performance and increase job satisfaction.

7. As the nurse manager who wants to increase motivation by providing motivating factors, which action would you select? a. Collaborate with the human resource/personnel department to develop onsite daycare services. b. Provide a hierarchical organizational structure. c. Implement a model of shared governance. d. Promote the development of a flexible benefits package.

ANS: C Complexity theory suggests that systems interact and adapt and that decision making occurs throughout systems, as opposed to being held in a hierarchy.

In complexity theory, every voice counts, and therefore all levels of staff would be involved in decision making. This principle is the foundation of shared governance.

8. A charge nurse on a busy 40-bed medical/surgical unit is approached by a family member who begins to complain loudly about the quality of care his mother is receiving. His behavior is so disruptive that it is overheard by staff, physicians, and other visitors. The family member rejects any attempt to intervene therapeutically to resolve the issue. He leaves the unit abruptly, and the nurse is left feeling frustrated. Which behavior by the charge nurse best illustrates refined leadership skills in an emotionally intelligent practitioner? a. Reflect to gain insight into how the situation could be handled differently in the future. b. Try to catch up with the angry family member to resolve the concern. c. Discuss the concern with the patient after the family member has left. d. Notify nursing administration of the situation.

ANS: A Goleman suggests that emotional intelligence involves insight and being able to step outside of the situation to envision the context of what is happening as well as being able to manage emotions such as frustration effectively.

9. The chief nursing officer has asked the staff development coordinator to facilitate the development of a clinical competency program for the facility.

While making rounds on the units, the staff development coordinator overhears RN staff complaining that they feel it is insulting to be required to participate in a competency program. Which behavior by the staff development coordinator is most appropriate in this situation? a. Disregard staff concerns and continue with development of the program. b. Inform the nurses that this program is a requirement for JCAHO accreditation. c. Schedule a meeting with the chief nurse executive to apprise her of the situation. d. Facilitate a meeting so nurses can articulate their values and concerns about a competency program.

ANS: D The manager role involves guiding others through a set of derived practices

that are evidence-based and known to satisfy preestablished outcomes such as participation in a competency program. This involves engagement of staff through sharing of concerns and ideas. A close analysis of the IOM report and the summary of the PPACA suggests that no health reform can unfold without active nursing engagement. Each document emphasizes that nurses must lead, manage, and behave as active collaborators with other members of the health team and with those being served.

10. As the manager, you have been asked to implement an evidence-based approach to teach ostomy patients self-management skills postoperatively that is being operationalized throughout your organization. Which of the following illustrates effective leadership? a. The training modules are left in the staff room for times when staff are available. b. The current approach is continued because it is also evidence-based and is more familiar to staff. c. You decide to implement the approach at a later date because of feedback from the RNs that the new approach takes too much time. d. A RN who is already familiar with the new approach volunteers to take the lead in mentoring and teaching others how to implement it.

ANS: D Followership occurs when there is acquiescence to a peer who is leading in a setting where a team has gathered to ensure the best clinical decision making and actions are taken to achieve clinical or organizational outcomes.

Followership promotes good clinical decisions and use of clinical resources.

11. You overhear a newly graduated RN telling one of your colleagues that leadership and management belong to the unit manager and not to her. As a nursing colleague, you respond by demonstrating understanding that the perception of the new graduate: a. Is correct. Leadership is not the role of the staff nurse. b. Would benefit from further understanding of her role as a professional, whose influence may affect the decision making of patients, colleagues, and other professionals. c. Has been influenced by nurse leaders and managers who leave for other positions. d. Is related to the general perception that nurse leaders and managers are not satisfied in their jobs.

ANS: B

Care coordination that involves the intersection of individual, family, and community-based needs requires that nurses have self-confidence, knowledge of organizations and health systems, and an inner desire to lead and manage.

There is often a view that leadership is isolated to those holding managerial positions and that a direct care nurse is subject to following by adhering to the direction of others. Such views fail to acknowledge that to be a nurse requires each licensed individual to lead, manage, and follow when practicing at the point-of-care and beyond.

12. You walk into Mr. Smith’s room and find him yelling at the LPN, Miss Jones. He is obviously very upset and after you speak with him regarding his behavior, you determine that he has not slept for three nights because of unrelieved pain levels. The LPN is very upset with Mr. Smith and calls him an “ugly, old man.” You acknowledge her feelings and concerns and then suggest that Mr. Smith’s behavior was aggressive but is related to lack of sleep and to pain. You say to Miss Jones, “Can you both, together with Mr. Smith, determine triggers for the pain and effective approaches to controlling his pain?” This approach demonstrates: a. Lack of empathy and understanding for Miss Jones. b. Concern with placating Mr. Smith. c. Leadership behavior. d. Management behavior.

ANS: C The situation between Mr. Smith and Miss Jones is a complex situation involving unrelieved patient symptoms and aggressiveness toward a staff member. Providing engaged, collaborative guidance and decision making in a complex situation where there is no standardized solution reflects leadership.

13. After assessing an older adult patient in long-term care who has been slowly deteriorating for weeks, the nurse manager calls the family and asks them to come in, as the patient is dying. The nurse manager’s decision and actions are based on: a. An established clinical pathway. b. Confirmatory scientific evidence. c. Unit protocol. d. Experience.

ANS: D The nurse manager is employing knowledge and experience in determining that the patient is dying, because the course of dying is not standardized and

cannot be determined by clinical pathways.

14. Chart audits have revealed significant omissions of data that could have legal and funding guidelines ramifications. As the unit manager, you meet with the staff to discuss audit findings and to find approaches that will address the gaps in charting and achieve desired goals. This is an example of: a. Leadership. b. Management. c. Decision making. d. Vision.

ANS: B The process of guiding others to meet established goals, outcomes, and procedures is management. This can require collaborative decision making to determine how best to reach pre-determined goals and follow established practices.

15. A family is keeping vigil at a critically ill patient’s bedside. Other, distant family members, not yet able to come, call the unit continuously, asking for updates and wanting to express concern. You speak with the distant family members and suggest that you are going to refer them to the hospital social worker, whose role is to work with people in such situations. What role are you assuming through this action? a. Manager b. Leader c. Follower d. Laissez-faire ANS: A As a manager, you are concerned with managing and coordinating resources to achieve outcomes in accordance with established clinical processes.

Referral to a social worker alleviates demand on staff time and is consistent with hospital procedures.

16. A family is keeping vigil at a critically ill patient’s bedside. Other, distant family members, not yet able to come, call the unit continuously, asking for updates and wanting to express concern. You speak with the distant family members and suggest that you are going to refer them to the hospital social worker, whose role is to work with people in such situations. In response to this situation, you approach the unit manager to apprise her of your concerns that the family dynamics of the patient involved may lead to staff-family and

patient-family conflicts. You suggest that the physician may need to discuss the treatment plan with the family. The unit manager advises that he will arrange this discussion. If, after the meeting with family members, this is identified as a desired approach, you support the manager’s decision. Your actions indicate that you are acting in what role? a. Leadership b. Management c. Follower d. Evidence-based ANS: C In the followership role, you bring to the manager your concerns about potential litigation and maximization of outcomes and accept the direction given by the manager in response to your concerns.

17. You pull staff together to assess a situation in which the family of a seriously ill patient is anxious and is absorbing a great deal of staff time in consultation, discussion, and questioning of treatment decisions. Staff members are becoming distanced from the family. After inviting the concerns of staff, you explain that the organization values patient-centered care and that evidence supports that acting as an advocate and a listener is helpful to families. You ask the staff for ideas as to strategies that are effectively patient-centered in these situations. In this situation, you are taking on which role? a. Leadership b. Management c. Follower d. Visionary ANS: A As a leader, you provide and communicate vision and direction based on evidence and experience, and you engage others in decision making that moves them toward the vision with a reasonable level of risk taking.

18. Joan, the nursing unit manager, finds it difficult to work with Thomas, a new graduate. Thomas has many ideas, and his manner of presenting them irks Joan. After reflection and discussion with others, Joan recognizes that she also feels threatened by his behavior. She comes to understand that Thomas is trying to establish his own role on the unit, is not trying to challenge her, and needs guidance, coaching, and affirmation. Joan is demonstrating:

a. A positive self-concept. b. Deepening self-awareness. c. Leadership. d. Acquiescence.

ANS: B According to Goleman (1995), stepping outside oneself to envision the situation while assuming ownership is a component of emotional intelligence.

19. As the head of a nursing program, you consistently invite the ideas of your team about innovations in teaching, community partnerships, and curriculum design and invite participation in decisions. Many of these ideas have been implemented successfully, and your staff members are keen to try on other ideas. You are employing _____ leadership. a. Situational b. Trait-based c. Contingency-based d. Transformational ANS: D Transformational leadership involves attending to the needs and motives of followers, which results in creativity, improvement, and employee development.

REF: Page 10 | Page 11 TOP: AONE competency: Professionalism 20. As a leader on a rehab unit, you encourage all staff members to see themselves as having a role in decision making and quality care. You see your role as involving particular responsibilities in decision making but not as a hierarchal role. This view of decision making and leadership is consistent with: a. Trait theories. b. Complexity theory. c. Situated theory. d. Emotional intelligence.

ANS: B Complexity theory involves envisioning each member of the team involved in decision making, management, and leadership, with the leader not seen in a hierarchal relationship to other team members.

21. You recently acquired a position as a unit manager. During your time on the unit, you have formed a strong social network among your staff, have

promoted the development of relationships between your staff and workers in other areas of the organization, and have formed relationships that generate ideas from patient organizations and the local nursing education program.

According to complexity theory, you are engaging which principle? a. Empowerment b. Systematic thinking c. Development of networks d. Bottom-up interactions ANS: C According to complexity theory, social networks evolve around areas of common interest and are able to respond to problems in creative and novel ways.

22. According to the complexity theory, which of the following should be the focus of measurement? a. Cost per hospital day b. Bed utilization c. Infection rates d. Staff morale and budgets ANS: D According to complexity theory and the principle “Think systematically,” you cannot ignore objective data or nonmeasurable data, as both inform decisions.

23. During a staff meeting held to discuss developing a mission statement for the unit, the idea of placing patient needs first is: a. Empowering. b. A leadership tag. c. A symbol. d. A management task.

ANS: B According to complexity theory, leadership tags, which are similar to values, reflect the patient-centered philosophies and values-driven characteristics that define an organization and give it personality.

24. A dispute arises between an RN staff member and an LPN over a patient issue. The tension between the two begins to affect other staff members, who

are drawn into the conflict; eventually, the team becomes polarized toward either the RN or the LPN. This situation might have been prevented through: a. Expediency in responding to the initial dispute, once it became apparent that it could not be resolved by the two parties themselves. b. Asking other staff members what the real issues were in the dispute between the RN and the LPN. c. Reassigning one of the parties to another unit when it became apparent that the two individuals could not resolve the dispute themselves. d. Calling a staff meeting at the onset of the dispute to allow the team and the RN and LPN to discuss the initial dispute.

ANS: A The initial step in conflict resolution should have involved an expedient response to the issues and putting a focus on the issues involved in the dispute between the LPN and RN through negotiation involving the two parties, before the dispute involved others.

25. The unit is shifting from primary nursing to a team model in an effort to contain costs. Staff members are angry and ask for a meeting to discuss the change. After hearing their concerns related to reduction in professional autonomy and care quality, you: a. Acknowledge the loss. b. Explain the reasons for change, emphasizing the need to reduce costs. c. Repeat the information several times, giving detailed budget overviews. d. Adjourn the meeting and provide explanation through e-mail.

ANS: A Visioning involves engaging with others to assess the current reality, specify the end point, and then strategize to reduce differences. This requires trusting relationships that acknowledge the differences in values and ideas. When done well, the nurse and the nurses within a unit experience creative tension that inspires working in concert to achieve desired goals.

MULTIPLE RESPONSE 1. Sarah wonders about the direction that you have given regarding management of incontinent, confused patients. She brings you evidence that she has found regarding incontinence interventions and asks you if she and you could talk about the guidance that you have given after you have had an opportunity to read the articles she has given you. This is an example of :

a. Assertiveness. b. Followership. c. Management. d. Insubordination.

ANS: A, B This is an example of followership in which a staff nurse is demonstrating assertive behavior and presenting evidence that may influence the decision making of her nurse leader and manager.

REF: Page 5 TOP: AONE competency: Knowledge of the Health Care Environment Chapter 02: Safe Care: The Core of Leading and Managing MULTIPLE CHOICE 1. In an effort to control costs and maximize revenues, the Rehabilitation Unit at Cross Hospital reduced the number of its managers and increased the number of units for which each manager was responsible. Within a year, the number of adverse events on the units had doubled. This may be attributable to: a. The overload of staff nurses. b. Resistance to change by staff. c. A change in reporting systems. d. Fewer clinical leaders to remove barriers to care.

ANS: D Eliminating barriers to the implementation of best practices is the role of managers and leaders. When there are insufficient resources for leadership to encourage a culture in which evidence-based practice is embraced, frontline nurses recognize this as a stumbling block for delivering quality care.

REF: Page 24 TOP: AONE competency: Knowledge of the Health Care Environment 2. The Rehabilitation Unit at Pleasant Valley Hospital has a high number of falls. Which of the following interventions might assist to reduce the number of falls on the unit? a. Determining who is responsible for the falls b. Strengthening unit policies to avoid inappropriate admissions c. Encouraging involvement of nurses in education related to falls and safety d. Ensuring that patients are appropriately restrained if they are at risk for

falls ANS: C The IOM (2010) emphasizes the need for nurses to engage in lifelong learning and to use evidence and best practices to inform practice and ensure safety.

3. To increase safety in patient care areas of the Valley Hospital, the executive begins by: a. Asking the community what the safety issues are. b. Consulting with a management expert about staffing schedules. c. Ensuring that the senior nursing officer attends the board meetings. d. Instituting improved practices to reduce needle-stick injuries.

ANS: C The IOM report (2004) highlighted the importance of the attendance of the senior nurse executive at board meetings to be a key spokesperson on safety and quality issues.

4. During review of back injuries, it is determined that a large number of injuries are occurring in spite of mechanical lifts being used. Furthermore, it is determined that some lifts are outdated. In addressing this concern, the unit manager: a. Meets individually with nurses who are observed to be using the lifts incorrectly to review the correct procedure. b. After consultation with the staff about the review, orders new lifts to replace older ones that are malfunctioning. c. Blames the system for inadequate funding for resources. d. Reviews the system of reporting incidents to ensure that appropriate reporting is occurring.

ANS: A The IOM report (2004) points to the need to involve nurses in decisions that affect them and the provision of care.

5. The IOM Health Professions Education report highlighted patient safety concerns as: a. A normal risk in professional practice. b. A result of disciplinary silos. c. A reflection of frontline staff. d. Related to systems errors.

ANS: B

The IOM Health Professions Education report (2004) highlighted the education of health disciplines in silos as a major concern in patient safety and endorsed five recommendations.

6. If you are supporting the steps in the AHRQ document “Five Steps to Safer Health Care,” you would ensure that: a. Patients are actively encouraged to make decisions related to care. b. Rules and decisions are made through centralized processes. c. You monitor the performance of each staff member closely. d. Preference is given to increasing staff numbers rather than staff credentials.

ANS: A The Agency for Healthcare Research and Quality (AHRQ) outlines “Five Steps to Safer Health Care,” which suggests that safe, patient-centered care is facilitated by assisting patients to become active partners in their own care.

7. After consulting with practice environments about quality and safety concerns in health care, the Dean of Health Programs at U.S. University develops: a. A nursing program that emphasizes the development of a strong disciplinary identity. b. Programming that stresses discipline-based research. c. Partnerships with health care to develop software for the reporting of adverse events. d. An interdisciplinary program for nurses, pharmacists, and medical practitioners that emphasizes collaborative learning teams.

ANS: D Health Professions Education identified that education related to health disciplines in silos leads to compromised communication and inability to function as an integrated whole for patient-centered care.

8. In designing a quality, safe healthcare environment, the primary emphasis needs to be on: a. Evidence-based practice. b. Informatics. c. Staffing. d. The patient.

ANS: D Focusing on the patient moves care from concern about who controls care to

a focus on what care is provided to and with patients, which was an aim identified in the IOM report Crossing the Quality Chasm.

9. As a patient care advocate, you regularly coach patients on how to stay safe in health care by educating them about: a. The need to understand and record all medications being taken. b. Bringing their own linens and other personal items to the hospital. c. Washing hands frequently while in a healthcare environment and using a hand sanitizer. d. Following closely the directions and orders of healthcare providers.

ANS: A The Five Steps to Safer Health Care for patients include keeping a list of medications that patients are taking.

10. As a nurse manager on the West Surgery Unit, you are interested in increasing patient safety and reducing morbidity and mortality on your unit.

Which of the following recommendations would be consistent with the IOM The Future of Nursing report? a. Careful screening of nursing staff for substance use and abuse b. Increased RN staffing on the unit c. Salary and benefits that reflect nursing accountabilities d. Increase in the percentage of baccalaureate-prepared nurses to 80% ANS: D The Future of Nursing advocates for having 80% of the nursing population at a baccalaureate-prepared level. This recommendation reflects research that suggests that improved mortality and morbidity rates occur with a better educated workforce.

11. On the West Surgery unit, you want to institute a new system for checking armbands that evidence suggests may increase safety in medication administration. The system involves technology. Which of the following strategies may assist with rapid adoption of the technology and system? a. Employ a centralized decision-making approach. b. Use simulators for initial practice to build confidence. c. Bring in a nurse consultant who is familiar with the technology. d. Use early adopters among the staff as leaders and role models in implementation.

ANS: D The Institute for Healthcare Improvement (IHI) is dedicated to rapid

improvement in patient care through a variety of mechanisms such as rapid cycle change. Rapid cycle change diffuses innovation and changes quickly through early adopters who share information and energy over time and act as role models for others.

12. To achieve nurse-sensitive care standards developed by the NQF, you advocate for which of the following in your health facility? a. Evidence-based practice to reduce the prevalence of pressure sores b. Implementation of informatics at the bedside c. Staff-manager conferences to review reporting of adverse medical events d. Patient councils to review food, recreation, and nurse-patient relations ANS: A The National Quality Forum (NQF) outlines nursing-centered intervention measures related to prevalence of pressure sores, ventilator-associated pneumonias, volunteer turnover, nursing care hours per day, and skill mix of staff.

13. You notice that Sally, a student on your unit, is giving information to an anxious young teen who seems very uncertain about preparation for an upper GI series. After Sally leaves the room, you ask her how she thought her conversation with the patient went and: a. Encourage her to ask the patient if he has questions or concerns about the procedure. b. Advise her to consider providing the patient with more information. c. Suggest that she leave some brochures on the procedure with the patient. d. Suggest that she also provide teaching to the adolescent’s parents.

ANS: A The Five Steps to Safer Health Care for Patients includes the step of asking questions if there are doubts or concerns. The nurse can encourage patients to take a larger role in care by taking these steps and by providing patients with coaching in the steps.

14. The NQF provides a model for advancement of healthcare quality that could be used in healthcare organizations. The use of this model by the Centers for Medicare & Medicaid Services specifically affects the interaction between adverse events and: a. Staffing. b. Funding.

c. Composition of executive councils. d. Composition of consumer-based councils.

ANS: B The Centers for Medicare & Medicaid Services (CMS) have adopted a policy based on the NQF’s “never events.” The CMS will no longer pay for patient conditions or events that result from poor practice while patients are under the care of a health professional.

15. In accordance with changes by the Joint Commission (TJC), Pleasant Valley Hospital amends its safety practices and policies to emphasize: a. Safety goals specific to Pleasant Valley. b. Decision-making processes. c. Sufficient staffing for safe care. d. Increased numbers of baccalaureate-prepared RNs. ANS: A When the TJC, a not-for-profit organization that accredits healthcare organizations, changed its focus from processes to outcomes, it emphasized patient safety and issues setting-specific annual patient safety goals.

16. Which of the following would managers and staff review annually in order to ensure compliance with the Joint Commission (TJC) to improve patient safety? a. Appropriateness of charting terms and abbreviations b. Nursing hours per patient c. Acuity of patient admissions d. Wait times for care ANS: A The Joint Commission issues setting-specific patient goals annually, as well as a list of “do-not-use” terms, abbreviations, and symbols and sentinel events.

17. In preparation for redesignation as a MagnetTM Hospital, how would you prepare? a. Commit staff resources over a 6-month period to updating procedure manuals. b. Educate staff through meetings and training sessions regarding appropriate answers to questions. c. Prepare a manual that outlines orientation procedures and ensure that all safety issues are addressed.

d. Ensure that there are empirical data to support review of patient outcomes, actions taken, and results of actions.

ANS: D Through the MagnetTM model, organizations must demonstrate how they provide excellence in five areas. Between designation and redesignation as a MagnetTM organization, greater emphasis is placed on empirical quality results.

18. Sarah is a second-year nursing student. The clinical instructor overhears Sarah telling a patient that she “always” checks patients’ bracelets before giving medication and she is not sure how the nurses on the unit “get away with” not making more errors than they do. The clinical instructor pulls Sarah aside and explores with her how her communication might affect the patient and what it reflects about her beliefs related to the team. The actions of the clinical instructor reflect competencies outlined by: a. QSEN. b. IHI. c. DNV/NIAHO. d. AHRQ. ANS: A The Quality and Safety Education for Nurses (QSEN) project provides resources related to competencies that prelicensure and graduate students need to develop to serve as safe practitioners. These competencies include leading and managing, teamwork and collaboration.

19. The SBAR approach to patient safety encourages: a. Consistency in assessment and practices. b. Continuing education. c. Multidisciplinary approaches. d. Patient feedback.

ANS: A The use of SBAR (Situation, Background, Assessment, and Recommendation) checklists are designed to decrease omission of important information and practices.

20. As a manager in a new nursing home, where might you consult for guidance and evidence to support the development of safe patient practices? a. Hospitals

b. Business c. Industry d. Outpatient clinics ANS: A Practices that were once mostly studied in hospital settings are now scrutinized for implementation in other settings, such as outpatient clinics, rural settings, and nursing homes.

21. As a manager, the development of your decision-making skills related to safe patient care is facilitated by: a. Regular reflection on decisions. b. A culture of perfectionism. c. Recognition of who should be held responsible for individual errors. d. A culture of trust between the staff and you.

ANS: A Reflection on how well decisions were enacted enables knowledge of the complexity of situations and ramifications of the decisions made. Reflection enables elimination of strategies and methods that are inappropriate in meeting needs and aids in narrowing choices of best actions to take.

22. Mary, an 85-year-old patient with cognitive impairment and gross instability, wanders continuously. Lately, she has fallen twice, and the family demands that she be restrained. As the unit manager, you have initiated a least restraint practice. An appropriate action in this situation would be: a. Setting up a nursing team meeting to review practices. b. Calling the family to inform them of the practice. c. Initiating a multidisciplinary and family meeting to focus on Mary’s needs. d. Restraining Mary to satisfy the family’s wishes.

ANS: C Crossing the Quality Chasm emphasizes the importance of rendering care with the client (client-centered) rather than to the client. In this situation, the patient includes family in transparent discussions about quality needs and takes a team approach that involves healthcare professionals, the family, Mary’s needs, and evidence associated with safe practice.

23. A client requires an appendectomy. The surgeon explains the procedure and asks the client to sign the consent. The patient speaks very little English and looks worried. As a nurse, you would: a. Suggest that an interpreter explain the procedure to the client and answer

any questions. b. Ask the client if he has any questions. c. Draw a picture to show the incision. d. Not intervene.

ANS: A The Five Steps to Safer Patient Care identifies that encouraging patients to ask questions when there are doubts and concerns and ensuring understanding before surgery is performed are ways in which nurses can support patients in having greater influence in their own care. In this situation, asking an interpreter to help enables access to information for the patient and active assessment of his understanding.

24. As the manager on an acute care medical unit, you note that the incidence of medication errors has increased since the implementation of staffing changes. As part of your strategy to reduce errors, it is important to a. Re-visit reporting standards for medication errors in your organization. b. Ensure that medication errors are consistently reported. c. Provide staff with additional education related to safe practice in medication administration. d. Involve RN staff in determining reasons for errors and practice solutions to increase the safety of medication administration.

ANS: D Keeping Patients Safe: Transforming the Work Environment of Nurses (2004) identified many past practices that had a negative impact on nurses, and thus on patients, and recommended the inclusion of nurses in direct care in decision making involving their practice. Future of Nursing: Leading Change, Advancing Health (2010) also emphasizes the role of nurses as leaders in changes that improve health.

MULTIPLE RESPONSE 1. Which of the following patients would be at greatest risk in a healthcare visit ? a. Clyde requires an anticoagulant. He tells the nurse about his medications.

He does not include an herbal supplement. b. George is very shy and withdrawn. He asks the nurse to leave him alone. c. Sarah is a new parent who finds that nurses on the children’s unit are very helpful. She is eager to accept all suggestions, including those that she does not yet understand.

d. Claude is booked for bowel surgery. His doctor explains about the colostomy. Later, Claude tells his wife that he really doesn’t know what the doctor meant by colostomy.

ANS: A, C, D Safer health care involves the patient as an active consumer who keeps and brings a list of all medications, including natural remedies, and questions if there are doubts, concerns, or lack of understanding.

Chapter 03: Developing the Role of Leader Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. As the clinical director of 24 employees, you have been asked to explain to staff members why they are not getting a raise this year, even though they have been working short-handed for many months and patient satisfaction scores have never been higher. Because you believe yourself to be a transformational leader, you will approach this problem by: a. Telling the assistant clinical director and asking her to share the bad news with the other staff members. b. Posting a note on the bulletin board that includes the phone number of the chief nursing officer, so anyone who has complaints may express them. c. Showing staff members the budget and asking for input about how to cut costs so that raises will be possible in the future. d. Meeting with a small group of seasoned staff members and asking them how to break the news.

ANS: C Transformational leadership involves engaging those being led and inspiring shared vision in moving toward a goal that all will accept as desirable. This involves enabling and empowering others to believe that their input and effort will make a difference in solving problems.

2. After a newly hired director of nursing has reviewed the hospital’s strategic plans, she develops a timeline for achieving those plans. The new leader is: a. Not expecting that novice leaders will have a vision. b. Demonstrating mistrust of the abilities of her staff to implement the plans. c. Instituting deadlines against which the performance of staff will be evaluated. d. Translating a global document into realistic plans for nursing.

ANS: D Followers need three things from leaders: direction, trust, and hope.

Developing timelines for the strategic plan involves translating a vision into reality and being able to communicate a vision meaningfully, which is an example of a leader’s influencing behavior.

3. A nurse executive is hired to restore a unit’s productivity, which has decreased as the result of low staff morale. The nurse executive utilizes which of the following leadership principles? a. The leader declares the intent and goals to enhance productivity and assumes that the unit also wishes to increase productivity, which allows nurses to feel in control of the environment. b. If staff members increase productivity, then they are given opportunity to engage in learning events such as workshops and conferences. If the staff members are not satisfied, they will insist on a different leader, who will get them what they want. c. Leaders at the national level who are seeking relief for nurses in the workplace are seen as the solution to the nursing shortage. d. Workplace satisfaction depends on staffing ratios, adequate pay, and tuition reimbursement, and these are things the leader can control.

ANS: A Stephen M.R. Covey suggests that Smart Trust is a method for restoring trust in organizations. Smart Trust Actions include declaration of the leader’s intent and assumption by the leader that others also have positive intentions.

Building trust involves signaling goals and intended actions in advance.

Actions such as promising external rewards such as additional learning opportunities, workload relief, and compensation are consistent with transactional leadership, which leads to low to stable commitment and limited satisfaction.

4. The director of nursing has been observing staff interactions in a 20-bed coronary care unit. Based on her observations, which of the following staff members is an obvious leader? a. The unit secretary who knows everyone’s business b. The chief nursing officer who is in charge and is responsible for nursing services c. The chief cardiologist who admits the largest number of patients and brings in more revenue than any other physician d. The staff nurse who persuades other staff members to practice by making

evidence-based decisions ANS: D Leaders are those who do the best job of sharing their vision of where the followers want to be and how to get there. It is the ability to inspire others to bring a vision (such as evidence-based decision making) to reality and is not necessarily tied to status or information flow.

5. After being interviewed for the unit manager position, the staff nurse reflects on the interview process. The staff nurse is aware that leadership begins: a. Within. b. Through a relationship with a mentor. c. With the job description. d. With the chief nursing officer of the organization.

ANS: A People notice differences in workplaces and tend to choose those that evidence a high degree of trust between leaders and followers. Stephen M.R. Covey suggests that trust begins with self and that leaders must focus first on developing character and confidence, which is their credibility. Credibility enables leaders to trust themselves and gives others someone or something that they can trust.

6. The nurse manager in the Emergency Department needs to implement new staffing patterns. As a transformational leader, the nurse manager should: a. Explain in detail how well the new idea will work. b. Reinforce how this change will respond to the ideas and solutions generated by staff members. c. Reason with staff members that the new idea will save money and allow more free time. d. Imply that raises will be smaller than anticipated if the new idea is not accepted.

ANS: B Transformational leadership inspires and motivates others through influence and persuasion rather than through rewards (e.g., free time) and punishment (e.g., smaller raises). This type of leader listens to the views of others (such as those of the staff members), empowers others to lead (such as in generating solutions for staffing problems), finds ways to remove barriers, and serves as an advocate

7. To retain supervisory staff members, the director of nursing develops a mentoring program. The best person to be a mentor for a new supervisor in a leadership position is someone who has: a. Been in exactly the same position and can relate to the new supervisor’s problems. b. Had vast leadership opportunities and likes to talk about his or her past experiences. c. Leadership experience and time to spend communicating with the new supervisor about his or her experiences. d. People who can help the new supervisor get what he or she needs to make the organization grow quickly and prosper in the process.

ANS: C Mentors need to have experience and some success in the leadership area of interest, as well as interest in the future development of the novice. The mentor can be geographically distant or close and able to provide advice and feedback.

8. Recruiting among the emerging workforce (18- to 35-year-olds) is a challenge for healthcare agencies. Marketing brochures should address the leadership and vision of the healthcare agency. Which of the following workplace environments will attract applicants in the emerging workforce? a. A highly professional environment b. A nurturing and receptive environment c. An environment highlighted by lots of meetings, so staff members can have lots of input d. A totally online environment, so staff members will not have to interface with uncaring colleagues ANS: B A study of student nurses who represent this age group indicates that they want a leader who is receptive, approachable, a team player, and motivating.

9. A nurse executive who considers herself a Baby Boomer will have the challenge of convincing the emerging workforce of the necessity of committee meetings. One of the primary reasons that the Baby Boom generation appears to have so many meetings in the work environment is that: a. They feel more comfortable in a group. b. They find that the journey to the solution is as important as the solution itself.

c. They were deprived of collective action opportunities in the past and now feel that solutions are better when many people have input. d. Baby Boomers are aging and need the respite from work that meetings offer, so they can recuperate from the physical demands of the work environment.

ANS: B Baby Boomers mistrust authority and trust in collective action, based on successes with social movements in their formative years.

10. The hospital administration is discussing the possibility of closing hospital beds in your unit because of a nursing shortage and the increased amount of overtime required to care for patients. As the leader on the unit, which of the following examples best demonstrates your transformational leadership style? a. Your entire staff walks out on strike. b. Your staff sends an ultimatum to the clinic director demanding higher pay. c. A group of your staff members goes to the administration to propose closing of a different unit. d. A group of your staff members goes to the administration to request that they be allowed to work the overtime hours.

ANS: C Commitment to the vision that has been created is seen in the ability of the leader to influence, motivate, and persuade others. The transformational leader can motivate employees by encouragement of novel, innovative thinking. Drenkard (2013) describes true transformational leadership as occurring when the leader “created an environment that brought leaders and followers together to solve problems, create new ways of doing work, and manage change together” (p. 57).

11. John is interested in leadership positions within his nursing organization.

Al-though he has been on the same unit for 10 years, he has attended two workshops during that time and has steadfastly refused opportunities to engage in leadership development opportunities or other learning offered as part of the hospital’s succession planning strategy. He says that he is interested in a leadership role primarily because it will give him a more stable work schedule and will enable him to spend more time with his family. In coaching John, it would be important to: a. Affirm that his years of service and stability on the unit are the most important attributes for assumption of a leadership role.

b. Reinforce that his concern with maintaining balance outside work would be a key factor in selecting him for a leadership position. c. Encourage him to consider the financial rewards of the position, as well as the positive effect on his work schedule. d. Encourage him to seek out new experiences and learning that will complement his existing strengths derived from experience and his interest in life-work balance.

ANS: D According to Covey, effective leaders continually engage in learning and self-renewal, as well as in maintaining a balanced life, radiating positive energy, believing in other people, being concerned with the common good, and being synergistic.

12. Becky graduated five years ago and is keenly interested in pursuing leadership opportunities. She has been active in learning about leadership through workshops and Internet research and recently began a graduate degree program with a focus on nursing administration. She has excellent clinical skills and eagerly accepts responsibility for various projects on the unit. Her sarcastic and sometimes aggressive behavior tends to alienate other staff members on the unit. In coaching Becky, you: a. Suggest that she reflect on situations in which she has had a positive influence and consider how her interactions contributed to the situation. b. Suggest that she not consider leadership roles because her interaction skills are more suited to roles in which she has limited opportunities to work with others. c. Ask staff members on the unit with whom she works to provide her feedback about ways in which her behavior irritates or turns them away. d. Encourage her to continue her graduate courses, as information about strategies and technical aspects of the role will compensate for negative interactions.

ANS: A Leadership involves radiating positive energy and the ability to inspire and motivate others. Management can be taught through formal instruction, but leadership is attained through reflection on rich personal experience.

13. The Sunny Long-Term Care Facility has experienced numerous difficulties with staff relationships, despite its success in maintaining financial viability and judicious use of resources. Staff members complain that the primary concerns of the facility include applying policy, saving

money, and ensuring that lawsuits are avoided. There is little trust in, and involvement of, staff members. This facility may be: a. Well managed and well led. b. Overly managed and not well led. c. Poorly managed and well led. d. Overly led and overly managed.

ANS: B This organization is concerned primarily with coordination of resources, application of current policy, and economic issues connected to the present.

These behaviors are consistent with the management role. There is little evidence that the organization displays leadership, which involves trust, belief, hope, and vision.

14. While explaining the importance of developing leadership skills among nurses to a group of first-year nursing students, Natalie, a nursing unit manager, emphasizes that: a. Most nurses are not expected to assume leadership roles. b. The role of nurse leadership is only at the bedside, ensuring that patient care is performed according to established standards. c. Only individuals in formal leadership roles are expected to be leaders. d. The public depends on nurses to assume leadership in moving consumer advocacy concerns forward.

ANS: D The complexity of nursing and the healthcare environment demands that all nurses assume roles of manager, leader, and follower, depending on the situation. Nurses are involved in providing leadership in direct patient care, in leading others at a unit or organizational level, in moving the profession forward, and in participating in legislative and policy arenas. Consumers depend on nursing leadership to carry the healthcare agenda forward.

15. Which of the following nurses is MOST likely to inspire others to do their best? a. Nancy, RN, is an individual who enjoys details and organization. She regularly leaves notes for the next shift about what has been done incorrectly or omitted. b. Jim, RN, has been involved in nursing for several years and is well liked by patients and families. He continually searches for new knowledge and skills, and his sense of humor and optimism are infectious. c. Clara has been the head nurse on Unit 3Y for years. She is quiet but enjoys

patients and their families. She has not been to a conference in years because the unit is her entire life. d. Karen is a team leader. She is extraordinarily vigilant about ensuring that everyone is treated fairly in assignments. She is also very conscientious about care and regularly checks up on what everyone is doing to ensure that it is done correctly.

ANS: B To be inspired, people must have a positive leader who radiates energy, a zest for learning, and an interest in the common good, and is engaged in selfrenewal. This leader is hopeful and optimistic. Leaders, not managers, inspire others to work to their highest level.

16. The new head nurse on G Unit has been the subject of a great deal of discussion and complaining during breaks. She is a competent nurse of tremendous integrity with approximately 30 years’ experience. Her predominant method of problem solving and communication is through meetings, which can go over the allotted time. The staff may: a. Be represented by a high number of Baby Boomers. b. Be presenting different generational values and attitudes than the head nurse. c. Be unresponsive to her transactional leadership style. d. Want a leader rather than a manager.

ANS: B Leaders who come out of the Baby Boomer generation may be more comfortable with collective action than followers who come out of the Emerging Workforce generation, who are more comfortable with interactions if they are seen as having value for them and with activities if they are seen as having benefit. A group that is highly weighted toward the Emerging Workforce generation may find the approach of a leader who is part of the Baby Boomer generation frustrating and may not understand the meaning or value of the meetings.

17. The adage “leaders are born and not made” reflects which of the following ideas around leadership? a. Management can be taught; leadership depends on abilities. b. Mentorship is important in developing innate skills of leaders. c. Leadership is a natural skill that cannot be refined or developed. d. Succession planning and formal education related to leadership are ineffective.

ANS: A Leadership is an abilities role that is reflective of rich personal experience. It can be developed and refined through such strategies as coaching, mentorship, and reflection. Management can be taught and learned.

18. Kari, a head nurse on the dialysis unit, has been informed during budget planning meetings that budget cuts are likely. She discusses this at the next unit meeting and tells staff members that unless they do their jobs well, their positions may be terminated, and there will be no replacement. Kari is enacting which management style? a. Transformational b. Transactional c. Trusting d. Truthful ANS: B Transactional leaders tend to rely on position and power, and they tend to reward and punish according to performance and conformity with expectations.

19. Susan, a new graduate on the dialysis unit, appears to take Kari’s remarks very seriously and works even harder, often volunteering for extra assignments. She also is often in Kari’s office, advising of successes with her patients and of the extra effort that she is committing. This behavior suggests that Susan: a. Is fearful of losing her job. b. Lacks understanding of Kari’s leadership style. c. Is not intimidated by Kari’s leadership style. d. Knows how to “play the game.”

ANS: D Followers under transactional leadership feel secure about what will happen next or what is needed to be rewarded; therefore, they learn to “play the game.”

20. The style of leadership that Kari is exhibiting is likely to: a. Ensure that the organization is financially stable. b. Stifle innovative thinking about ways to move out of financial jeopardy. c. Lead to apathy and disinterest in the organizational goals. d. Lead to decreased attrition of staff on her unit.

ANS: B

Whether or not the organization achieves financial stability is a function of financial envisioning and planning, but the style of leadership (transactional) that Kari is demonstrating is likely maintaining the status quo within the organization, without generating creative and innovative ideas to address the financial issues. Staff commitment is low to stable, and conformity to organizational goals is motivated by external rewards.

21. A group of managers is meeting to discuss ideas related to the successful implementation of evidence-based practice on their units. Susan has been asked by the director of care to assume leadership of these discussion groups.

After two such sessions, Susan expresses disappointment to her mentor that the group seems disinterested in her ideas and that they are listening to Ken, who has much less experience with leadership. In discussing this with Susan, the mentor understands that leadership: a. Is a designated role. b. Must be earned. c. Is more likely to be taken by someone who is more talkative. d. Rarely is taken over by someone with less experience.

ANS: B A person can have an impressive title, but title or designation does not make the person a leader. A leader must have the ability to inspire others to follow.

22. The senior executive praises John for the positive patient evaluations that his unit has received. As an effective leader, John: a. Thanks the senior executive for having confidence in him and celebrates by going out to a special restaurant. b. Points out the impact that the changes he has initiated have had on the unit. c. Advises the senior executive that the mission statement and goals are important to him. d. Points out the contributions of his staff to the outcomes and shares the praise with his staff.

ANS: D An effective leader is eager to share the glory with those who have worked with him or her to achieve outcomes and success. The act of acknowledging the achievement to the senior executive and of sharing the positive feedback with his staff empowers the staff and builds a support base for the leader.

23. During a discussion of concern about approaches used with aggressive patients in the Emergency Department, several staff members express

concern for their safety. As a leader, the nurse manager should: a. Look directly at speakers and acknowledge their comments. b. Promise to implement each suggestion that is made. c. Implement the idea that receives the most discussion. d. Listen but implement the plan that she had in mind before the discussion began.

ANS: A One of the five rules for leaders is to listen to the constituents—in this instance, the staff members who have safety concerns. Active listening in the United States means establishing direct eye contact and asking probing questions. Listening does not obligate the leader to any one course of action.

Action will be based on what is best for the group.

24. In working with Cheryl, her mentor suggests that it is really important for Cheryl to engage in self-appraisal and to know her strengths. This observation is based on an understanding that: a. Self-confidence comes automatically out of leading. b. Self-confidence requires constant self-affirmation of strengths. c. There is little external motivation and affirmation in leadership. d. Supervisors of leaders rarely provide feedback.

ANS: C Followers usually hold opinions about decisions that are made; these opinions can be favorable or not, which means that external motivation and affirmation are rare. Leaders have to be confident in their own abilities and enthused about the vision that they have created.

MULTIPLE RESPONSE 1. As a senior executive, you are keen to develop your hospital as a learning organization. Part of your purpose in translating this vision into practice is to : a. Retain funding from third-party payers. b. Develop leaders. c. Maintain and/or improve quality of care. d. Stay abreast of new knowledge and evidence.

ANS: B, C, D Learning organizations are concerned with providing opportunities and incentives for individuals and groups to engage in lifelong learning, in recognition of the positive impact that learning has on patient outcomes and

staying abreast of new knowledge. Lifelong learning and reflection are also characteristics of leaders.

Chapter 05: Legal and Ethical Issues Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. The manager in the coronary care unit believes that the most important ethical considerations in performance evaluations are that they include the employee’s good qualities and that they give positive direction for professional growth. This belief is an example of: a. Justice. b. Fidelity. c. Beneficence. d. Nonmaleficence.

ANS: D Nonmaleficence refers to “doing no harm.” For a nurse manager following this principle, performance evaluation should emphasize an employee’s good qualities and give positive direction for growth. Destroying the employee’s self-esteem and self-worth would be considered doing harm under this principle.

2. A staff nurse in the area that you manage has excelled in the delivery of patient education. You are considering implementing a new job description that would broaden her opportunity to teach patients and orient new staff members to the value of patient education. The ethical principle that you are most directly reinforcing is: a. Justice. b. Fidelity. c. Paternalism. d. Respect for others.

ANS: C The principle of paternalism allows one person to make partial decisions for another and is most frequently deemed to be a negative or undesirable principle. Paternalism, however, may be used to assist persons to make decisions when they do not have sufficient data or expertise. Paternalism becomes undesirable when the entire decision is taken away from the employee.

3. A patient refuses a simple procedure that you believe is in the patient’s

best interest. The two ethical principles that are directly in conflict in such a situation are: a. Fidelity and justice. b. Veracity and fidelity. c. Autonomy and beneficence. d. Paternalism and respect for others.

ANS: C Autonomy refers to the freedom to make a choice (e.g., refuse a procedure), and beneficence to doing good (performing a procedure that will benefit the patient).

4. An individual in a wheelchair is applying for the position of receptionist in an outpatient clinic. The nurse manager understands that the Americans with Disabilities Act of 1990 requires that employers: a. Make reasonable accommodations for persons who are disabled. b. Allow modified job expectations for persons recovering from alcoholism. c. Hire disabled individuals before hiring other qualified, non-disabled persons. d. Treat, for purposes of employment, homosexuals and bisexuals as disabled.

ANS: A The purposes of the ADA are to eliminate discrimination against persons with disabilities and to provide consistent, enforceable standards to address discrimination in the workplace.

5. A staff nurse who was fired for reporting patient abuse to the appropriate state agency files a whistleblower lawsuit against the former employer.

Reasons that the court would use in upholding a valid whistleblower suit claiming retaliation include that the nurse: a. Had previously reported the complaint, in writing, to hospital administration. b. Had threatened to give full details of the patient abuse to local media sources. c. Was discharged after three unsuccessful attempts at progressive discipline had failed. d. Had organized, before filing the complaint, a work stoppage action by fellow employees.

ANS: A An employer is unable to fire an employee who, in good faith, reports what is

believed to be a violation of a law, rule, or state or federal law.

6. In keeping with standards of The Joint Commission (TJC), the nurse manager organizes an orientation for new staff members. As part of the orientation, the nurse manager reviews the employee handbook. Employers may be bound to statements in the employee handbook: a. Under the doctrine of apparent agency. b. Under the doctrine of respondeat agency. c. Based on the employee’s or the employer’s expectations. d. Based on the theory that the handbook creates an explicit contract.

ANS: C The handbook is an implied contract and frames the employment contract.

7. To reduce the incidence of falls in a skilled nursing unit, the nurse manager contacts the risk manager. Risk management is a process that attempts to identify potential hazards and: a. Compensate for previous injuries. b. Eliminate these risks before anyone else is harmed. c. Supersede the need for staff members to file incident reports. d. Discipline staff members who have been involved in previous incident reports.

ANS: B Risk management involves taking proactive steps to identify and eliminate risks and liability.

8. One means of ensuring that nurses floated to other patient care areas in healthcare organizations are qualified to work in those areas is: a. Employing additional staff to assist with orientation processes. b. Cross-educating staff members to other areas of the institution. c. Transferring patients to units where the staffing pattern is optimal. d. Orienting staff members to all patient care areas as part of their general orientation to the institution.

ANS: B Nurses should be floated to units as similar as possible to their own to decrease the potential for liability. Negotiating cross-training, a proactive approach to temporary staffing problems, reduces the potential for liability.

9. A colleague asks you to give her your password access so that she can view her partner’s healthcare record. This request violates the patient’s right to:

a. Privacy. b. Confidentiality. c. Undue authorization of treatment. d. Protection against slander.

ANS: A Privacy refers to the right to protection against unreasonable and unwarranted interference with the patient’s solitude. Privacy standards limit how personal health information may be used or shared and mandate safeguards for the protection of health information. Institutions can reduce potential liability in this area by allowing access to patient data, either written or oral, only to those with a “need to know.” Persons with a need to know include physicians and nurses caring for the patient, technicians, unit clerks, therapists, social service workers, and patient advocates. Others wishing to access patient data must first ask the patient for permission to review a record.

10. On your nursing unit, you employ LPNs, RNs, and advanced practice nurses. You will need to be familiar with at least: a. Two nursing practice acts. b. Two nursing practice acts in most states. c. At least one nursing practice act. d. One nursing practice act and a medical act.

ANS: C In all states, you will need to be familiar with at least one nursing practice act. In some states, there may be two nursing practice acts if RNs and LPNs/LVNs come under different licensing boards.

11. A nurse on your inpatient psychiatric unit is found to have made sexually explicit remarks toward a patient with a previous history of sexual abuse. The patient sues, claiming malpractice. Which of the following conditions may not apply in this situation? a. Injury b. Causation c. Breach of duty d. Breach of duty of care owed ANS: A By virtue of employment, the nurse owes a duty of care to the patient; this care has been breached by a nurse, who would be expected to know that this behavior violates usual standards of care. The resultant injury, the fifth malpractice element, must be physical, not merely psychological or transient.

In other words, some physical harm must be incurred by the patient before malpractice will be found against the healthcare provider, which is not evident in this situation where the action did not involve physical harm.

12. As a charge nurse, you counsel your RN staff member that he has satisfied his duty of care by notifying a child’s physician of his concerns about deterioration in the child’s status at 0330 hours. The physician does not come in. The child dies at 0630 hours. As the charge nurse, you could be held liable for: a. Professional negligence. b. Assault. c. Avoidance. d. Murder.

ANS: A Professional negligence can be asserted when there is failure to do what a reasonable and prudent nurse would do in the same situation. In this situation, the charge nurse might have advocated further for the patient in light of the evident seriousness of the child’s condition.

13. The parents of a toddler who dies after being brought to the ER launch a lawsuit, claiming that the failure of nurses to pursue concerns related to their son’s deteriorating condition contributed to his death. The senior nurse executive is named in the suit: a. As a global respondent. b. Under the doctrine of respondeat superior. c. As a frivolous action. d. Under the element of causation.

ANS: B Known as vicarious liability, the doctrine of respondeat superior makes employers accountable for the negligence of their employees, using the rationale that the employee could not have been in a position to have caused the wrongdoing unless hired by the employer.

14. During a staff shortage, you hire an RN from a temporary agency. The RN administers a wrong IV medication that results in cardiac arrest and a difficult recovery for the patient. Liability in this situation: a. Is limited to the temporary agency. b. Is restricted to the RN. c. Could include the RN, the agency, and your institution.

d. May depend on the patient’s belief regarding the employment relationship.

ANS: D Apparent agency may apply here because your liability and that of your institution could be established if it can be shown that the patient believes that the RN was an employee of yours and of your institution.

15. You volunteer at a free community clinic. A 13-year-old girl claims to have been diagnosed with SLE and presents with chlamydia. The team leader at the clinic advises that: a. The state-defined age of legal consent is 18; therefore, no treatment can be delivered. b. The teen is underage and should be referred to the family general practitioner. c. Care can be provided as long as consent is voluntary and information about treatment and options is provided. d. Treatment is provided as long as telephone consent is obtained from a parent or legal guardian.

ANS: C All states have a legal age for consent; generally, this age is 18. However, emancipated minors, minors seeking treatment for substance abuse, and minors seeking treatment for communicable diseases can provide their own consent.

16. Three gravely ill patients are candidates for the only available bed in the ICU. As the supervisor, you assign the bed to the patient with the best chance of recovery. This decision reflects which of the following ethical principles? a. Beneficence b. Autonomy c. Veracity d. Nonmaleficence ANS: A Beneficence refers to doing what’s good for the patient; in this situation, doing what’s good means providing care to the patient with the best likelihood of recovery.

17. Which ethical principle is primarily involved in informed consent? a. Veracity b. Autonomy c. Beneficence

d. Nonmaleficence ANS: B Autonomy refers to the right to choose freely, which is inherent in informed consent.

18. The principle that requires nurses to uphold a professional code of ethics, to practice within the code of ethics, and to remain competent is which of the following? a. Veracity b. Autonomy c. Fidelity d. Honesty ANS: C Fidelity refers to promise keeping or upholding one’s promise to practice as a reasonable and prudent nurse would do and in an ethically competent manner.

19. Mr. M. complains to you that one of your staff asked him details about his sexual relationships and financial affairs. He says that these questions were probing and unnecessary to his care, but he felt that if he refused to answer, the nurse would be angry with him and would not provide him with good care. Mr. M.’s statements reflect concern with: a. Privacy. b. Confidentiality. c. Veracity. d. Informed consent.

ANS: A Privacy protection includes protection against unwarranted intrusion into the patient’s affairs.

20. To satisfy duty of care to a patient, a nurse manager is legally responsible for all of the following except: a. Notifying staff of changes to policies related to medication administration. b. Scheduling and staffing to ensure safe care. c. Delegating in accordance with practice acts. d. Supervising the practice of the physician.

ANS: D Legally, the nurse manager is accountable to nursing practice standards, standards for nurse administrators, and hospital policies and procedures.

21. In a telehealth organization, a nurse who is licensed in New York and Pennsylvania provides teaching to a patient who resides in Pennsylvania. The patient charges that the teaching failed to provide significant information about a potential side effect, which led to delay in seeking treatment and untoward harm. Under which state nurse practice act and standards would this situation be considered? a. New York b. Pennsylvania c. Neither New York nor Pennsylvania d. Both New York and Pennsylvania ANS: B Under the law, the state in which the patient resides and not the state where the nurse holds his or her license determines the state nurse practice act that is considered.

22. A member of a patient’s family calls the nurse manager of the palliative care unit to express concern that a member of the family, who died on the weekend, had requested analgesics from the RNs on duty. An RN came with the analgesic nearly 45 minutes later, just after the patient had died. The manager is aware that the unit was especially busy that weekend because many patients were seriously ill, staff had called in ill, and the staffing manager was unable to completely replace staff who were absent. The manager is deeply troubled that the family member had to die in pain because it violates what she knows should have been done. This manager is experiencing: a. Compromised agency. b. Moral distress. c. Moral sensitivity. d. Moral dilemma.

ANS: B Moral distress is experienced when nurses cannot provide what they perceive to be best for a given patient. Examples of moral distress include constraints caused by financial pressures, limited patient care resources, disagreements among family members regarding patient interventions, and/or limitations imposed by primary healthcare providers.

23. While walking past a patient’s room, you overhear one of the RN staff telling a patient that the patient has no right to refuse chemotherapy treatment because the family and the doctor think the treatment is the best option for

the patient. This patient is 40 years of age and alert. When you meet later to discuss what you heard with the RN, it is important to: a. Discuss how statute law enforces the right of the doctor, but not of families, to ensure that patients comply with recommended treatment plans. b. Discuss that statute law provides for patient autonomy and refusal of treatment. c. Remind the nurse to provide clearer explanations to aid in the patient’s comprehension of the treatment and compliance. d. Acknowledge the nurse’s role in ensuring that she does not fail in her duty of care for the patient.

ANS: B Statute law states that the patient must be given sufficient information, in terms he or she can reasonably be expected to comprehend, to make an informed choice. Inherent in the doctrine of informed consent is the right of the patient to informed refusal. Patients must clearly understand the possible consequences of their refusal.

MULTIPLE RESPONSE 1. One of your staff nurses asks for your advice because a patient refuses to sign a consent for surgery. The patient says that he won’t sign because he doesn’t understand the nature of the surgery. You advise that : a. Consent must not be coerced. b. The patient has a right to choose not to consent. c. The patient must sign the consent because the doctor wants him to sign. d. Witnessing a consent is related only to the voluntary nature of the signature.

ANS: A, B, D Consent must be voluntary and not coerced; the patient must understand what he is signing, must have legal capacity, and must understand the consequences of refusal. Witnessing a consent means attesting to the voluntary nature of the patient’s signature.

2. With regard to nursing practice, nurse managers are held responsible for : a. Practicing within legal guidelines established under state law and nurse practice acts. b. Ensuring that nursing staff under their supervision are currently licensed to practice. c. Referring all errors in nursing judgment to state discipline boards.

d. Ensuring that physicians are properly licensed to provide care on patient care units.

ANS: A, B Nurses are responsible for knowing and practicing under state law and nurse practice acts. Managers are responsible for monitoring staff practice and ensuring that staff hold current, valid licensure.

Chapter 06: Making Decisions and Solving Problems Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. The risk manager informs the nurse manager of an orthopedic unit that her unit has had an increase in incident reports about patients falling during the 11-7 shift. The nurse manager knows that the best way to resolve the problem is to: a. Use creativity. b. Obtain support from the 7-3 shift. c. Use institutional research. d. Identify the problem.

ANS: D Identification of a problem is the first step in problem solving and occurs before any other step. The most common cause for failure to resolve problems is the improper identification of the problem/issue; therefore, problem recognition and identification are considered the most vital steps.

2. The nurse manager of a rehab unit wants to purchase a new anti-embolic stocking. To make a high-quality decision, the nurse manager would: a. Involve the rehab staff in the decision. b. Involve the sales representative. c. Make the decision alone. d. Involve administration in the decision.

ANS: A In a shared decision model, the decisions are made through an interactive, deliberate process and the staff may express and discuss options and preferences. The shared decision model has been shown to increase work performance and productivity, decrease employee turnover, and enhance employee satisfaction.

3. Several nurses on an adolescent psychiatric unit complain that the teens are

becoming unmanageable on the 0700-1900 shift. To resolve this problem, the nurse manager decides that the staff should have a brainstorming session. The goal of brainstorming is to: a. Evaluate problem solutions. b. Critique the ideas of others. c. Generate as many solutions as possible. d. Identify only practical and realistic ideas.

ANS: C Brainstorming encourages creativity when one is beginning to problem-solve and avoids premature shutting down of ideas through early evaluation. The goal is to generate ideas, no matter how seemingly unrealistic or absurd.

4. During a fire drill, several psychiatric patients become agitated. The nurse manager quickly assigns a staff member to each patient. This autocratic decision style is most appropriate for: a. Routine problems. b. Crisis situations. c. Managers who prefer a “telling” style. d. Followers who cannot agree on a solution.

ANS: B An autocratic style is appropriate when rapid decision making is required, such as in a crisis situation.

5. After the nurses who work on an adolescent psychiatric unit have had a brainstorming session, they are ready to resolve the problem of teenagers who are unmanageable. To maximize group effectiveness in decision making and problem solving, the nurse manager has: a. Prevented conflict. b. Formed highly cohesive groups. c. Used majority rule to arrive at decisions. d. Encouraged equal participation among members.

ANS: D Groups are more likely to be effective if members are involved, the group is cohesive, communication is encouraged, and members demonstrate some understanding of the group process. The nurse leader or manager should provide a nonthreatening and positive environment in which group members are encouraged to participate actively.

6. To solve a problem, the nurse manager understands that the most important

problem-solving step is: a. The implementation phase. b. Identification of numerous solutions. c. Accurate identification of the problem. d. Evaluation of the effectiveness of problem resolution.

ANS: C To proceed effectively, it is important to determine if a problem exists and to accurately identify a problem. Failure to resolve problems is most often linked to improper identification of the problem.

7. A clinic nurse has observed another nurse deviating from agency policy in performing wound care. The best approach for the clinic nurse to take is to: a. Stay out of it. b. Inform the nursing supervisor. c. Fill out a notification form (incident report). d. Assess the risk to the client and the agency before proceeding.

ANS: D If the situation is subjective, non-routine, and unstructured or if outcomes are unknown or unpredictable, the nurse leader and manager may need to take a descriptive or behavioral approach. More information (such as degree of risk to the client and to the agency) needs to be gathered to address this situation effectively.

8. In a rural hospital, the unit for which you are charge nurse has a particularly busy morning. A 52-year-old patient is complaining of left-sided chest pain and a multiparous patient is about to deliver. A child with asthma is experiencing early signs of an attack. The other RN on the unit is a recent graduate who has not yet been orientated to the labor room and has limited cardiac nursing experience. An unregulated assistant is also available. You must decide which patient situation you will take and where the RN’s skills can best be used. Given the limitations in skills and experience, number of staff available, and time constraints, you must make a decision that involves: a. A higher-order thinking process. b. Selecting the best option for reaching a predefined goal. c. Optimizing. d. Satisficing.

ANS: D With this approach, the decision maker selects an acceptable solution, one that may minimally meet the objective or standard for a decision. This

approach allows for quick decisions and may be the most appropriate when lack of time is an issue.

9. The risk manager wants to evaluate the reasons for an increased number of falls on the rehab unit. The risk manager devises a fishbone diagram. A fishbone diagram is a useful tool to: a. Identify the root causes of problems. b. List possible solutions to problems. c. Help leaders select the best options. d. Evaluate the outcomes of decisions made.

ANS: A A fishbone diagram, also known as a cause-and-effect diagram, is useful for determining the reasons (causes) for an effect (falls).

10. An outpatient surgery manager is evaluating infusion pumps for the operating room. The manager should: a. Select the least expensive brand. b. Use a decision-making tool to evaluate brands. c. Ask the nursing staff which brand they prefer. d. Select the vendor the institution usually buys from.

ANS: B Decision-making tools such as decision grids and SWOT analyses are most appropriate when information is available and options are known.

11. Select the statement that best defines the difference between problem solving and decision making: a. Decision-making skills require critical thinking; problem-solving skills do not. b. Problem-solving skills require critical thinking; decision-making skills do not. c. Decision making is a goal-directed effort; problem solving is focused on solving an immediate problem. d. Problem solving is a goal-directed effort; decision making is focused on solving an immediate problem.

ANS: C Problem solving is focused on solving immediate problems, whereas decision making is a goal-directed process that is aimed at selecting appropriate actions from among options. Not all decisions begin with a problem.

12. Sue, a nurse manager, has a staff nurse that has been absent a great deal

for the past three months. A whistleblower gives some information to Sue indicating that the staff nurse will be resigning and returning to school.

Because of this, Sue decides to do which of the following? a. Immediately fire the staff nurse. b. Speak to the whistleblower and elicit more information. c. Speak to the staff nurse and ask her to resign. d. Do nothing.

ANS: D Doing nothing is often warranted because of lack of energy, time, or resources to solve the real problem adequately, and because the benefits are not seen as sufficiently compelling to commit to an action.

13. The maintenance department wishes to have the nursing lounge renovated, so the lounge will be more “user-friendly.” The department asks the nursing staff to make a wish list of everything that they would like to see in the new lounge. This process is an example of which part of the decisionmaking process? a. Assessment/Data collection b. Planning c. Data interpretation d. Generating hypotheses ANS: A In this particular model (a model similar to the nursing model), data collection is the first step toward identifying important alternatives or determining if there is a problem or problems.

14. A good nursing decision maker is one who: a. Uses various models to guide the process based on the circumstances of the situation. b. Adopts one model and uses it to guide all decision making. c. Decides not to use any models because they are all useless. d. Develops a new model each time a decision has to be made.

ANS: A The decision model that a nurse uses depends on specific circumstances. Is the situation routine and predictable or complex and uncertain? Is the goal to make a decision that is “just good enough” (conservative) or one that is optimal?

15. From the information supplied in this chapter, which statement best

defines critical thinking? Critical thinking is a: a. High-level cognitive process. b. Process that helps to develop reflective criticism for the purpose of reaching a conclusion. c. High-level cognitive process that includes creativity, problem solving, and decision making. d. Discussion that guides the nursing process.

ANS: C It is generally accepted by many authors and researchers that this statement best defines critical thinking.

16. Decision making is described by the nursing educator as the process one uses to: a. Solve a problem. b. Choose between alternatives. c. Reflect on a certain situation. d. Generate ideas.

ANS: B The hallmark of decision making is choosing among options. Generating options is one phase of decision making, and solving a problem refers to problem solving, which is problem centered. Decision making does not always begin with problems, but rather is defined as a purposeful, goaldirected effort that uses a systematic process to choose among options.

17. Justin is a nurse manager in a rehabilitation unit in a small urban center.

There is a high turnover rate among rehab-assistants because of the heavy work assignments. Despite his need for staff, Justin decides to review each application thoroughly and interview candidates carefully because he recognizes that it is important to hire staff who can best provide high-quality care and who will fit well with the team. Which of the following decisionmaking models did Justin use in making his decision? a. Subjective model b. Objective model c. Optimizing model d. Satisficing model ANS: C Optimizing is a decision style in which the decision maker selects the option that is best, based on an analysis of the pros and cons associated with each option. A better decision is more likely when using this approach, although it

takes longer to arrive at a decision.

18. Justin is a nurse manager in a rehabilitation unit in a small urban center.

There is a high turnover rate among rehab-assistants because of the heavy work assignments. Despite his need for staff, Justin decides to review each application thoroughly and interview candidates carefully because he recognizes that it is important to hire staff who can best provide high-quality care and who will fit well with the team. Which of the following decisionmaking solutions should Justin consider to have a more efficient department a. Replace staff only with qualified applicants. b. Determine what the problem or problems are before hiring new staff. c. Consult with the human resources department and develop a plan for hiring new staff. d. Consider all the options listed.

ANS: D Decision making involves a goal-oriented consideration of many options that are objectively weighed according to their possible risks, consequences, and positive outcomes. The options should be ranked in the order in which they are likely to result in the desired goals or objectives. The solution selected should be the one that is most feasible and satisfactory and has the fewest undesirable consequences. In this instance, all of the options listed might be considered and weighed.

19. When confronted with the controversy and the apparent poor morale of the evening staff, the unit manager decided the staff needed to take some time off. He scheduled holidays for the staff without consulting them. A couple of the staff nurses approached the manager and indicated that the problem was not scheduling, but rather the team leader and her patient assignments. What was the unit manager’s first missed step in problem solving? a. Not using a problem-solving model b. Not considering a number of alternatives c. Poor evaluation of outcomes d. Incorrect problem identification ANS: D The unit manager did not begin with an accurate identification of the problem. Problem solving needs to begin with “why?”

20. John Smith, one of three managers at BSG Labs, drafted a policy that would allow his department to do more testing in his lab. This policy

included the times for regular collection as well as a new process for emergency laboratory testing. The policy and procedures were never followed. The reason was that: a. The policy was too lengthy and inundated readers with too much detail. b. The policy made decisions for other departments in the company. c. The staff did not believe that the new policy would be effective. d. Testing should not be done in the lab.

ANS: B Two primary criteria make for effective decisions. First, the decision must be of a high quality; that is, it achieves the predefined goals, objectives, and outcomes. Second, those who are responsible for its implementation must accept the decision. Higher-quality decisions are more likely to result if groups are involved in the decision-making and problem-solving process.

Taking ownership of the process and outcome provides a smoother transition in changes.

21. High-quality decisions are most likely to be made in nursing situations when: a. Team leaders make the crucial decisions. b. Individuals are advised of the problems. c. Group size is neither too small nor too large. d. Members are passively involved.

ANS: C Research has shown that group size is important. Too small a group means a limited number of options generated. Too large a group can mean lack of structure or lack of meaningful discussion.

22. Knowing when to have the entire team participate in the decision-making process or when to have only the team leader make the decisions depends on the situation and the desired outcomes. The autocratic process is used in which of the following situations? a. The task and the outcome are relatively simple and defined b. It is unlikely that the group will reach a consensus. c. A decision has to be discussed thoroughly. d. A number of options need to be considered.

ANS: A An autocratic style is appropriate when rapid decision making is required and in situations where the task and the potential outcome are well-defined.

23. Jane, an experienced head nurse, is given the task of completing the summer vacation schedule for the pediatric unit. She is fully aware of the hospital’s restrictions on time off and the number of staff on vacation at any given time, as well as its issues regarding seniority. She weighs the options of allowing staff choice, such as it takes more time but gives employees options.

However, if choice is allowed, this could cause arguments. Which of the following is the best alternative? a. Ask for requests for vacation time in advance, and post the times. b. Post the completed vacation schedule. c. Post a tentative schedule, and request feedback. d. Post a blank schedule, and ask staff members to fill in their times by a given date.

ANS: D This is based on a decision-making model that allows experience and knowledge to predict whether a decision will or will not work. The experience of the head nurse suggests that it is important to involve staff in decisions that affect them the most.

24. The agency in which you are a nursing leader makes a decision to reduce the number of RN positions in favor of PN positions because agency data suggest that the clients in the agency can receive appropriate care from PN staff. Furthermore, the agency is facing a decline in funding and without restructuring, some clients might not receive services at all. You provide this information on this decision to the staff and ask them to advise you if they have any feedback, concerns, or alternative solutions. This decision-making style is known as: a. Paternalistic. b. Shared. c. Reasoned d. Informative.

ANS: D The informative model offers the staff the ability to make a decision after the information has been shared and without the active involvement of the manager.

MULTIPLE RESPONSE 1. In a busy rehabilitation unit, the team manager decided that the best way to reward the staff was to give them a monetary bonus rather than time off. The

staff was very concerned about the decision and went to the administration with a number of complaints. Critical thinking is a process that entails a number of steps. What steps did the manager omit? She should have : a. Identified what assumptions were underpinning the issues. b. Considered why it was important to make this change or the context for the change. c. Considered how this change might affect staff relationships. d. Attained a majority consensus of all staff.

ANS: A, B, C Taking a majority consensus is not a step in the critical thinking process.

Points A, B, and C are “what,” “why,” and “how” questions that are part of effective critical thinking processes.

Chapter 07: Healthcare Organizations Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. To prepare for the orientation of newly hired nurses, the nurse manager plans a presentation outlining the concept of healthcare networks. Healthcare networks are: a. Units that provide only primary care services. b. Owned by the institutions. c. A feature of all public institutions. d. Units that serve large populations.

ANS: D Healthcare networks are interconnected units. Their aim is serving large regional populations.

2. A local hospital has formed a corporate partnership with a reputable HMO (health maintenance organization). The nurse manager has had to educate staff and personnel about the financial implications of this partnership. An HMO: a. Provides more expensive care than other types of insurance plans. b. Has a centralized administration that directs and compensates physician services. c. Pays physicians on a fee-for-service basis. d. Does not pay as much for acute care as other practice plans.

ANS: B The HMO is a configuration of healthcare agencies that provide basic and

supplemental health maintenance and treatment services to voluntary enrollees who prepay a fixed periodic fee without regard to the amount of services used. HMOs have a centralized administration that directs and pays salaries for physician practice (e.g., HMOs).

3. With the help of a federal grant, the local school nurse has established a spreadsheet that contains relevant nursing data so that she can analyze children’s health. School health programs are: a. Increasingly seen as primary care sites for children. b. Providing only health education programs for children and their parents. c. Capable only of providing referrals for health problems to primary care providers. d. Funded exclusively by local authorities.

ANS: A Traditionally, school health programs were organized to control infectious disease outbreaks, treat and control on-site injuries, and educate parents and children about basic health. Increasingly, schools are being seen as primary healthcare sites for children.

4. The local health department nurse manager has developed and implemented a disaster readiness plan as part of a community service.

Community services: a. Care for the specific needs of individual families in the community. b. Focus on the treatment of community-wide problems rather than on individual health problems. c. Do not include services provided by public health departments. d. Provide personal health follow-up for all acute care hospitalizations.

ANS: B Community services, including public health departments, are focused on the treatment of the community rather than that of the individual. These funds provide personal health services, care for communicable diseases, services for children with birth defects, mental health care, investigation of epidemiology, and treatment of bioterrorism threats and attacks. Monies are allocated also for environmental services and for health resources.

5. A nursing informatics specialist hired by Blue Cross/Blue Shield (a form of third-party payers benefit package for a prepaid fee that uses specific standards to approve a period of time for the use of inpatient and community health services) is participating in:

a. Critical pathways. b. Healthcare networks. c. Health maintenance organizations. d. Managed care.

ANS: D Managed care strives to contain costs (e.g., through limitation of time in care) while maintaining quality. Managed care combines care delivery with financing and provides comprehensive services for a fixed prepaid fee. Group practice plans take various forms. One form has a centralized administration that directs and pays salaries for physician practice (e.g., HMOs).

6. A merger has occurred between a hospital and a local home health agency, creating new roles for the nursing staff in both agencies. The nurse managers of both systems begin to evaluate and revise patient care processes and systems. With the merger, the healthcare organization’s changes are: a. Creating more jobs in the community for registered nurses. b. Resulting in an overall loss of jobs for registered nurses. c. Controlled by the federal and state governments. d. Controlled by the insurance agency.

ANS: A Home care agencies staffed appropriately with adequate numbers of professional nurses have the potential to keep older adults, those with disabilities, and persons with chronic illnesses comfortable and safe at home.

Home care is the fastest growing segment in health care and the volume of home health care may have a subsequent impact on the numbers of nurses required.

7. You are a nurse manager in a facility that is part of a national system of specialized hospitals that provide services to children and that is funded and managed through a religious charity organization. This system emphasizes compassionate, faith-based care. What level of consolidated system is represented in this example? a. First level b. Second level c. Fourth level d. Fifth level ANS: D Consolidated systems tend to be organized into five levels. The fifth level

involves special interest groups that own and operate units along religious lines, teaching interests, or related special interests that drive their activities.

In this example, the facilities are funded and managed by a religious organization that provides care that is congruent with its particular faithbased values.

8. A nurse manager at a home healthcare service has resigned to take a position at a local ambulatory care center. She has been hired because of her expertise in TJC accreditation. To initiate the changes, the nurse manager has to be knowledgeable about the differences between a home healthcare institution and an ambulatory care center, which is a primary care institution.

Primary care institutions are facilities that provide: a. Rehabilitative or long-term care. b. Disease-restorative care. c. First access to care. d. Only outpatient services.

ANS: C The spectrum of care services provided are typically described as primary care (first-access care), secondary care (disease-restorative care), and tertiary care (rehabilitative or long-term care). Ambulatory care centers are an example of primary care.

9. A nurse manager working for a not-for-profit organization should be familiar with the regulations that impact the organization. Not-for-profit organizations: a. Pay dividends to stockholders. b. Can refuse clients who are unable to pay. c. Have no paid employees. d. Pay no taxes.

ANS: D Not-for-profit organizations, often referred to as voluntary organizations, are controlled by voluntary boards and provide services to both paying and charity clients. Funds are redirected toward maintenance and growth as opposed to profit shares for stockholders. Historically, non-profit organizations have been exempt from paying taxes as they commit to providing an important community service.

10. In reviewing the current delivery model, the nurse manager is aware that a demographic change that will have a significant effect on the healthcare

delivery systems of the future is: a. Changes in staffing patterns. b. Increasing reports of violence in the workplace. c. The increasing percentage of the population that will be over age 65. d. Escalations in the cost of health care.

ANS: C A demographic change that will significantly impact the healthcare system of the future is the increasing proportion of individuals 65 years and older. By 2025, more than 18% of the population is expected to be 65 years and older, which means that new healthcare organizations will evolve as the system attempts to maintain older adults in the community for as long as possible.

11. A facility that provides care for patients whose average length of stay is less than 30 days and to patients whose average length of stay is longer than 30 days, and who require inpatient and ambulatory care for addictions, through a spectrum of wellness and illness services and providers, would be considered: a. A healthcare network. b. A tertiary care institution. c. Rehabilitative. d. Long-term care.

ANS: A Healthcare networks embrace and provide wellness and illness services, including primary, secondary, and tertiary care, through a network of providers.

12. Healthcare organization XYZ provides women’s health services on an inpatient basis (average stay of less than 30 days). This facility would likely be considered: a. Primary care, specialized. b. Tertiary care, long-term. c. Acute care, specialized. d. Public care, specialized.

ANS: C The AHA defines an acute care hospital as a facility in which the average length of stay is less than 30 days. Because of the focus on women’s health services, it would also be considered specialized.

13. You are the nurse manager for a not-for-profit health service for the

homeless and for drug users in an impoverished neighborhood. As the manager, your concern about sustainability is related to: a. The possibility of violence. b. An increase in prescription drugs available for abuse. c. Decisions of the public board. d. An increase in uncompensated care events.

ANS: D Public and non-profit hospitals are tax exempt and have a concomitant responsibility to provide mandated community service such as delivering care to the poor and indigent. To keep a non-profit status, facilities must make a good-faith effort to provide community service and charity care Non-profit organizations located in impoverished urban and rural areas are often economically disadvantaged by the amount of uncompensated care that they provide.

14. A nurse manager in a for-profit environment finds it difficult to recruit staff. This difficulty may be most related to aggressive profit goals and: a. Lower salary compensation for staff. b. Rising expectations of impoverished and indigent individuals for services. c. Poor orientation and retention practices for staff. d. An overwhelming emphasis on accepting learners from health disciplines.

ANS: A For-profit hospitals tend to have lower wage and salary costs that are most likely connected to aggressive goals for profit.

15. Which of the following is an example of an HMO? a. Nurse practitioners are paid promptly at discounted fees for each service rendered at a women’s health clinic. b. Physicians in a large urban center are reimbursed for visits made to their clients. c. Physicians are paid for each service delivered to enrolled patients through a prepaid plan. d. Patients pay fixed annual fees for ambulatory care services, regardless of actual utilization of health services.

ANS: D Fee-for-service systems provide compensation to healthcare providers in group practices based on fee-for-service, which in PPQs means that fees are paid promptly but at a discounted rate. HMOs are configurations of healthcare agencies that provide health maintenance and services for enrolled

patients for a fee that is preestablished regardless of utilization of service.

16. As a nurse manager, you have been asked to assist in designing a subacute facility for open heart patients who require further complex care after hospitalization. In setting up the facility, which of the following would require reassessment? a. Patients admitted to the facility must have adequate health insurance to cover the services provided. b. A local nurse education program asks you if nursing students can gain clinical experience with recovering surgical patients in the facility. c. Public funding will be provided to enable care of patients who have an ordinary course of recovery. d. The facility is an older house that is more than 30 minutes away from the acute care center.

ANS: D Because of the types of patients being accepted for care and the distance of the subacute facility from acute care, emergency response and seamless transfer issues in the event of an unanticipated crisis must be addressed. As a nurse manager, an important part of your position may be assisting to develop strategies to maximize the benefits and minimize the risks in this situation.

17. Which of the following would be the most appropriate focus in developing a business plan for a nurse-owned home healthcare service? a. Programs to educate the community on preparing healthy meals for a limited cost b. Reduction of injuries from alcohol-related accidents c. Pain management for patients with low back pain d. Reduction of falls among seniors ANS: C Nurse-managed and nurse-owned healthcare services are part of a growing number of organizations that extend health care beyond that offered through traditional services. Growth in these organizations and services has been spurred by the implementation of the prospective payment system, which resulted in early discharge of many patients from acute care facilities. These nurse-managed and nurse-owned services focus on the care of individuals and families rather than on community-based outcomes for populations such as older adults, or on community-based issues such as injuries related to drunk driving.

18. As a nurse manager, you have been offered a position at a Veterans Administration hospital. In accepting the position, it is important for you to understand that veterans hospitals provide: a. Primary care and are privately funded. b. A range of services and are responsible to government and taxpayers. c. Secondary care only and are publicly administered and funded. d. Services to veterans under an HMO. ANS: B Veterans Administration hospitals provide a range of services to veterans and are responsible to government and thus to taxpayers, who support the hospitals.

19. A group of patients with early Alzheimer’s disease and their spouses approach you regarding help with the establishment of a local Alzheimer’s Society for the support and education of affected individuals and their families. As a manager in an ambulatory care clinic, what suggestion or advice would you offer this group? a. Self-help groups are, by nature, directed, funded, and led by those requiring help, and therefore, the patients and families should need no help from your clinic. b. Your healthcare organization would be pleased to help as long as your organization financially takes over responsibility for direction, leadership, and management. c. Through partnership, you will provide supports, if possible, that the patients and spouses themselves identify as necessary in the establishment of the group. d. The services that the patients and spouses are proposing are likely being offered somewhere else already.

ANS: C Self-help groups often are made up of, and are directed by, peers who have healthcare needs. A growing trend is the development of community-based geriatric organizations in partnership with healthcare organizations. The request of the patients and their spouses indicates that this service is needed in the community and that they are looking for assistance in setting up the Alzheimer’s Society rather than having your agency take over the management of the group.

20. Tracy is an RN case manager who interfaces between the Centers for Medicare & Medicaid. Tracy’s responsibilities most likely would include:

a. Managing physician-led research. b. Monitoring physician documentation of the need for medical care. c. Determining which services are designated fee-for-service. d. Identifying errors in physician diagnoses.

ANS: B Nurse case managers serve as interfaces for the Centers for Medicare & Medicaid Services (CMS) and are key in monitoring compliance with Conditions of Participation (CoP) elements. The case managers routinely monitor for appropriate physician documentation of medical necessity and other required CoP elements.

21. The Wellington Mental Health Institute is fully accredited by the AOA and not directly by the CMS. This means that the Wellington facility: a. Cannot accept mental health patients who are Medicare beneficiaries. b. Can care for only Medicaid and not Medicare beneficiaries. c. Has not met the standards set by the CMS as determined by an external review panel. d. Has been reviewed and accredited by the AOA, which is a deeming authority for CMS. ANS: D CMS accreditation or external review of an organization’s compliance with the standards set by the CMS can be conducted by the AOA, which is a deeming authority for CMS. 22. As a nurse manager in a hospital, you would expect which of the following to be the major contributor to funding and revenues in your organization? a. The federal government b. Medicare c. Medicaid d. Blue Cross/Blue Shield ANS: A The federal government is responsible for both Medicare and Medicaid and is the largest and most influential health insurance program in the United States.

The federal government is the primary payer of healthcare costs in the United States.

23. As a nurse manager, you have been asked to be part of a design team for health services that have vertical integration. In planning for these services,

your team will design a proposal that will: a. Cluster like services together, such as outpatient clinics for the care of children with various developmental and medical needs. b. Plan for the smooth transition of patients from the emergency services department to other units in the hospital. c. Ensure that funding follows the patient from acute care to long-term care services. d. Bring together acute care, ambulatory, home care, and palliative care services for the management of patients diagnosed with cancer.

ANS: D When organizations align to provide a full array or continuum of services, the arrangement is referred to as vertical integration. Benefits attributed to vertical integration include enhanced coordination of services, efficiency, and customer services.

24. Which of the following patients would be most likely covered under Medicare? a. Jim, who lives on the street and has occasional infections b. Alysha, who is on social assistance and has a 5-year-old daughter with frequent ear infections c. Karen, a housewife, 45 years of age, whose husband recently abandoned the family d. Dan, who is 68 years of age and in good health ANS: D Medicare is a federal government program for individuals over 65 and with certain permanent illnesses, such as end-stage renal disease. Medicaid provides financing of health care for the medically indigent.

25. Which of the following is an outcome of managed care? a. Shift of patients to outpatient and home health services b. Less complexity in funding sources c. Less complexity in rules for consumers to follow d. Greater consistency in the quality of care ANS: A A goal of managed care is to reduce the cost of expensive acute hospital care by focusing on out-of-hospital preventive care and illness follow-up care, which has led to shifts in where health care is delivered.

MULTIPLE RESPONSE

1. As a nurse manager in a for-profit hospital, you are interested in promoting teaching programs for physicians, because evidence suggests that hospitals with teaching programs tend to promote better care for patients. Your administration indicates that it cannot support your ideas or proposal because of : a. Increased salary costs. b. Duplication of tests and procedures. c. Graduate medical education. d. Potential damage to reputation through learner error.

ANS: A, B, C Teaching hospitals tend to incur higher costs because of the salaries required for supervision of physicians, duplication of tests and procedures through the learning process, longer times required to process patients, costs of state-ofthe art technology, biomedical research, and stand-by capacity of specialized care. Because of the additional costs, few for-profit agencies and organizations support teaching programs.

Chapter 08: Understanding and Designing Organizational Structures Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. Because of rapid turnover and the ongoing hiring of new graduates, the skill levels of staff in a busy CCU are varied. Senior staff are becoming burned out with the need to provide mentorship and guidance to new staff. As the manager, you propose the addition of a nurse in advanced practice to provide consultation and education for staff. This position is termed a(n): a. Hierarchical position. b. Ancillary. c. Line position. d. Staff position.

ANS: D Line personnel have authority for decision making, whereas personnel in staff positions provide education, support, advice, and counsel. The nurse in the advanced practice is providing advice and support through education as well as consultation.

2. A hospital is working toward becoming a Magnet™ hospital. The chief nursing officer is aware that professional nursing departments of the future will:

a. Not be directed by nurses. b. Be virtual organizations. c. Be designed to maintain nursing standards of practice. d. Be entitled to have client care departments.

ANS: C Hospitals that are successful in recruiting and retaining nurses have found that the major contributing characteristic to success is a nursing department that is structured to provide nurses the opportunity to be accountable for their own practice. Accountability is guided by nursing standards of practice and thus, successful nursing departments emphasize maintenance of these standards.

3. The chief nursing officer and the dean of the School of Nursing believe that by establishing rules and regulations and controlling the environment, this partnership will: a. Promote professional medical authority, autonomy, and responsibility. b. Need a degree of flexibility to engender success. c. Be essential for self-governance. d. Provide for the establishment of medical committees.

ANS: B Bureaucratic structures have a centralized command structure (chain of command). with a clear division of labor and well-articulated and commonly accepted expectations for performance. Rules, standards, and protocols ensure uniform actions and limit individualization of services and variance in workers’ performance. Although bureaucracy enhances consistency, by nature, it limits employees’ autonomy and thus the potential for innovations.

4. In matrix organizational structures, a nurse manager understands that this type of structure: a. Is a simplified organizational structure. b. Has both a functional manager and a service or product-line manager. c. Arranges departments strictly according to function. d. Promotes harmony in organizational decision making.

ANS: B Matrix structures are complex, integrated organizational structures that involve both functional and service or product-line managers. In this structure, team members or teams from various functional departments may combine to complete a project or program, thereby becoming responsible to both their functional department manager and their product-line manager.

5. Collaborative partnerships between hospitals and schools of nursing are examples of hybrid organizational structures. A hybrid organizational structure: a. Has many divisions of labor. b. Best fits long-term care units. c. Has a mixture of the characteristics of various organizational types. d. Places the authority for decision making closest to the places where workers perform.

ANS: C Hybrid structures include characteristics of various organizational types and reflect the needs of the situation and the environment.

6. In opening a new dialysis unit, the nurse manager has to develop a philosophy for the unit. This philosophy needs to: a. Reflect the culture of the unit and its values. b. Be developed by the nursing manager on the unit. c. Identify the clients that will be served on the unit. d. Replicate the organization’s philosophy.

ANS: A A philosophy expresses the values and beliefs that members of the organization hold about the nature of their work, about the people to whom they provide service, and about themselves and others providing the services.

7. The hospital administration gives approval to the chief nursing officer to hire clinical nurse specialists in staff positions rather than in administrative positions. A clinical specialist who has staff authority but no line authority typically is able to: a. Function through influence. b. Take complete responsibility for the care of clients. c. Interview and hire staff nurses for designated nursing units. d. Be granted functional authority to determine standards of nursing care and enforce them.

ANS: A Staff positions provide support to line positions but have no direct accountability for staff or patient outcomes and therefore function through influence.

8. A new director of nursing in a small rural hospital wants to make changes from the traditional model of governance to a shared-governance model.

Select the characteristic below that best describes the traditional organizational structure in which a staff nurse is assigned to carry out nursing tasks for clients but is not given the chance to provide input into forming the policies and procedures by which care is delivered or the standards by which care is evaluated: a. Bureaucratic b. Decentralized c. Delegated authority and responsibility d. Delegated responsibility but no authority ANS: D In traditional structures, decision-making authority (right to act) is held by a centralized decision-making body, so that staff members have responsibility for certain functions but do not participate in decisions related to those functions.

9. The chief nursing officer is given the task of reviewing and revising the organization’s mission, philosophy, and technology. In reviewing them, the chief nursing officer understands that they should be reflected in: a. The organizational structure. b. Line and staff responsibilities. c. The policies and procedures. d. Government regulations.

ANS: A The mission statement is an important foundation for the organizational structure and defines technology and human resources required for the organization.

10. The facilities department is experiencing some challenges and is undergoing reorganization. Because of your familiarity with systems theory, you: a. Know that this challenge is their issue and that it has nothing to do with your unit. b. Understand that such events are localized and do not have an impact on the organizational culture. c. Know that the nature of challenges and reorganization in facilities will have an impact on other areas. d. Anticipate that your prior experiences with facilities have no effect on the current situation.

ANS: C

By nature, a system such as an organization is an interacting collection of parts that together make up the whole. Changes to one part will affect other parts and the system as a whole.

11. “Georgia Hospital will provide care that is a national example of consumer service” is a: a. Vision statement. b. Statement of philosophy. c. Mission statement. d. Rationale for care.

ANS: A A vision statement is an articulated goal that provides an inspirational target to which the organization aspires at some future time. A statement of philosophy expresses values and beliefs, and a mission statement provides the reason for the existence of the organization.

12. “At Thoroughcare, we provide health care for women and children in transition” is an example of a: a. Vision statement. b. Mission statement. c. Goal statement. d. Statement of philosophy.

ANS: B Mission statements provide a reason or rationale for the existence of the organization and are indicative of the structure of the organization and of who consumes the services provided.

13. Which of the following would be the most appropriate mission statement for a nursing center? a. “At Plentyville, we provide rehabilitative services for addicted adolescents.” b. “Georgiatown provides treatment and prevention services for county residents.” c. “At Heart, our aim is to provide services that lead the nation in health education and research.” d. “At Coeur, we strive to achieve optimal pain management with patients who are experiencing chronic pain.”

ANS: D The mission statements of nursing centers are oriented toward achieving

optimal health status for a defined group of patients or consumers rather than being treatment or maintenance or social-support oriented.

14. A primary care clinic is established in Pleasantville to provide comprehensive services to infants, children, and families within the community. The executive director of the clinic oversees physician and nursing services for infants, children, and families; a neurodevelopmental clinic; psychology, family counseling, and social work services; nutritional counseling; speech and hearing services; and physiotherapy. This type of organizational structure is known as: a. Hierarchical. b. Bureaucratic. c. Service-line. d. Matrix ANS: C In service-line structures (sometimes called product lines), the functions necessary to produce a specific service or product are brought together into an integrated organizational unit under the control of a single manager or executive.

15. In which of the following situations would you expect low morale and frustration? a. Statement of philosophy indicates “We value our staff.” When staff members leave, careful evaluation is done to determine whether staff should be replaced by full- or part-time employees. b. Practices include annual staff recognition celebrations. During times of change, staff members are actively included in issue identification and solution finding. c. Recruitment ads promise opportunities for advancement for everyone.

Promotions are given only to individuals with long-standing service and entrenched relationships. d. The vision indicates that there is strong commitment to lead in research.

The organization has tried to implement a strong campaign to attract leading nurse researchers but has experienced difficulty in doing so.

ANS: C Although frustration may occur with external factors that affect ability to act on values and aspirations, lack of congruence between what is espoused as a value within the organization (such as promising advancement as an incentive to join the organization) and what is actually done (such as

restricting advancement to internal candidates with much organizational history) can cause low morale and confusion.

16. At Orangetown Hospital, the nursing department is developing a mission statement for nursing. Which would be a suitable mission statement? a. “Nursing provides services for patients admitted to Orangetown Hospital.” b. “To participate fully in the professional services offered by Orangetown Hospital.” c. “To lead by the lamp; services for seniors.” d. “At Orangetown, the nursing department provides caring services that recognize the diversity of clients and promote optimal health with clients through partnership, education, and interprofessional collaboration.”

ANS: D A nursing mission statement within an organization needs to establish the reason for nursing within the organization and lays out relationships with clients, the community, and other disciplines.

17. At Hospital XYZ, staff members on Y3 have dealt with the third head nurse in three years. Donna, the current head nurse, lacks confidence in patient-nurse relationships, and scheduling and other processes are routinely left to the last minute. Staff members approached Donna first and then administration with their concerns about Donna’s effectiveness as a leader.

The staff was told that the problem is likely staff related, that it is simply an unhappy group, and that there is nothing that will be done further about their concerns. The philosophy of the organization indicates that “open, transparent communication between staff and management is desired and supported,” and that “innovation and creative thinking are the foundation of the organization’s progress.” In assessing this situation as a newly hired senior executive, you anticipate that: a. Staff members will resolve the conflict on their own. b. The situation will lead to ongoing disgruntlement and attrition. c. No further discussion or concerns will come out of the situation. d. The head nurse will be able to resolve the conflict on her own.

ANS: B Lack of congruence between the stated philosophy of the hospital and the experienced organizational culture does not support either the staff or the head nurse and likely will result in ongoing frustration, confusion, and morale, which could result in increased attrition.

18. A new CEO has been hired at Valley Hospital who proposes to change the centralized organizational structure that was put in place ten years ago, based on widespread consultation with staff. The proposed structure involves substantial flattening of the organizational structure, with significant decision making being made at the point-of-care and an emphasis on interprofessional collaboration. There is a great deal of discussion about the balance between hospital-wide budget decision making and unit-based decision making. This discussion represents: a. Chaos theory. b. Organizational redesign. c. Organizational reengineering. d. Restructuring.

ANS: C Reengineering involves a total overhaul of an organizational structure. It is a radical reorganization of the totality of an organization’s structure and work processes. In reengineering, fundamentally new organizational expectations and relationships are created. Redesign is a technique to analyze tasks to improve efficiency, and restructuring is a technique to enhance organizational productivity.

19. With revenue reductions and cost-saving measures, the number of managers has been reduced, which has increased the number of team leaders supervised by managers by as many as three. This change may result in: a. Decreased patient satisfaction. b. Increased efficiency in costs. c. A more positive perception of managers. d. Little change to manager-staff relationships.

ANS: A When a span of control becomes too large, supervision can become less effective, which can have a negative effect on staff-manager relationships and on the overall quality of patient care.

20. Taylor Hospital has well-defined organizational units that provide maintenance, financial services, care for cardiac patients, care for surgical patients, and so on. The organizational chart indicates that surgical units report to a surgical manager and all nursing units report to a vice president of nursing; financial services to an accountant and then to a business executive; and so on. The primary disadvantage of this organizational structure is: a. Breakdown in function and communication across specialties.

b. Lack of congruence in culture and organizational values. c. Highly centralized decision making and authority. d. Wide span of control.

ANS: A In a functional organizational structure, departments and services function according to specialty. This model supports professional expertise but can lead to silos in communication and decision making and discontinuity in patient services.

21. In the Unity Healthcare organization, decisions, including those at the unit level, are made by a group of senior executives. Rules for employees are clear, and nursing care is delineated by procedures and protocols. This exemplifies: a. Transformational leadership. b. Transactional leadership. c. Bureaucratic organization. d. Chaos theory.

ANS: C Organizational structure refers to the organization of a work group, rather than to its leadership, and includes where decisions are made and what the relationships are between groups. In the example given, power is centrally located, with all decisions regarding policies and procedures flowing from this central location, which is characteristic of bureaucratic organizations.

22. In the Unity Healthcare organization, communication flows: a. Laterally. b. Bottom to top. c. Top to bottom. d. Intermittently.

ANS: C In a bureaucratic organization, communication flows vertically top to bottom.

23. Sarah is a clinical nurse educator in the dialysis unit at Pines Health Center and provides education, consultation, and training support. Sarah has: a. Direct responsibility for patient care. b. Direct accountability for patient outcomes. c. An authority relationship to staff. d. An influence over patient outcomes.

ANS: D

In a staff position, Sarah supports line positions in accomplishing the primary goals and objectives of the unit and provides support, counsel, and advice, but she has limited or no authority for decision making.

24. A statement such as “We believe in the right of patients to make choices and to have care that is sensitive to their preferences and needs” is a _____ statement. a. Mission b. Goal c. Vision d. Philosophy ANS: D Philosophy statements capture significant beliefs and values of the organization.

MULTIPLE RESPONSE 1. Organizational culture includes : a. Norms. b. Traditions. c. Behaviors. d. Values.

ANS: A, B, C, D Organizational culture, the reflection of the norms or traditions of the organization, is exemplified in behaviors that illustrate values and beliefs.

Chapter 09: Cultural Diversity in Health Care Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. According to Leininger, “cultural imposition” is a major concern in nursing because nurses have a tendency to impose their values, beliefs, and practices on patients of other cultures. The discussion topic most likely to be without cultural imposition would be: a. Abortion. b. Wound management. c. Blood transfusion. d. Advance directives.

ANS: B Abortion, blood transfusion, and advance directives are heavily imbued with values, beliefs, and practices that may be different between patients and

nurses.

2. Cultural diversity is the term used to describe a vast range of cultural differences. Events have symbolic meanings for the nurse manager and the staff. The event that would be most likely to provide symbolic meaning to a nurse manager and staff is a: a. Task force formed to commemorate a New Year’s celebration in the Western tradition. b. Project to provide Christmas gifts to the children in a daycare program. c. Celebration of National Nurses Week with the focus on cultural care. d. Task force to develop a poster for the unit depicting religions of the world.

ANS: C Human cultures have material items or symbols such as artifacts, objects, dress, and actions that have special meaning in a culture. National Nurses Week, with a focus on nursing interests, reflects the culture of nursing.

3. One of the staff nurses on your unit makes the comment, “All this time I thought Mary was black. She says she is Jamaican.” The best response would be to say: a. “Who cares what she is?” b. “What did you think when you learned she was Jamaican?” c. “Why did you assume she was black?” d. “We have never had a Jamaican on this unit.”

ANS: B The response of the nurse manager invites cultural awareness, which involves self-examination and in-depth exploration of one’s own biases, prejudices, and assumptions.

4. As a nurse manager, you notice that Maria, a Hispanic nurse aide, is visibly upset. When you ask her if something is wrong, she becomes tearful and says, “Why is it that when John and I work together in giving patients care, he jokes about my being “a little fat Mexican”? The nurse manager’s best response is, “Do you think he: a. Is sensitive to your culture?” b. Wants to learn more about you?” c. Has been hurt and wants to hurt others?” d. Is stereotyping you without thinking?”

ANS: D Prejudices “enable us to make sense of the situations in which we find

ourselves, yet they also constrain understanding and limit the capacity to come to new or different ways of understanding. It is this contradiction that makes prejudice paradoxical.” (Spence, 2004, p. 163). Prejudices enable us to predict behaviors and make sense of situations but constrain our understanding and development of new insights.

5. The nurse manager of a unit is asked by a family member of a dying Native American patient if it is possible to have the patient’s eight-member family recite the rosary by the bedside. The manager responds affirmatively.

The nurse manager is most likely exhibiting behavior related to: a. Acculturation. b. Ethnocentricity. c. Cultural diversity. d. Cultural sensitivity.

ANS: D Cultural sensitivity involves the capacity to feel or react to ideas, customs, and traditions unique to a group of people.

6. A 66-year-old native Chinese patient, hospitalized for a myocardial infarction, asks the nurse manager about seeing his “acupuncture doctor” for treatment of his migraine headache. The best response to this patient would be: a. “How long have you been using acupuncture treatment?” b. “Do you think acupuncture relieves your pain satisfactorily?” c. “What have you told your heart specialist about your migraines and treatment?” d. “Have you tried nonprescription pain medication or been given a prescription drug for your headaches?”

ANS: A Acknowledging the patient’s use of acupuncture demonstrates cultural sensitivity through acknowledgement of treatments that would be consistent with the patient’s cultural interpretation of illness and responses to it. The other responses indicate lack of cultural sensitivity as well as cultural imposition, in that the nurse diverts the line of inquiry toward interventions that would be common to the nurse’s experience of health care in Western cultures.

7. Maintaining a culturally diverse staff and working with a culturally diverse patient population is an important function of a nurse manager who works in

the hospital of a large medical center. On your palliative care unit, you have recently received complaints from families about ineffective pain management for their family members and you determine this occurs primarily when certain nurses are working. What approach might you take to resolve the concerns of the families, patients, and potentially, the staff? a. Reinforce to staff that practice guidelines support as-needed analgesia for the terminally ill. b. Ask staff input on the development of stricter guidelines to ensure that all terminally patients are given sufficient analgesia. c. Encourage conversation with patients and among staff that facilitates learning about cultural beliefs and priorities in dying. d. Advise families that the administration of analgesia is based on the expert clinical judgment of nurses who are familiar with care of patients in palliative care.

ANS: C The cultural and religious backgrounds of nurses influence their perceptions of dignity-conserving care. For example, foreign-born Catholic nurses stated the dying experience should not be altered by analgesics to relieve suffering or by attempts to hasten death by forgoing curative therapy or by other means. Approaches to working with differences in the diverse cultural and religious backgrounds of patients, families, and nurses alike include taking time to have conversational chats with patients in end-of-life and with colleagues that will facilitate learning about each other and provide care that fits with the patient’s cultural beliefs about dying.

8. Because an increasing number of Hispanic patients are being admitted, a nurse manager designs a staff-development program to help her staff understand the Hispanic culture. A nurse should understand that culture is determined by which of the following? a. Behavior b. Love for people c. Shared vision d. Genetic predisposition ANS: A Culture is determined by behaviors and beliefs and develops slowly.

9. The nurse manager for a unit’s culturally diverse staff creates a staffdevelopment program so the professional nursing staff members can enhance

their understanding of cultures on the basis of published literature. The literature reveals that the following characteristic is inherent in a culture. It: a. Develops over time. b. Maintains a strong work ethic. c. Changes easily. d. Develops quickly.

ANS: A Culture is a patterned behavioral response that evolves slowly as times change. The culture may or may not maintain a strong work ethic.

10. In designing programs through your institution to address the health needs of Hispanics in your community, you most likely would develop programs related to: a. Diabetes. b. Cardiovascular disease. c. Cancer. d. Asthma.

ANS: A Hispanics with diabetes are twice as likely to die from diabetes as nonHispanics.

11. Within the deaf culture, there is considerable disagreement about the use of SEE (Signed Exact English) and ASL (American Sign Language). This is indicative of: a. Dominant versus nondominant behaviors. b. The need to recognize diversity within groups. c. The impact of cross-culturalism. d. How language separates subgroups.

ANS: B When working with various cultural groups and diversity, it is important to recognize that diversity also exists within groups. Cultural differences among groups should not be taken in the context that all members of a certain group or subgroup are indistinguishable.

12. When interviewing a candidate for a nursing position who has an Aboriginal background, you recognize that the candidate’s lack of eye contact reflects the candidate’s: a. Lack of confidence. b. Professional behavior.

c. Cultural sensitivity. d. Ethnicity.

ANS: D Ethnicity refers to groups of people who are classified according to common racial, tribal, religious, linguistic, or cultural backgrounds.

13. When interviewing a candidate for a nursing position who has an Aboriginal background, you recognize that the candidate’s lack of eye contact reflects the candidate’s cultural sensitivity. You are exhibiting: a. Acculturation. b. Cultural sensitivity. c. Ethnocentrism. d. Transculturalism.

ANS: B Cultural sensitivity refers to the affective capacity to feel, convey, or react to ideas, habits, customs, or traditions unique to a group of people. In this situation, acknowledgement of the candidate’s background in relation to eye contact demonstrates cultural sensitivity.

14. Mary joins 5W nursing unit. Mary is a new graduate who is anxious to fit in. She soon learns that some of her “book learning” is being criticized by her colleagues, so she adapts her practice to what others on the unit are doing.

She is demonstrating: a. Cultural awareness. b. Cultural sensitivity. c. Acculturation. d. Cultural marginality.

ANS: C In accepting the practices of the dominant group on the unit, Mary is demonstrating acculturation.

15. At Health Center XYZ, staff members on the rehab unit have a head nurse who is intolerant of error and publicly chides anyone who makes a mistake. Over time, the rules on the unit dictate that mistakes are hidden and that areas of concern related to the functioning of the unit are discussed in tub rooms and are never openly discussed during periodic meetings. New staff members are quickly made to realize that silence is expected. The situation described is an example of: a. Ethnicity.

b. Work environment. c. Work culture. d. Marginalization.

ANS: C Culture develops over time, is essential to survival, is learned and shared by members, and changes with difficulty.

16. As a nurse manager, you have hired two new staff members who have recently come to the United States from other countries. Which of the following strategies might indicate your efforts to assist these staff members with acculturation to your unit? a. Analyze a recent situation with them in which an order with a physician was not clarified and explore their beliefs about nurse-physician relationships. b. Expect them to behave in ways that are expected of staff who have grown up and been educated in the United States. c. Stress to these new staff that your unit is a “family” and that staff members take pride in saying that they are from Unit 4. d. Recognize that culture develops over time and leave them alone to figure out differences between their culture and that of the unit.

ANS: A Acculturation refers to adapting to a particular culture. Assimilation occurs when individuals now define themselves as members of the dominant culture and is evidenced by when individuals say they are from where they live and practice. When individuals grow up within a culture and take on the characteristics of that culture, it is referred to as socialization. Assisting the staff to recognize differences in the relationships between physicians and nurses on the unit and those in their country of origin is assisting adaptation or acculturation and is promoting positive patient outcomes.

17. During managers’ meetings, Lindsay is surprised by the forthrightness of male managers. She finds that, during discussions, she would be more likely to say: a. “I wonder if we should consider changing our policy on performance appraisals? What do you think?” b. “Sean, your approach to appraisal is completely off track and does not reflect available evidence.” c. “The system that has been developed needs to be implemented. We have already spent enough time in discussion.”

d. “Forget about change in this policy. It is fine as it is.”

ANS: A Males and females in the workplace are likely to have different management styles, and although not all males are authoritative or females more participatory, women are likely to use more participatory and inclusive methods.

18. As a manager, you are responsible for two separate units: a CCU and a cardiac step-down unit. The organization and relationships on these units are distinct and very different from one another. Your decision has been to support the uniqueness of these units because each is effective in different ways in providing patient care. This approach is consistent with which principle? a. Transculturalism b. Cross-culturalism c. Multiculturalism d. Acculturation ANS: C Multiculturalism refers to maintaining several different cultures, such as the uniqueness of different work units. Cross-culturalism means mediating between/among cultures, and transculturalism denotes bridging significant differences in cultural practices.

19. During performance appraisal, you praise Xia for her attention and care to nursing details. You suggest that her care would be further enhanced by greater acknowledgment of patients’ feelings. Xia bursts into tears and leaves the office. Later, you learn that criticism is perceived as akin to failure in Xia’s culture. You reflect on how you could modify your approach in the future to acknowledge different cultural interpretations of feedback. Your response is indicative of: a. Bias. b. Cultural awareness. c. Cultural diversity. d. Ethnocentricity.

ANS: B Cultural awareness involves self-examination and in-depth exploration of one’s own cultural and professional background, including biases, prejudices, and assumptions, including assumptions about thinking modes and decision making.

20. Individuals living with asthma, who also live in poverty, are much less likely to seek early care and are more likely to go to emergency rooms for assistance. This example reflects: a. Stereotyping. b. Cultural diversity. c. Ethnocentricity. d. Transcultural care.

ANS: D Transcultural care involves consideration of health beliefs and practices between genders among races, ethnic groups, and those with different socioeconomic status.

21. Sarah, RN, complains to you that a male nurse from a different culture sits very close during charting and leans toward her when speaking. In responding to Sarah, you consider that differences across cultures that are relevant to this situation include: a. Eye contact. b. Personal space. c. Harassment. d. Expressions of feeling.

ANS: B Body movements, eye contact, gestures, verbal tone, and physical closeness when communicating are all part of a person’s culture. For the nurse manager, understanding these cultural behaviors is critical in accomplishing effective communication within the diverse workforce population.

22. A new graduate RN joins your unit. After a few weeks, she complains about some of her peers on the unit and compares their practices negatively to what she learned in her nursing program. She also is vocal about how she has learned so much here that she did not learn in her program. She is best described as: a. Having cultural sensitivity. b. Experiencing cultural diversity. c. Experiencing cultural marginality. d. Experiencing acculturation.

ANS: C The new graduate is caught between two cultures at this point—work and education—and expresses feelings of belonging to neither.

23. In caring for a patient from an East Indian culture, the staff expresses frustration that many people are in the room at any one time, which interferes with care. As the nurse manager, you provide leadership in understanding that this behavior of the family and friend network reflects: a. Lack of understanding of the seriousness of the patient’s illness. b. Lack of communication between family members. c. The social organization of friendships and family networks in East Indian culture. d. Lack of caring about the hospital environment by the friends and family.

ANS: C The Giger and Davidhizar Transcultural Model identifies six phenomena to assess provision of care for patients who are from different cultures, including social organizations, which include how relationships are formed and expressed in different cultures.

24. Sarah, one of your RNs, tells you that she can’t understand why Jim, an Aboriginal patient, wants to do a smudge. Sarah’s response is based on her: a. Cultural marginality. b. Circle of familiarity. c. Cultural understanding. d. Acculturation.

ANS: B The “circle of familiarity” refers to constrained interpretation based on one’s values, attitudes, and beliefs.

25. Sarah, one of your RNs, tells you that she can’t understand why Jim, an Aboriginal patient, wants to do a smudge. In coaching Sara, you suggest which of the following? a. “Explain to Jim that there is no smoking in the hospital.” b. “Inform Jim that fires are not allowed in the hospital.” c. “Insist that he give you his tobacco because it is unhealthy for him.” d. “Ask him what he means by a smudge and what meaning it has for him.”

ANS: D By talking with Jim, Sarah is able to step outside her “circle of familiarity” and find and enhance her understanding of personally held prejudices.

Prejudice enables Sarah to find meaning in situations, but it also limits understanding. Paradox describes this tension. We have the responsibility to acknowledge the “possibility of tension” as a potential for new and different understandings derived from our communication and interpretation.

Possibility, therefore, presumes a condition for openness with a person from another culture (Spence, 2004).

MULTIPLE RESPONSE 1. As a nurse manager, you have to be effective in managing a culturally diverse staff. Which of the following nurse manager attributes would assist you in addressing the cultural needs of your staff ? a. Stereotyping of others b. Respecting others c. Understanding the importance of language d. Encouragement of potential in all staff e. Age bias f. Disrespect for others ANS: B, C, D Cultural competence involves knowledge of diverse cultural and ethnic groups, including knowledge of staff members and respect for others and their cultural differences.

Chapter 10: Power, Politics, and Influence Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. A nurse manager is experiencing poor staff morale on her unit. While participating in a baccalaureate course, the nurse manager had learned that one of the reasons nurses lack power today is probably because of the past. In the early decades of the profession, nurses lacked power because: a. Nurses freely chose to defer to physicians and administrators with more education. b. Women lacked legal, social, and political power because of legal and cultural barriers. c. The first nursing licensure laws prohibited nurses from making most decisions. d. Nurses astutely recognized the risks of grabbing too much power too soon.

ANS: B Nursing mirrored the lack of legal, social, and political power that was prevalent in the early decades of the profession.

2. Nurses who engage in in-fighting, seek physician support against nursing colleagues, and avoid political advocacy through membership in nursing organizations:

a. Refuse to believe that they are acting like members of groups that suffer socioeconomic oppression. b. Do not understand how their failure to exercise power can limit the power of the whole profession. c. Purposefully choose to exercise their power in the workplace through indirect means. d. Suffer from learned helplessness as a result of abuse by powerful nurse executives.

ANS: B Becoming an active, productive, collegial member of groups and teams within the workplace and in professional associations and community groups ensures that the nursing voice is heard on healthcare issues and problems and is an appropriate exercise of power.

3. A nurse belongs to several professional organizations, serving on a statelevel committee of one group and on two task forces at work. The nurse is committed to a range of health issues and knows the state senator from the nurse’s district, as well as the name of the representative in Washington, DC. This nurse exemplifies which level of political activism in nursing? a. Gladiator b. Buy-in c. Self-interest d. Political astuteness ANS: D Political involvement is a professional responsibility and nurses’ perspectives of the critical issues for improving the healthcare system can shape the policy agenda of the nation’s political leadership. This nurse exemplifies several of the skills associated with political astuteness.

4. A manager relies on his director (immediate supervisor) for advice about enrolling in graduate school to prepare for a career as a nurse executive. The director may exercise what kinds of power in the relationship with the manager in this advisory situation? a. Expert, coercive, and referent b. Reward, connection, and information c. Referent, expert, and information d. Reward, referent, and information ANS: C Because the director is in a leadership role, he comes with knowledge or

expertise that is required to assume a leadership role, and he has information that he is willing to share, which gives him the power of information. The employee sees him as credible and seeks his advice, which gives him referent power.

5. A nurse manager must implement a 2% budget cut on the nursing unit.

Which approach should the manager use to most effectively empower the staff of the unit? a. Discuss the guidelines for the budget cuts with the staff, making the decisions with those who participate. b. Inform the staff of the budget cuts in a series of small group meetings and accept their ideas in writing only. c. Provide the staff with handouts about the budget cuts and let them make recommendations in writing. d. Hold a series of mandatory meetings on the budget cuts, asking staff for ideas on the cuts.

ANS: A Empowerment is the process of exercising one’s own power to facilitate the participation of others in decision making and taking action so they are free to exercise power It means releasing authority and enabling others to have accountability, for participation and decisions.

6. During orientation of new nurse managers, the chief nursing officer stresses strategies that help nurse managers to achieve a powerful image.

Which groups of behaviors best contribute to a powerful image for the nurse manager? a. Greeting patients, families, and colleagues with a handshake and a smile; listening carefully when problems arise b. For men, no facial hair, always wearing a suit and tie; for women, always wearing a suit and high-heeled shoes c. Maintaining a soft voice during times of conflict; making unbroken eye contact during interactions d. Smiling all the time; always wearing a suit, carrying a briefcase, and, if a woman, wearing no jewelry ANS: A A powerful and positive approach is communicated through confident behaviors such as greeting others, smiling, and showing respect for the opinions of others through listening. Grooming and dress need to be clean, neat, and appropriate to the situation. Speech needs to be firm and confident.

7. Two nurses approach their manager about a conflict regarding the next month’s schedule. The nurses are talking loudly and at the same time. The manager most effectively uses communication skills to resolve the conflict by: a. Taking both nurses aside, separately and then together, and charging them with resolving the problem without her direct intervention. b. Listening to each nurse speak to the other without interruption and asking clarifying questions to help them resolve the issue themselves. c. Separating the nurses, instructing each to decide how the problem can be resolved, and meeting with them the next day. d. Calling an emergency scheduling committee meeting and asking volunteers to resolve the conflict between the two nurses.

ANS: B Negotiation involves the presentation of an opening position with each party, then moving on until they achieve a mutually agreeable result or until one or both move away from a failed negotiation. Negotiation occurs when one party has something that the other party values, such as a desired schedule.

8. A nurse manager recognizes the need to expand her professional network as she begins a job search for a middle-management position. Which of the following actions is least likely to expand her job-searching network? a. Reviewing her address book or card file for names and phone numbers of former colleagues who are now in middle-management positions b. Making an appointment to meet with a former instructor from her graduate program in nursing administration c. Making a long overdue return call to a former colleague who is now a chief nurse executive d. Attending a state-level conferences for nurse managers and executives and volunteering to help with professional organizations’ informal luncheons and receptions ANS: C Networking is the result of identifying, valuing, and maintaining relationships with a system of individuals who are sources of information, advice, and support. Many nurses have relatively limited networks within the organizations where they are employed. Active participation in nursing organizations is the most effective method of establishing a professional network outside one’s place of employment.

9. A staff nurse asks the nurse manager for a few days off for personal

reasons. The nurse manager turns in the request to the human resources office with a note indicating that the staff nurse has demonstrated excellent working skills and is a valued employee. The nurse manager has used the influence of her position to help this staff member. Influence is the process of: a. Using power. b. Empowering others. c. Understanding power. d. Moving past apathy.

ANS: A Influence involves the use of power to effect certain outcomes—in this situation, to arrange days off for a valued employee.

10. A nurse is participating in a baccalaureate course. For the class, she has to attend the legislative session regarding the new role of medication assistants.

Nurses should be involved in shaping public policy primarily because: a. Involvement will enable nurses to take over the healthcare system at some point in the future. b. Other healthcare professions are less concerned about the essential needs of clients. c. Such activities are important career builders for nurses who seek top-level executive positions. d. They are closest to the front line of health care and see how it affects clients and families.

ANS: D Nurses can no longer be passive observers of the political world. Political involvement is a professional responsibility. Nurses’ perspectives of the critical issues for improving the healthcare system can shape the policy agenda of the nation’s political leadership.

11. Sondra, a new graduate, recently began a position as a registered nurse in a rural hospital, where she is the youngest and newest staff member.

Although she has limited experience, she has a strong knowledge base, is confident, and was considered to have strong entry-level skills on graduation.

Sondra meets with her former instructor and confides that she is very frustrated that others do not seem to accept her leadership. What might you suggest that would help Sondra to understand what is happening in terms of power and influence? a. As a new graduate, it is unlikely that she has acquired the experience and knowledge of other staff, including aides and practical nurses.

b. Rural settings tend to be closed systems and therefore are, not welcoming of those who are not from their community. c. Morale on her unit can be improved by engaging in shared decision making. d. Identify the informal leaders on her unit and how they affect care decisions.

ANS: D Developing organizational savvy includes identifying the real decision makers and those persons who have a high level of influence with the decision makers. Recognize the informal leaders within any organization may have more power than the formal leader because of more knowledge of the organization, more informational power, or more expertise.

12. Literature on oppression in nursing has: a. Verified the presence of behaviors associated with oppression within nursing. b. Suggested that oppression leads to bullying but has little or no effect on patient outcomes. c. Failed to establish that oppression is present in nursing groups. d. Indicated that nurses use oppression negatively.

ANS: A Oppressed group behavior is apparent when a population is dominated by another group and begins to take on the characteristics of the dominant group (Roberts, 1993), often bullying and abusing their peers. In the twenty-first century, bullying and incivility have become epidemic in both nursing education and clinical settings.

13. Politics is usually: a. Confined to legislatures. b. Seen in dysfunctional workplaces. c. Found in all social organizations. d. A representation of self-interest.

ANS: C Politics involves social interaction among organizations and as such, politics permeates in all organizations, workplaces, legislatures, professions, and even families.

14. Your colleague Mary, a recent graduate, announces one day that she intends to leave nursing in 3 to 4 months to pursue a position in marketing.

While at your agency, she plans to give patients excellent care and to learn as much as she can, because “Who knows? Nursing is a great job with a great pay and I may return someday.” Mary’s statements most accurately exemplify which orientation to the concept of nursing? Nursing as a(n): a. Profession. b. Occupation. c. Flexible discipline. d. Career with off and on ramps.

ANS: B Concern with nursing as potentially one in a series of possibly well-paid jobs reflects a view of nursing as an occupation.

15. Lucy, head nurse on the surgical unit, works with her staff to find ways in which they can work together with other disciplines to provide more effective care for patients on the unit. Lucy likely knows her power is: a. Limited, thereby necessitating involvement of others in implementing ideas. b. Restricted, which necessitates finding alternative means to achieve strong patient outcomes. c. Directed primarily toward those who are subordinate to her. d. Of unlimited capacity when shared with others.

ANS: D Those like Lucy, who share power, tend to be the strong collaborators and see power as an unlimited quantity when shared. Empowered nurses make professional practice possible, creating a culture that satisfies all nurses.

16. One day, at coffee, your co-worker suggests that you and she sit with unit members of the hospital research committee. She suggests that this would be an excellent way to get to know people who share her interest in research.

Her actions are an example of: a. Mentorship. b. Politics. c. Networking. d. Empowerment.

ANS: C Meeting individuals outside the normal workgroup to share ideas and gain support and encouragement is an example of networking.

17. The workgroup on NU 23 is marked by apathy toward the ward’s

patients, high absenteeism, open conflict among team members, and high turnover of personnel, including managers. The underlying behavior in this situation may be characterized as: a. Powerlessness. b. Anger. c. Apathy. d. Oppression.

ANS: A Emotions such as anger and apathy result from a workplace in which powerlessness is exhibited.

18. During a unit meeting, you notice that Vivian listens attentively when Mary is speaking and offers support and advice when Mary presents ideas to the group. You are surprised because Vivian has often confided that she does not like Mary. Vivian’s behavior is best described as: a. Insincere. b. Networking. c. Politically sophisticated. d. Collegial.

ANS: D Collegial behavior requires respect, not friendship.

19. Which of the following interactions is MOST consistent with the idea of networking? a. Meet with the same colleagues daily to have coffee and share concerns about the workplace and stories about colleagues. b. Join an online workplace forum to gain ideas about how to handle workplace conflict. c. Suggest that you and a new team member meet after work for coffee to review unit guidelines. d. Join a nurse executive interest group to meet other executives for support and for sharing ideas of expertise.

ANS: D Networking is the result of identifying, valuing, and maintaining relationships with a system of individuals who are sources of information, advice, and support. Many nurses have relatively limited networks within the organizations where they are employed. Active participation in nursing organizations is the most effective method of establishing a professional network outside one’s place of employment. Successful networking involves

sharing similar ideas and maintaining relationships within a system of individuals who serve as sources of information, advice, and support.

20. The institution where you are a nurse manager has resisted the adoption of a new document management software, citing cost as a concern. You meet with other nurse managers who are in favor of the software and prepare a proposal to take to the senior executive with the goal of persuading the executive to adopt the software. This is an example of: a. Collaboration. b. A coalition. c. Networking. d. Policy building.

ANS: B The formation of temporary groups to achieve particular goals involves the development of coalitions.

21. Which of the following is the best example of skilled negotiation? a. Linda, the manager on pediatrics, takes a proposal to her supervisor, outlining the benefits of a walk-in preoperative area for children. b. Kim, RN, asks for leave to pursue a semester of full-time study in her graduate program. She proposes to accept less popular rotations during peak vacation time, in return. c. George, the head nurse in ER, asks for additional staff for his department and points out the benefits of being able to keep patients for longer periods. d. Jerry speaks with his supervisor about his supervisor’s concerns related to bedside reporting before presenting a proposal to change this process.

ANS: D Successful negotiators are well informed about not only their own positions but also those of the opposing side. Negotiators must be able to discuss the pros and cons of both positions. They can assist the other party in recognizing the costs versus the benefits of each position.

22. Amy has worked in the dialysis unit on staff for about 12 years. She is frequently consulted by other nursing staff regarding protocols and policies on the unit. What type of power is Amy using? a. Position power b. Expert power c. Personal power d. Competency power

ANS: B According to the types of power outlined in the text, Amy is most likely evidencing expert power in that she is being consulted regarding areas of knowledge and competency on the unit and is at the same level, potentially, in the hierarchy as her colleagues.

23. Despite repeated invitations by his colleagues to become involved in regional and state nursing practice committees, Tom refuses. His reason is that “nursing committees rarely get anything worthwhile done because of politics and conflicts.” According to the text, Tom’s view of involvement: a. Is rare in nursing today. b. Reflects a fear of power. c. Reflects the essential process of power. d. Reflects empowerment and capacity to make his own decisions.

ANS: C Tom’s response reflects a distancing from other nurses related to discomfort with conflict associated with human interactions. The text defines human interactions within organizations as politics, a component of which is the essential process of power.

24. A unit manager watches a new RN graduate interacting with a patient.

When the RN comes out of the room, the unit manager says, “I don’t know what they taught you in your nursing program, but if I see you do that again, I will write you up.” This example demonstrates: a. Coercive use of power. b. Appropriate application of control. c. Use of informatory power. d. Use of power to provide coaching.

ANS: A Influence is the process of using power. Influence can involve the punitive power of coercion, as is used in this example.

25. Susan, an RN in the ED, would like to pursue leadership roles in her career. She is frustrated that others in her working environment seem to pay little attention to her creative ideas or place her in informal leadership positions. As her colleague, you want to provide her with helpful feedback.

Which of the following statements will provide feedback as to how she might communicate power and demonstrate that she is capable of handling other leadership responsibilities?

a. “I find your soft voice and manners very reassuring and calming to patients.” b. “Try using a wider vocabulary and big words so that people will think that you are knowledgeable.” c. “At times, you tend to slump and avoid eye contact when you are talking with colleagues and families.” d. “Don’t worry about what others think of you. If you feel like saying something, say it, even if it hurts other people’s feelings.”

ANS: C A powerful image comes from thinking of oneself as powerful and effective, and this is communicated through posture, maintaining eye contact, treating others with courtesy and respect, and using a firm, confident voice with vocabulary that is appropriate (which does not necessarily involve using bigsounding words).

MULTIPLE RESPONSE 1. As a new manager in the ED, you meet with each of the staff to ask about their priorities and what they think is going well in the department or what is of concern to them. Almost all of the staff express frustration and distress at being treated rudely or disrespectfully by patients, staff from other departments, and physicians and complain that they feel that nurses in the ED are not valued. With the staff, you brainstorm to raise the profile of nurses.

Which of the following strategies would be most effective? a. Requesting increased compensation b. Speaking positively about one’s work c. Dressing and grooming in a clean and neat manner d. Using titles (e.g., Mr., Mrs., Ms.) and last names e. Submitting a written complaint to senior administration regarding rude behaviors f. Developing a code of conduct for the ED staff.

ANS: B, C, D, F Demonstrating a positive and professional attitude about being a nurse to nursing colleagues, patients and their families, other colleagues in the workplace, and the public facilitates the exercise of power among colleagues while educating others about nurses and nursing. A powerful image is an important aspect of demonstrating this positive professional attitude and includes how we identify ourselves, how we dress, whether we are punctual for commitments, and whether we speak positively about our work. Bullying

and incivility are negative expressions of power that can affect patient outcomes. The Joint Commission standard demands that leaders ensure that a code of conduct is implemented to ensure patient safety and a culture of quality.

Chapter 11: Caring, Communicating, and Managing with Technology Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. A nurse manager was orienting new staff members to computerized charting. To understand computerized charting, staff members must understand informatics. The three core concepts in informatics are: a. Hardware, software, and printers. b. Data, information, and knowledge. c. Decision making, data gathering, and reporting. d. Wireless technology, voice recognition, and handheld devices.

ANS: B Informatics is the application of technology to all fields of nursing to facilitate and extend nurses’ decision-making abilities and to support nurses in the use, storage, and linkage of clinical information to provide effective and efficient patient care.

2. The nursing manager of a surgical unit has been asked by administration to evaluate client outcomes post cardiac catheterization. Using data about client outcomes post cardiac catheterization for the past 6 months so as to modify practice is an example of: a. Information. b. Cost-effective care. c. Meeting standards. d. Evidence-based practice.

ANS: D Technology enables evidence-based practice by collecting good clinical knowledge, translating nursing knowledge into reference materials that can be accessed at the point-of-care, and, potentially, assisting nurses to take action based on best evidence for practice (Lang, 2008; Lang et al., 2006; Staggers & Brennan, 2007).

3. Mr. Cruiser has been surfing the Web. He is looking for healthcare information on low back pain. He shows the clinic nurse a Webpage he thinks is great and tells her that he has been following the exercises

recommended by the author. He wants to know what she thinks about the site. When the clinic nurse evaluates this site, she discovers that its author is a personal trainer. No credentials are listed. In several testimonials on the page, people (their pictures are included) say how wonderful they feel after having done these exercises. The exercises all have animated demos when you click on the pertinent highlighted text or icon. They seem easy to follow. The site was posted five years earlier and was last updated three years before. The clinic nurse advises Mr. Cruiser to: a. Avoid this site. b. Check with his primary healthcare provider. c. Continue with the exercises. d. Contact the author for additional exercise and feedback.

ANS: A Patients need coaching as to how to use and decipher information that is available through the Internet. In this situation, the provider on the site lacks credibility because no credentials are listed, and the information is not current.

4. A primary care clinic in a small urban center sees a high volume of cardiology patients. Patients who attend the clinic have smart cards that they use at hospitals, clinics, and emergency departments within that region of the state. A primary benefit of the smart card for these patients would be: a. Rapid and accurate treatment in emergency situations. b. Reduced wait times to see specialists. c. E-mail notification of test results. d. Readily available information regarding medications.

ANS: B Credit card–like devices called smart cards store a limited number of pages of data on a computer chip and serve as a bridge between the clinician terminal and the central repository of the electronic health record (EHR), making patient information available to the caregiver quickly and cheaply at the point-of-service. Smart cards provide information to healthcare providers regarding the patient’s demographic and contact information, allergies, immunizations, lab results, and past patient care encounters and are presented at the point-of-service.

5. The clinic nurse has just accessed a client’s chart on the computer. The resident comes over and asks her to stay logged on because he needs to add a note to that client’s chart. She should say:

a. “No problem. Just log me off when you’re done.” b. “I’ll put the note in for you. What do you want to say?” c. “Just make sure that you sign your note because it’s under my password.” d. “I’m sorry, but you will have to enter the information using your own password.”

ANS: D System users must never share the passwords that allow them access to information in computerized clinical information systems. Each password uniquely identifies a user to the system by name and title, gives approval to carry out certain functions, and provides access to data appropriate to the user. All users must be aware of their responsibilities for the confidentiality and security of the data they gather and for the security of their passwords.

6. A home health nurse has been assigned to cover a 300-square-mile area of remote Montana. Mrs. Baker has just been discharged home following bowel surgery and has a new colostomy. She will need daily contacts for at least two weeks and then regular weekly contact following that week. Because it is not possible to visit Mrs. Baker in person every day and see all of the other clients, the nurse gives her a laptop computer with net meeting software installed. Each morning, both dial in at an agreed-upon time and discuss her progress. The home health nurse assesses whether or not the client needs to be seen that day and is able to view the colostomy site. This type of technology is called: a. Distance learning. b. Knowledge software. c. Telecommunications. d. Biomedical technology.

ANS: C Telecommunications and systems technology facilitate clinical oversight of health care via telephone or cable lines, remote monitoring, information links, and the Internet. Patients sitting in front of the teleconferencing camera can be diagnosed, treated, monitored, and educated by nurses and physicians.

EKGs and radiographs can be viewed and transmitted.

7. At a newly built outpatient surgical center, an integrated information system has been purchased. The chief nursing officer creates a series of staff development classes to orient the staff to this new system. One of the advantages of an integrated information system is that client-care data from all sites can be stored in and retrieved from a:

a. Nursing information system. b. Central data repository. c. Nurse expert system. d. Handheld device.

ANS: B Computer information systems manage large volumes of data, examine data patterns and trends, solve problems, and answer questions. In other words, computers can help translate data into information from both within and among organizations. Data from all patient encounters with the healthcare system are stored in a central data repository, where they are accessible to authorized users. Patient information in a centralized database is organized, legible, and easily retrievable from a variety of sources and reflects a variety of data.

8. Nurses need to know how to operate a computer, compare data across time, and look for patterns in client responses to treatments. These are examples of: a. JCAHO standards. b. Information systems. c. Informatics competencies. d. Requirements for nursing licensure.

ANS: C The Quality and Safety Education for Nurses (QSEN) project identified informatics competency as a necessary component of the knowledge, skills, and attitudes for quality patient care. Nurses are anticipated to be able to use information and technology to communicate, manage knowledge, mitigate error, and support decision making. Nurses must utilize hospital database management, decision support, and expert system programs to access information and analyze data from disparate sources for use in planning for patient care processes and systems.

REF: Page 187 TOP: AONE competency: Business Skills 9. The chief nursing officer understands that to be able to compare data across client populations and sites, it is important that nurses use: a. Similar settings. b. Information systems. c. Knowledge systems. d. Structured nursing languages.

ANS: D Data are standardized and use structured terminology, which enables crosssite comparisons.

10. Leaders in nursing must advocate for information and knowledge systems that support nursing practice. This is best accomplished by: a. Participating in organizational information technology committees. b. Submitting written requests for needed information systems. c. Requesting budgetary funds needed for systems. d. Sending staff nurses to conferences that discuss cutting-edge technologies.

ANS: A Nurse leaders and direct care nurses must be members of the selection team, participate actively, and have a voice in the selection decision. The information system must make sense to the people who use it and fit effectively with the processes for providing patient care.

11. You are in the process of designing a patient education program that will provide education and monitoring for patients with hypertension. To support your planning, you draw out and present patient data from: a. A clinical database. b. Biomedical technologies. c. E-mail. d. Internet sources.

ANS: A Clinical databases are collections of elements organized and structured for the processing, organization, and presentation of data for interpretation as information, which, in this particular instance, includes outpatient data.

12. You document your patient’s vital signs into a bedside documentation device and are able to compare your patient’s vital signs with patients who have similar diagnoses and similar medications, and who are of a similar age.

You are accessing: a. E-mail. b. Telecommunications. c. A database. d. Technology.

ANS: C A database is a collection of data elements stored and organized together for the purposes of interpreting information such as vital signs.

13. In an ICU, you order new devices to measure heart rhythm and rate, respiratory rate, oxygen levels, and intracranial pressure. These devices involve: a. Biomedical technology. b. Telecommunications. c. Retrieval of patient history information. d. Internet.

ANS: A Physiologic monitoring devices and patient surveillance systems involve biomedical technology.

14. As the head nurse involved in leading determination of which patient surveillance systems to acquire for your unit, one of your aims is to avoid adverse events through the implementation of appropriate technology. This particular aim recognizes that: a. Human error is significant in contributing to adverse events. b. Documentation of patient data is often illegible and therefore, misinterpreted. c. Data systems provide backup documentation with adverse events that staff cannot provide. d. Physiologic monitoring systems enable detection of early changes before an adverse event occurs.

ANS: D Data about adverse events suggests that a majority of physiologic abnormalities are not detected early enough and may be present hours before the event actually occurs. Physiologic monitoring aids in early detection of changes.

15. A 39-year-old patient awaits a kidney transplant. Because he must immediately arrange to get to the hospital when a donor kidney is available, it is important that he can be reached anywhere and at any time. To ensure that he receives the message, what type of technology is most effective? a. Internet b. Telecommunications c. WL pager d. CDS ANS: C Wireless (WL) communication is an extension of an existing wired network environment and uses radio-based systems to transmit data signals through

the air without any physical connections. Patients awaiting organ transplants are provided with WL pagers so that they can be notified if a donor is found.

16. A recent nursing graduate in a busy emergency department triages a patient who has sustained a large, deep puncture wound in his foot while working at a construction site. He is bleeding and is in pain. The nurse enters the triage data that she has obtained from the patient into a computerized, standard emergency patient classification system. After she enters the assessment data, she notices an alert on the computer screen that prompts her to ask the patient about the status of his tetanus immunization. What system of technology is involved in generating the alert? a. Clinical decision support b. WL technology c. Computerized provider order d. Electronic health record ANS: A Clinical decision support (CDS) is a clinical computer system, computer application, or process that helps health professionals make clinical decisions to enhance patient care. The clinical knowledge embedded in computer applications or work processes can range from simple facts and relationships to best practices for managing patients with specific disease states, new medical knowledge from clinical research, and other types of information.

17. Despite the implementation of bar-code medication administration (BCMA) on your busy medical unit, you notice that the number of medication errors has not significantly decreased. Which of the following reasons might explain the lack of change in errors? a. A number of new medications have been introduced into the hospital pharmacy that are not yet recognized in the CDS. b. There have been an unusually high number of patients on the unit who have been unable to confirm their identity at the time of medication administration. c. Lack of staff understanding and support for BCMA has led to overrides or failures to scan bar codes during busy times. d. Clinical data that have been entered into the system to guide administration of the medications are outdated.

ANS: C Most errors related to technology involve mislabeled bar codes on medications, mistakes at order entry because of confusing computer screens,

or issues with management of information. Errors also are related to dispensing devices and human factors, such as failure to scan bar codes or overrides of bar-code warnings.

18. A rural-urban health consortium enables physicians in a rural remote setting to consult with specialists in care through electronic conferencing, which includes consultation using intranet radiology images. This system may be in which phase of electronic medical technology adoption, according to the Healthcare Information and Management Systems Society (HIMSS)? a. 0 b. 1 c. 3 d. 6 ANS: D According to the HIMSS, this healthcare organization may be in phase 6, which includes the capacity to transmit all radiology images through intranet or another secure source. Level 1 refers to the installation of major ancillary clinical systems (such as radiology) and level 3 to the retrieval of radiology images from picture archives and communication systems.

19. As a nurse manager representative on a clinical information system selection team, you would be particularly concerned if the favored system: a. Involves screen displays that are best configured for non-clinical users. b. Requires an upgrade to servers in the facility. c. Requires staff orientation and training during implementation of the software. d. Minimizes the amount of data entry necessary.

ANS: A An ideal hospital information system should include as much instrumentation as possible to minimize data entry. As a clinical end user, you would expect orientation and training on how the screen display can be configured so as to suit the purposes and preferences of users in clinical areas.

20. When assessing the appropriateness of adopting WL PDAs for a nursing unit, you need to consider the advantages, which include: a. Lower cost relative to PCs. b. Small display screen. c. Font size. d. Speed of operation.

ANS: A PDAs offer a lower-cost method of documentation and communication than PCs, as well as easy portability. Disadvantages of PDAs include small screen size, suboptimal readability, and slowness in situations when speed is most needed.

21. A nurse manager is excited by the possible use of speech recognition (SR) systems for documentation of patient care, especially during crisis situations when staff members need to focus on performing rapid assessments and implementation of procedures. She learns, however, that SR systems would be impractical at this point. What would lead to this conclusion? a. SR systems are not available outside pilot projects. b. The type of speech required for voice recognition is unlikely to occur in a pressured situation. c. The hands-free function has not been perfected in SR technology. d. Wireless communications are prone to unreliability in transmission.

ANS: B Speech recognition systems rely on staccato-like speech, pauses between words, and programming for each user, any and all of which would be unlikely in a pressured crisis situation. SR is being used primarily for therapeutic purposes and in situations where data entry is stable.

22. As a nurse manager, one challenge is to orient new staff to your agency’s policies and procedures, as well as to provide training across various shifts. A cost-effective and effective learning strategy would be: a. Development of new learning modules and software to support document retrieval. b. E-mail distribution to staff home e-mail addresses regarding important policies. c. Preparation of DVDs that can be viewed on computers at the nursing station during “down times.” d. Linking policies and procedures to the network for access when required at the point-of-care.

ANS: D Knowledge technology consists of systems that generate or process knowledge and provide clinical decision support (CDS). The clinical knowledge embedded in computer applications can range from simple facts and relationships to best practices for managing patients with specific disease states, new medical knowledge from clinical research, and other types of

information. The most accessible and cost-effective approach would be utilization of what is already available in the work environment, such as the systems that provide CDS. 23. A necessary, basic condition for successful integration of clinical information systems is: a. Software. b. Standard medical nomenclature. c. Confirmatory evidence from nursing-led studies. d. Strong interdisciplinary cultures.

ANS: D An integrated clinical information system draws on specific knowledge from many involved disciplines that interface at the patient. Successful integration of clinical information systems requires that the various disciplines work together collaboratively to transform the data into meaningful knowledge.

24. To improve outcomes on the stroke recovery unit, the unit manager leads an evidence-based practice (EBP) project. The goal of this project is to: a. Enable detection of variations in clinical outcomes from well-researched standards that are supported by confirmatory evidence. b. Gain quick access to literature based on studies of patients and families who have experienced stroke. c. Develop a list of articles that could be accessed to address clinical issues and problems with stroke patients. d. Advance the development of staff who are able to conduct independent nursing research on stroke outcomes.

ANS: A Several “intelligent” clinical information systems are in place that collect good data and then translate nursing knowledge, such as well-researched standards, into reference materials at the point-of-care. In addition, computer applications assist nurses to take action and provide patient care based on the best evidence for practice.

25. As part of an information technology implementation team, you are implementing a clinical decision support system. Particular considerations for successful implementation of this project include: a. Ensuring that the system is reliable. b. Ensuring that patient information is reliable. c. Developing unique identifiers for individuals.

d. Developing rules that support inferences.

ANS: D Clinical decision support systems provide support for novice nurses, in particular, as they enable entry of real-time data from patient situations and inferences that apply the logic that expert nurses would use. These inferences require rules to be developed for the system.

MULTIPLE RESPONSE 1. As a nurse manager, you want to institute point-of-care devices on your unit. The rationale that you provide to support the point-of-care devices includes a. Reduction in incidents of medication error. b. Immediate documentation of care. c. Comparison of patient data with previous data. d. Immediate access to staffing schedules.

ANS: A, B, C Point-of-care devices that allow documentation of assessment, care, and teaching at the bedside reduce the gap in time between care and documentation, thereby reducing error, increasing accuracy, and improving communication of care. Medication devices and patient databases enable accurate clinical decision making.

Chapter 12: Managing Costs and Budgets Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. The chief nursing office of a Magnet™ hospital has conducted a study of ways to improve healthcare services. Healthcare services that add value for clients: a. Accomplish healthcare goals. b. Minimize costs. c. Decrease the number of services used. d. Use high-technology treatments.

ANS: B Models of reimbursement affect which services and approaches (e.g., decreasing the number of services used) might be financially viable and add value for clients. It is critical to determine and advertise the value of nursing care. Services that add value are of high quality, affect health outcomes positively, and minimize costs.

2. The difference between a nurse practitioner’s charge of $45 for an office visit and the insurance company’s payment of $34 is: a. A contractual allowance. b. A profit. c. A flat rate. d. Revenue.

ANS: A Because the amount that is allowed for an office visit is less than the amount that the NP charges, this is known as a contractual allowance or discount. If the amount allowed were more than what the NP charges, then a profit would be realized. All of the answers represent sources of revenue.

3. The chief nursing office continues to seek ways to improve healthcare services to clients and to save the hospital money. However, with the federal guidelines of paying agencies based on capitation, the chief nursing office faces a challenge. Capitation provides incentives for healthcare providers to control costs by: a. Providing fewer services to fewer clients. b. Using fewer services per client. c. Using high-technology treatments. d. Requiring second opinions.

ANS: B In a capitated environment, a single fee is paid for all services provided. To be financially viable under this reimbursement model, organizations would be interested in decreasing the volume of services used and increasing the volume of patients. High-technology treatments and second opinions may increase the number of services used.

4. In a nurse managers’ meeting, the chief nursing officer encourages the managers to brainstorm ways to reduce costs. Nurse managers have the greatest impact on reducing costs by managing: a. Supplies. b. Staffing. c. Fixed costs. d. Medication costs.

ANS: B Because staffing constitutes the largest portion of any healthcare budget, managing the mix and numbers of staff required for patient care to meet

identified outcomes will have the largest impact on budgets.

5. The chief nursing officer works with her nurse managers by helping them understand how to develop and implement a budget. A nurse manager can best describe a budget as a: a. Day-to-day plan for operations. b. Unit of service. c. Statement of revenues and services. d. Financial plan.

ANS: D The budget is an overall financial plan that reflects organizational assumptions, objectives, and standards, and various types of budget planning, including operational and capital budgets, which, in turn, reflect revenues and costs.

6. A nurse manager approves two staff nurses to attend a national conference.

When reviewing the budget, the nurse manager looks at which line item? a. Cash budget b. Capital budget c. Operating budget d. Supply and expense budget ANS: C The operating budget includes a personnel budget, which takes into account productive and nonproductive paid work hours. Education hours are covered under nonproductive paid work hours in the operating budget.

REF: Page 223 TOP: AONE competency: Business Skills 7. A staff nurse regularly works two 12-hour shifts each week and one 8-hour shift every other week. How many FTEs is this position? a. 0.6 b. 0.7 c. 0.8 d. 1 ANS: B Assuming that a full-time RN works 2080 hours/year (40 hours ´ 52 weeks), the nurse works (24 hours ´ 52 weeks + 8 hours ´ 26 weeks)/2080, which is 0.7 FTE. 8. After reviewing her monthly budget report, the nurse manager sees that she has a negative variance, which prompts her to change the staffing schedule. A

negative or unfavorable variance in a monthly expense report may result from: a. Overestimation of inflation. b. Higher than expected client acuity. c. Net revenue exceeding net expenses. d. Not replacing staff who called in sick.

ANS: B Variance reflects the difference between what was projected and the actual performance in a budget. When the variance is negative or unfavorable, the amount spent is more than what was budgeted (expenses exceed revenue); this may be a result of higher acuity. To help managers interpret and use variance information better, some institutions use flexible budgets that automatically account for census variances.

9. An example of an initiative that may reduce total healthcare costs would be: a. Offering nurse practitioner–led clinics that educate parents about nonpharmacologic strategies for managing ear infections. b. Educating seniors about the comparative costs of medications that are prescribed to them. c. Lowering copayments for prescription drugs for seniors. d. Advocating for more readily available MRI services to ensure early diagnosis.

ANS: A Total healthcare costs are a function of prices that are established for various services and the volume or quantity of services used. Utilization of high-tech diagnostic services and lowering of copayments have been implicated in increasing total healthcare costs (thus C and D would not be correct), as well as attitudes and behaviors of consumers of health care. In general, consumers prefer to “be fixed” when something goes wrong rather than to practice prevention. Many consumers still believe that the physician knows best, so they do not seek much information related to costs and effectiveness of different healthcare options. When information is sought, it is not readily available or understandable. Also, consumers are not accustomed to using other, less costly healthcare providers, such as nurse practitioners.

10. Which of the following factors is not implicated in rising healthcare costs? a. Rising expectations of consumers for cure and care

b. Marketing of drugs to consumers c. Large administrative staffs to process medical billings d. Rising Medicare costs ANS: D Unintentional injuries, socioeconomic conditions (e.g., poverty and violence), marketing of pharmaceuticals, and the rising expectations of consumers with regard to what should be done to manage health concerns all contribute to rising healthcare costs. The costs of Medicare are not considered in relation to rising costs of health care.

11. An older adult couple with limited means and on Medicare is considering options after the hospitalization of Mrs. A. with a fractured hip. Mrs. A. is stable but requires assistance with bathing, transfer, and mobility, and this will present stress for Mr. A., who was hospitalized with a mild myocardial infarction last year. Considering their means and health concerns, which of the following might be the best option? a. Hospice care b. Custodial nursing home care c. Home care d. Hospital care ANS: C Of the options presented, C is the best alternative . Custodial nursing care is not covered under Medicare and therefore, the financial burden of this option may cause further stress for the couple. Medicare Part A is an insurance plan for hospital, hospice, home health, and skilled nursing care that is paid for through Social Security. Because Mrs. A. is stable and not terminal, she does not require hospice care. The assistance provided through home care is covered under Medicare and provides assistance for needs such as those of Mrs. A. 12. After a major flu vaccination campaign, an agency bills a private insurance company for allowable costs for administration of each vaccination according to the schedule established by the insurance company for reimbursement. This is an example of which major payment method? a. Cost-based reimbursement b. Charges c. Contractual allowance d. Prospective reimbursement ANS: A

Because the agency is submitting costs after the campaign is completed and in accordance with an established schedule of allowable costs, a retrospective, cost-based reimbursement payment method is being utilized. If a desire for profit was indicated, then the answer would be “charges.”

13. Physicians in a small urban hospital are reluctant to discharge older adult patients because many of the patients lack private insurance and the resources to travel distances for follow-up care. The hospital administration pressures the physicians to discharge patients sooner and to be more consistent with the number of hospitalization days specified within the DRGs. Which of the following would most likely prompt the action of administrators? a. The hospital is incurring a deficit related to a gap between the PPS and the DRGs and costs of care. b. Local home care services are expressing concern about the increased acuity of patients being discharged into their care. c. The resource-based relative scale for physicians does not account for the increased length of stay. d. Acute care patients are being denied entry to the hospital because of the increased stay of patients.

ANS: A Length of stay (LOS) is the most important predictor of healthcare costs and extra days are a cost to the organization in terms of both the extra days and decreased patient volume. The situation, as outlined, does not indicate that there is a bed shortage and therefore, there is no evidence that other patients are being denied access to services or that additional patient volume is not being captured. The hospital would be concerned about the impact on its income because of the additional, uncompensated care costs incurred for patients who exceed the usual length of stay explicitly calculated under PPS and the DRGs. 14. Within a healthcare environment, where the gap between revenues and costs can mean the difference between sustainability of an organization and nonsustainability of an organization or services, it is critical for nurse managers to: a. Maintain a clear vision of how to trim healthcare costs. b. Balance value-added services against costs and revenues. c. Consistently delete programs that are of high cost. d. Implement programs that bring in additional revenues.

ANS: B

To achieve and maintain financial viability, nurse managers must be able to think strategically financially and in terms of nursing care. Cutting costs by deleting programs and bringing in additional revenue through new programs and services are not in themselves strategic unless the decisions made lead to quality care, have positive outcomes, and are efficient in terms of cost.

15. Because of the complexity of reimbursement systems and its implications for the services available to patients, the nurse has a key role in: a. Advocacy for patients with regard to services required and services utilized. b. Increasing the volume of services and decreasing the number of patients served. c. Accomplishing more with each visit and decreasing the volume of services used. d. Decreasing the volume of services used and the number of return visits.

ANS: A The specific strategies employed by organizations and nurses to contain costs and increase revenues depend on the reimbursement system(s) within which the organization operates and therefore on whether the volume of services is increased or whether the volume of services is decreased by placing greater emphasis on efficacy in each visit and reducing the number of return visits.

Because of the complexity of the reimbursement environment, the nurse is placed in a position of advocacy in terms of what the patient needs and how those needs can be best met within the funding structures.

16. Of the following, which is the most effective strategy that a nurse manager could employ to reduce unnecessary costs in specific healthcare settings? a. Training nurses on accurate documentation of supplies used for patient care b. Reducing the number of overtime hours worked by staff c. Reducing the number of staff on a unit d. Making decisions for patients about which care is important to their health ANS: A Reducing overtime hours needs to be carefully assessed against the reasons for overtime (e.g., staff overload, recent illnesses, increased acuity) in terms of whether this reflects an ongoing or temporary situation and therefore whether it is a necessary variance or not. Reducing staff may or may not be effective, depending on the services being provided. Making decisions for the

patient misses an important opportunity to invite the patient into discussion about patient priorities and needs and relative costs of options, which may lead to improved adherence with regimens and less waste of resources. An effective approach to cost containment is ensuring that supplies are accurately accounted for and charged in a timely manner.

17. In preparing her budget, a nurse manager determines that she needs to budget for six FTE RN positions in the upcoming year. Based on a 40-hour week, this means that the nurse manager has determined that the budget will provide for _____ hours. a. 12,480 productive b. 10,820 productive c. 12,480 paid d. 10,800 patient care ANS: C From the information given, it is not possible to determine how many nonproductive hours (vacation, holiday, sick time, education) the nurse manager has accounted for in her budget calculations and therefore whether the total number of hours (40 hours ´ 52 weeks ´ 6 staff = 12,480 paid hours) is productive (paid time that is worked) or nonproductive hours. 12,480 accurately reflects the total number of hours of work paid per year.

18. In preparing her budget, a nurse manager determines that she needs to budget for six FTE RN positions in the upcoming year. The nurse manager determines that RN 1 has 5 weeks of vacation and 3 days of education, and has averaged 3 sick days a year. RN 2 has 6 weeks of vacation, has asked to attend a 3-day conference and a 2-day workshop, and has no history of sick time. RN 3 is new, and you anticipate 3 weeks of orientation, as well as 4 weeks of vacation. RN 4 has 6 weeks of vacation and has an ongoing health condition, so you anticipate 2 weeks of sick time, as well as 3 days for education. RN 5 has 5 weeks of vacation, has no education planned, and averages 5 sick days per year. RN 6 has 6 weeks of vacation, has no educational opportunities planned, and has been off ill for 4 weeks. How many hours of productive paid time can be anticipated for the budget? a. 12,480 b. 11,200 c. 10,848 d. 10,688 ANS: C

From the information given, there are 32 weeks of vacation (40 hours ´ 32 weeks = 1280 hours), 11 days of education (11 days ´ 8 hours = 88 hours), 15 days of orientation (15 days ´ 8 hours = 120 hours), and 18 days of sick time anticipated (18 days ´ 8 hours = 144) or 1280 + 88 + 120 + 144 = 1632 hours of nonproductive time. This will leave 10,848 hours of productive time available, based on the information available and the fact that the manager is not anticipating sick time for RN 6 in the upcoming budget year.

19. The primary reason for calculating productive hours paid instead of simply calculating work paid per year is that productive hours enable the manager to: a. Anticipate total costs for patient care. b. Know how much time staff will likely be unavailable because of illness. c. Determine when orientation needs to occur for new staff. d. Determine the number of hours available for patient care.

ANS: D Total hours are critical for determining the total number of hours that need to be paid for the year. Productive hours are needed to determine what hours are actually available for patient care. The number of FTEs required is determined by dividing the total patient care hours required by the number of productive hours.

20. In preparing a budget, the nurse manager needs to anticipate the cost of benefits (e.g., health, life insurance, pension and retirement plans). Based on the usual cost of benefits, how much should a nurse manager include for a total full-time salary cost of $312,000? a. $78,000-$93,600 b. $62,400-$78,000 c. $46,800-$93,600 d. $31,200-$46,800 ANS: C The average cost of benefits is approximately 25% to 30% of a full-time employee’s salary. In this example, the correct response is obtained by multiplying the total full-time salary cost by .25 and .30.

21. A nurse manager is planning to request three new infusion pumps at a cost of approximately $1500 each. This item would typically be included in which budget? a. Operating

b. Strategic c. Unit of service d. Capital ANS: D Items that have a useful life of longer than a year, which is likely with the pumps, and that have a cost that usually exceeds $300 to $1000 (specific amount is set by the organization) are considered capital items. Operating budget items include what is used on a day-to-day basis, such as staffing.

22. A nurse manager is planning to request three new infusion pumps at a cost of approximately $1500 each. What would BEST support the capital request? a. Number of patient care hours anticipated for the year b. Cost comparisons; how much and how often infusion pumps are used; condition of existing pumps c. Outline of cost for each pump d. Estimation of total cost; no further details ANS: B Complete well-documented justifications are needed because the competition for limited resources is stiff. Justifications should be developed using the principle of any business case and should include, at minimum, projected amount of use; services duplicated or replaced; safety considerations; need for space, personnel, or building renovation; effect on operational revenues and expenses; and contribution to the strategic plan.

23. As an experienced nurse manager who is new to an organization, it would be important to: a. Know the difference between operating and capital budgets. b. Understand the budget timetable and level of involvement expected of individual managers in budget preparation. c. Know why a budget is essential to the well-being of an organization. d. Understand what factors drive up healthcare costs in the healthcare system.

ANS: B Although all of the answers reflect knowledge that is critical to budgeting for nurse managers, an experienced nurse manager would likely be already familiar with general knowledge related to budgeting. The nurse manager, however, would need to become familiar with budget timetables and level of involvement expected in this specific organization because these elements of budgeting vary from work environment to work environment.

24. A nurse manager discovers that the actual number of visits per patient in a home health service is 3.8 visits per day when the standard is 5 visits per day.

Based on this information, the nurse manager: a. Concludes that the complexity of care in each visit has arisen. b. Concludes that patient volume has been decreased. c. Decides that more information is needed before a conclusion can be reached. d. Initiates a training session regarding the importance of ensuring that visits are made.

ANS: C Variance from measures of productivity or ratio of outputs to inputs does not necessarily offer an explanation of whether or not care was delivered as needed. Before proceeding to any further conclusion, the nurse manager will need to investigate reasons for the decreased output.

MULTIPLE RESPONSE 1. Which of the following are considered variable costs? a. Salaries for the minimum number of staff b. Utilities and rent c. Managed care d. Supplies e. Medication and treatment supplies ANS: D, E The total fixed costs in a unit are those costs that do not change as the volume of patients changes. In other words, with either a high or a low patient census, expenses related to rent, utilities, loan payments, administrative salaries, and salaries of the minimum number of staff to keep a unit open must be paid.

Variable costs are costs that vary in direct proportion to patient volume or acuity. Examples include nursing personnel, supplies, and medications.

2. During the budgeting process, nurse managers are typically responsible for which of the following? a. Determining inflationary rates for the upcoming year b. Developing unit operation objectives c. Justifying capital equipment requests d. Predicting cash flow e. Negotiating budget with other managers and administration ANS: B, C, E

Although involvement in budget processes will vary from institution to institution, these are typical responsibilities for nurse managers during the budget process.

Chapter 13: Care Delivery Strategies Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. Complex care of acutely ill patients is required on a surgical unit, which utilizes differentiated nursing practice as its model of care delivery. The concept of differentiated nursing practice is based on: a. Licensure status. b. Experience in the agency. c. Leadership capabilities. d. Education and expertise.

ANS: D Differentiated nursing practice models are models of clinical nursing practice that are defined or differentiated by level of education, expected clinical skills or competencies, job descriptions, pay scales, and participation in decision making.

2. The relief charge nurse has assigned a newly licensed baccalaureateprepared nurse to be one of the team leaders for the 3-11 shift. In making this decision, the charge nurse has overlooked this nurse’s: a. Clinical expertise. b. Leadership ability. c. Communication style. d. Conflict-resolution skills.

ANS: A Because the basic education of baccalaureate-prepared RNs emphasizes critical-thinking, clinical reasoning, and leadership concepts, they are likely candidates for such roles. Benner (2001), however, identified five stages of clinical competence for nurses: novice, advanced beginner, competent, proficient, and expert. She suggests that competence is typified by a nurse who has been on the job in the same or similar situation 2 to 3 years. Nurses who are at the novice or advanced beginner stage would be less likely than their more experienced counterparts to implement any type of delivery model effectively and thus, this assignment overlooks the nurse’s level of clinical expertise and leadership experience.

3. When interviewing an applicant for a position, the nurse manager describes the unit’s care delivery system as one in which each nursing assistant is cross-trained to perform specific tasks, and the RNs do all treatment, medication administration, and discharge teaching. The nurse applicant knows this nursing care delivery strategy to be: a. The case method. b. Functional nursing. c. Primary nursing. d. Nurse case management.

ANS: B The functional model of nursing is a method of providing patient care by which each licensed and unlicensed staff member performs specific tasks for a large group of patients.

4. You are the nurse manager of a nursing service organization that provides around-the-clock care to clients in their homes. To achieve maximum reimbursement for a client who is recovering from a hip replacement, the nursing staff most likely will follow the nursing care guidelines presented in the: a. Nursing care plan. b. Physician’s orders. c. Critical pathway. d. Clinical practice guidelines.

ANS: C A critical pathway outlines outcomes, clinical standards, and interventions for a patient in each phase of treatment. The goal of critical pathways is effective coordination of care across various staff and levels of care.

5. The nurse case manager is working with a client admitted for end-stage renal disease. The case manager’s major goal during this hospitalization is to: a. Implement the care pathway on admission. b. Provide direct nursing care throughout the hospitalization. c. Supervise the nursing staff members who implement the care map. d. Prevent additional hospitalizations resulting from complications of the client’s disease.

ANS: D The goals and outcomes established in a critical pathway are designed to support the aims of case management, which are shortened hospital stays and prevention of hospital readmissions.

6. The nurse manager at a cardiac rehabilitation unit was asked to select a care delivery model. Which of the following methods would be the most cost-effective? a. Functional method b. Case management method c. Primary care method d. Team method ANS: B Team nursing, functional nursing, and case management are all considered efficient, cost-effective methods of care delivery because they enable utilization of various types of healthcare providers (rather than baccalaureate nurses in direct care, which is the primary nursing method). Case management is considered particularly cost-effective in patient care settings because it maintains quality care while streamlining costs for high-risk, highvolume, high-cost patient populations and seeks the active involvement of the patient, the family, and diverse healthcare professionals.

7. In an acute care unit, the nurse manager utilizes the functional nursing method as the care delivery model. The nurse manager’s main responsibility is the needs of the: a. Department. b. Unit. c. Staff. d. Patient.

ANS: D In a functional nursing model, where other team members are focused on performing specific tasks, the nurse manager assumes primary responsibility for patient outcomes.

8. A patient is admitted to a medical unit with pulmonary edema. His primary nurse admits him and then provides a written plan of care. What type of educational preparation best fits the role of primary nurse? a. Baccalaureate b. Associate c. Diploma d. LPN/LVN ANS: A Because of the breadth of nursing knowledge required, baccalaureate education is preferred for primary nurses.

9. In a small rural nursing home, a director of nursing decides, because of a shortage of nurses, to implement a partnership model to help with basic tasks that comply with state rules regarding delegation. What type of design constitutes a partnership care delivery model? a. RN and LPN/LVN b. RN and RN c. RN and medication assistants d. RN and certified nurses’ aides ANS: C The partnership care delivery model is a variation of primary nursing in which an RN works with a consistent assistant, who performs basic nursing functions consistent with state delegation rules.

10. The case method of care delivery could be best justified in which of the following scenarios? a. Stable patient population with long-term care and family needs b. Acute care surgical unit with predictable postsurgical outcomes and many technical procedures c. Pediatric intensive care unit that heavily involves families as well as patients d. Home healthcare environment with patients at varying levels of acuity ANS: C This model is especially useful in the care of complex patients who need active symptom management provided by an RN, such as the care of the patient in a hospice setting or an intensive care unit. This method would be justifiable delivery in the pediatric intensive care unit, where the status of patients can change rapidly and where complex functions of care involve both patients and families.

11. During times of nursing shortages and increased nursing costs in health care, which of the following nursing care delivery models might come under greatest scrutiny? a. Case method b. Team nursing c. Functional nursing d. Nurse case management ANS: A The case method may involve total patient care provided by a registered nurse, which, in today’s costly healthcare economy, is very expensive. In

times of nursing shortages, there may not be enough resources or nurses to use this model.

12. A patient complains to you that she has no idea who “her nurse” is on any given day. “I ask one nurse for my pills and she says, ‘That’s not my job.’ I ask the pill nurse about my lab tests and she says that I should ask another nurse.” The nursing care delivery model most likely employed in this situation is: a. Differentiated practice. b. Team nursing. c. Functional nursing. d. Case management.

ANS: C Functional team nursing involves licensed and unlicensed personnel who perform specific tasks for a large number of patients. A disadvantage of functional team nursing is the fragmentation of care. The physical and technical aspects of care may be met, but the psychological and spiritual needs may be overlooked. Patients become confused with so many different care providers per shift. These different staff members may be so busy with their assigned tasks that they may not have time to communicate with each other about the patient’s progress.

13. A patient complains to you that she has no idea who “her nurse” is on any given day. “I ask one nurse for my pills and she says, ‘That’s not my job.’ I ask the pill nurse about my lab tests and she says that I should ask another nurse.” This nursing care delivery model employed in this situation might be particularly effective in: a. Promoting communication among diverse team members. b. Facilitating multiple perspectives on the total care of a patient. c. Avoiding patient-provider conflict. d. Developing competence and confidence in unskilled workers.

ANS: D An advantage of functional nursing is that both unskilled assistive personnel and skilled staff are involved in performance of specific tasks, and the repeated performance of tasks enables staff to become very efficient in specific functions. Disadvantages of the model include difficulty in being able to assess the patient’s nonphysical needs effectively and the potential for ineffective communication because of the focus on specific tasks.

14. For a nurse manager in the functional nursing model, an approach that will assist in maintaining staff satisfaction in this specific model is: a. Rotation of task assignments. b. Frequent opportunities for in-service education. c. Orientation to job responsibilities and performance expectations. d. Team social events in off hours.

ANS: A Although repetition of tasks increases confidence and competence, it can also lead to boredom. Rotation of tasks can assist specifically in this model to reduce the boredom that is a potential disadvantage of this model.

15. In comparing team and functional models of care, a nurse manager favors the team model. In particular, she finds that the team model: a. Can be effective in recognizing individual strengths and backgrounds of staff. b. Promotes autonomy and independence for the RN. c. Avoids conflict because of role clarity. d. Is efficient in delivering care to a large group of patients, utilizing a staffing mix.

ANS: A Team nursing delivers care to a small group of patients, using a mix of licensed and unlicensed personnel. Team nursing uses the strengths of each caregiver.

16. To effectively delegate in a team nursing environment, the RN team leader must be familiar with the legal and organizational roles of each group of personnel and must: a. Be able to effectively communicate with patients. b. Build relationships with physicians. c. Be able to adapt to daily changes in staffing. d. Adapt in communicating information to her supervisor.

ANS: C A particular challenge in team nursing is that staff mixes and staff may change daily because of individual schedules and shortages.

17. A nurse manager questions the true difference between primary nursing and total patient care. After careful consideration of both models, the nurse manager concludes that primary nursing differs significantly from total patient care in:

a. Breadth of nursing knowledge and expertise required. b. Intention to provide holistic nursing. c. Degree of task orientation. d. Levels and types of assessment.

ANS: C Significant overlap can be seen between primary nursing and total patient care in terms of breadth of assessment and knowledge required to provide holistic care. A primary difference is that nurses in the total care model assume accountability while on shift, whereas primary nurses assume responsibility from time of admission to discharge and 24 hours a day.

18. A conflict develops between an associate nurse and a primary nurse over the assessment of a patient with pulmonary edema. Based on her assessment of the patient, the associate nurse insists that it is her role to change the care plan because she is the one who has made the assessment. As the nurse manager, you clarify that: a. It is the role of the primary nurse to make alterations based on assessment data and input. b. The associate nurse is accountable and responsible while the primary nurse is off duty and therefore is able to alter the care plan. c. Neither the primary nor the associate should make changes without first consulting you as the manager. d. It really does not matter who alters the nursing care plan as it depends on situation and time to do so.

ANS: A The primary nursing model assumes that the primary nurse is accountable for patient care, even while off duty. The primary nurse is responsible for establishing the patient plan of care and therefore for altering it with the input of an associate. The associate is responsible for implementation of the established care plan when the primary nurse is off duty.

19. When comparing functional nursing and primary nursing, a nurse manager, after evaluating particular models of nursing care for potential adoption, determines that patient and nurse satisfaction in primary nursing are: a. Similar to those in functional nursing. b. Not of significance in either model. c. Low by comparison with functional nursing. d. High when compared with functional nursing.

ANS: D Although some studies suggest there is little difference between functional nursing and primary nursing, primary nursing tends to be more satisfying for RNs, who enjoy a high level of accountability and autonomy in decision making. Patient satisfaction is also high, as patients form close therapeutic relationships with the nurse because of the continuity of the relationship.

Functional nursing is criticized for low patient satisfaction and potential staff dissatisfaction related to boredom and an autocratic approach to management.

20. In transitioning to a primary nursing model, it is important for a nurse manager who enjoys a high level of control over patient care to understand that his or her decision making at the patient care level: a. Is increased. b. Is decreased. c. Is relinquished. d. Remains the same.

ANS: B The nurse manager who is considering movement to primary nursing needs to consider how the role of the manager changes, as well as the roles of the staff. The role of decision making at the patient care level is relinquished to the primary nurse, and the role of manager becomes that of facilitator, coach, mentor, role model, and clinical resource.

21. You are considering putting forward a proposal to move the model of care from team nursing to a primary nursing hybrid: patient-focused care model. In considering this proposal, you recognize that significant costs specific to operationalizing this model are related to: a. Implementation of an all-RN staff complement. b. Significant changes in the physical structure of units. c. Orientation of staff to new roles and responsibilities. d. Testing and piloting technology at the bedside.

ANS: B This particular model includes a focus on patient care that includes multidisciplinary teams and assistants at the bedside. Services, including laboratories and pharmacies, are decentralized to bring them closer to where care is delivered.

22. When hiring a case manager for a rehabilitation setting, you would most likely consider a:

a. Registered nurse with a master’s degree. b. Physiotherapist with a background in stroke rehabilitation. c. Social worker with a background in counseling. d. Health professional with advanced background who is client and outcome focused.

ANS: D Case managers can come from a variety of disciplines but should have advanced preparation with the particular at-risk population being served, be comfortable in an advocate role, and be outcome and patient focused.

23. Case managed care may enhance profit in a for-profit health organization by: a. Minimizing costs in high resource consumption areas. b. Combining licensed and non-licensed care providers in delivering patient care. c. Increasing reimbursement from third-party payers. d. Reducing the amount of technology used to support clinical decision making.

ANS: A Case managed care is not revenue generating but rather revenue protecting in that better coordination of care enables efficient achievement of patient outcomes, can result in shorter length of stay, and can prevent readmission.

24. In hiring nurses during the transition from team nursing to a primary nursing model, Benner’s work would suggest that you give priority to nurses who are at least at which level of competency? a. Advanced beginner b. Competent c. Proficient d. Novice ANS: B Nurses who have less than 2 or 3 years’ experience in primary nursing and/or less than 2 or 3 years of nursing experience will likely require more assistance than other nurses, which will put a greater demand on the unit during a time of transition.

25. In considering whether or not to accept a job offer as a nurse manager at a Magnet™ hospital, you look at an environment that you might encounter as a head nurse at the hospital. You determine that you could expect to:

a. Find it difficult to recruit new staff. b. See rapid turnover of staff on your unit. c. Find nurses who exemplify interest in quality care. d. Find limited interest in excellence in the nursing environment.

ANS: C Magnet™ hospitals exemplify hospitals whose focus processes attract and retain nurses who value and promote quality care and excellence in nursing environments.

MULTIPLE RESPONSE 1. Your organization has made a decision to implement TCAB in your hospital. As a manager, what strategies would you use to implement TCAB? a. Encourage recognition among staff of their knowledge of the patient-care environment. b. With staff, select small changes for consideration. c. Select only projects that have widespread impact. d. Secure external advisors to evaluate innovation. e. Present ideas based on best practices and ask staff for advice on implementation.

ANS: A, B, E Transforming care at the bedside (TCAB) relies on active involvement of staff in the generation of innovative ideas to improve patient care. Staff are actively engaged in selecting innovation, planning, and evaluation of the innovations. Critical to practice changes, rapid cycle change is a process that encourages testing creative change on a small scale while determining potential impact.

Chapter 14: Staffing and Scheduling Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. The number of adverse events such as falls and pressure ulcers on your unit is increasing. An ideal staffing plan to address this issue would include which of the following? Increasing the: a. Total number of staff on the unit. b. Staff and RN hours per patient. c. Total number of staff, and implementing 12-hour shifts. d. Number of RNs and number of RNs with experience on the unit.

ANS: D

A number of studies have identified that adverse events such as falls and pressure ulcers can be reduced by increasing the number of RNs on a unit (relative to other personnel) and utilizing experienced RNs. Overtime and 12hour shifts are linked to greater incidence of errors.

2. A small rural hospital has been designated as a critical access hospital. It has 40 beds and an average occupancy of 34 beds. To prepare the staffing, the chief nursing officer computes the occupancy as being: a. 90%. b. 85%. c. 75%. d. 60%.

ANS: B A way to assess a unit’s activity level is to calculate the percentage of occupancy. Formula: daily patient census (rounded) divided by the number of beds in the unit The occupancy level is calculated as 34/40, or 85%.

3. To prepare staffing schedules, a nurse manager needs to calculate paid nonproductive time. When calculating paid nonproductive time, the nurse manager considers: a. Work time, educational time, and holiday time. b. Paid hours minus worked hours. c. Vacation time, holiday time, and sick time. d. Paid hours minus meeting time.

ANS: C Nonproductive hours are hours of benefit time and include vacation, holiday, and personal or sick time.

4. An important aspect of managing the costs on a unit is to plan accurately for staffing needs. Nurse managers use staffing plans to: a. Assign staff on the unit on a daily basis. b. Ensure that days off are planned for the staff. c. Outline the number of individuals by classification on a per-shift basis. d. Predict the numbers and classifications of float staff needed to augment regular staff.

ANS: C A nurse manager needs to manage financial resources by developing staffing plans. Staffing plans plan for minimum number of professional nurses

required on a unit at a given time or to the amount of minimum staffing in an extended-care facility or prison, based on regulatory guidelines.

5. A nurse manager must consider a number of external variables when preparing the personnel budget and projecting the unit’s staffing needs. An external variable to be considered is: a. Organizational staffing policies. b. Staffing models. c. Changes in services that will be offered. d. Department of Health licensing standards.

ANS: D Licensing regulations of the state can determine staffing models. Staffing regulations can dictate the number of professional nurses required on a unit at any given time.

6. A nurse manager must also consider a number of internal variables that will affect staffing patterns. An internal variable to be considered is: a. Organizational staffing policies. b. State licensing standards. c. American Nurses Association. d. Consumer expectations.

ANS: A State licensing standards outline what a nurse can do. Internal policies determine what a nurse may do in a particular setting as well as the amount of flexibility that is allowed to manage times of high and low volumes, as well as changes in acuity. Organizational policies can put the nurse manager in a situation where patient safety cannot be maintained or financial obligations met.

7. A nurse manager uses many sources of data when planning the unit’s workload for the year. Which of the following data must be considered in the planning? a. Hours of operation of the unit b. Trends in acuity on the unit c. Maximum work stretch for each employee d. Weekend requirements ANS: B Acuity levels are determined through classification systems, which determine the nursing resources required.

8. Scheduling is a function of implementing the staffing plan by assigning unit personnel to work specific hours and specific days of the week. To retain nursing staff, the nurse manager must schedule: a. All weekends off. b. All holidays off. c. A variety of scheduling options. d. Rotating shifts.

ANS: C Creating a flexible schedule with a variety of scheduling options that leads to work schedule stability for each employee is one mechanism likely to retain staff, which is within the control of nurse managers.

9. The difference between staffing and scheduling is that staffing: a. Puts the right person in the right position. b. Puts the right person in the right time and place. c. Refers to the number of nursing hours per patient per day. d. Looks after interpretation of benefits and compensation.

ANS: A Nursing staffing involves planning for hiring and deploying qualified human resources to meet the needs of a group of patients. Scheduling, on the other hand, is a function of implementing the staffing plan by assigning unit personnel to work specific hours and days of the week.

10. A busy neurologic ICU and step-down unit most likely would use which patient classification system? a. Factor evaluation b. Prototype evaluation c. Hybrid system d. AHRQ system ANS: A A factor evaluation system is considered more objective than a prototype evaluation system. It gives each task, thought process, and patient care activity a time or rating. Some patient types with a single healthcare focus, such as maternal deliveries or outpatient surgical patients, would be appropriately classified with a prototype system. Patients with more complex care needs and a less predictable disease course, such as those with pneumonia or stroke, are more appropriately evaluated with a factor system.

11. A factor evaluation system:

a. Utilizes financial data to determine number of staff-to-patient ratios. b. Utilizes DRGs to determine acuity on a unit. c. Combines interventions and time required for interventions to determine levels of care required. d. Combines financial resources and nursing interventions to determine patient contact hours.

ANS: C A factor evaluation system considers tasks, thought processes, and patient care activities and gives them a time or rating. These are then used to determine the number of patient care hours required.

12. Staff members on your unit raise concern that there is rising acuity on the unit and lack of responsiveness in addressing these needs through appropriate staffing. They point to increased incidences of adverse and sentinel events on the unit. To address this concern, your hospital organization would do best to: a. Implement a patient classification system immediately. b. Participate in databases that compare the outcomes and staffing levels versus those of institutions similar to yours. c. Provide increased numbers of staff to the unit. d. Ignore such concerns because acuity is variable.

ANS: B Staff morale suffers both when acuity models indicate a gap between staffing and acuity and when there is no model but perceived acuity that is not being addressed. A truer approach is to monitor patient outcomes and participate in national databases that measure staffing levels through comparison with like institutions.

13. A particular classification system assigns revenue according to the functional capacity of patients and the progression of patients during their stay in rehabilitation units. More independent patient activities, such as prompted voiding, require higher staff utilization than dependent activities but do not result in increased staff resources. This is an example of: a. Bureaucracy. b. Concern related to the validity of classification systems. c. Inadequate reliability of classification systems. d. Inappropriate subjectivity in making judgments about staffing.

ANS: B Validity of categories and implications for staffing levels are in question in this situation because staffing levels are not reflective of the levels of activity

required for patient care.

14. In the past year, you have noticed an increase in patient falls on your unit.

In reading studies related to staffing and patient outcomes, you realize that you will need to plan for: a. Higher patient care hours. b. Safer facilities. c. Institution of a patient classification system. d. An increased number of RN positions.

ANS: D Lower fall rates are shown to be related to higher total nursing hours and a higher percentage of nursing hours supplied by RNs. 15. A strategy to increase RN staff retention at Valley Hospital includes: a. Better compensation and benefits. b. Clearer position descriptions. c. Lay-offs of nursing assistants. d. Adequate staffing to meet acuity levels.

ANS: D Over the past decade, a significant amount of research has been done in the United States to evaluate links among nursing staffing, workloads, skills mix, and patient outcomes. An analysis of this research demonstrates that ensuring adequate staffing levels has been shown, among other things, to improve nurse retention and job satisfaction.

16. In evaluating weekend mortality rates, the head nurse on the cardiac unit is surprised to find that they are higher than on weekdays. In exploring the reasons for this apparent anomaly, the head nurse focuses on: a. Availability of diagnostic personnel. b. Availability of physicians. c. Communication with on-call providers. d. Acuity level of patients.

ANS: C Studies to date of off-peak hours (weekends and nights) are limited, but those that have been done indicate increased mortality during weekends and nights, when staff work with fewer and often less experienced staff and when there may be strained communication among on-call healthcare providers.

17. A nurse staffing plan takes into account: a. Specific nurse-to-patient ratios per shift.

b. Participation of nurses in projecting staffing needs. c. Compensation and benefits for each level of staff. d. The occupancy load of a unit.

ANS: B Nurse staffing plans employ nursing judgment and flexibility that is based on acuity, nurse experience, and unit configuration rather than set nurse-topatient ratios. The American Nurses Association has opted to support the nurse staffing committee as the approach to ensure safe staffing. In 2013, national legislation was introduced that requires all acute care hospitals to establish a committee made up of 55% direct care RNs. 18. As the unit manager, you post the staffing plan and compliance reports.

This initiative is aimed at: a. Maintaining unit morale. b. Complying with national requirements. c. Demonstrating patient outcomes. d. Inviting staff participation in decision making.

ANS: A Hospitals are responsible for monitoring the extent to which actual staffing matches the staffing plans, making revisions as necessary. The Joint Commission accreditation reviews staffing plans against any obvious staffing deficiencies and patient care concerns. Posting of the staffing plan is required in some states so that staff may view it. Adequate staffing, as demonstrated through a staffing plan, and compliance reports contribute to staff morale.

19. To maintain patient safety, studies suggest that scheduling should avoid: a. Rotating shifts. b. Weekends. c. 8-hour shifts. d. Mandatory overtime.

ANS: A Rotating shifts and overtime past 12 hours (mandatory or not) are being shown to increase nurse error and jeopardize patient safety.

20. In a job interview for a staff position, which of the following indicates your knowledge of patient safety? a. “Will I be able to get overtime hours on your unit?” b. “If there is an opportunity to work extra shifts, I would really like that.” c. “Is there a strategy in place to reduce the number of overtime hours on the

unit?” d. “I see no reason why I wouldn’t be able to work overtime.”

ANS: C Overtime, whether voluntary or mandatory, to fill staff vacancies is seen as a risk to both patients and nurses because it is more likely to lead to compromised decision making and technical skills because of fatigue.

21. To reduce reliance on overtime hours, an organization develops a strategy for floating nurses during staff shortages. To maximize patient safety and reduce costs, the healthcare organization: a. Develops a centralized pool of float nurses. b. Assigns nurses from less busy units to ones with increased acuity levels. c. Floats nurses only between units on which the nurses have been crosstrained. d. Assigns float nurses to basic care only.

ANS: A A centralized pool usually includes experienced nurses who maintain a broad range of competencies. Other approaches are less satisfying for nurses, are less efficient, and may be less safe.

22. To project staffing needs and to avoid understaffing, it is important that nurse managers consider which of the following? a. Maximum productive hours b. Average nonproductive hours c. Minimum benefit hours d. Maximum vacation time ANS: B To avoid understaffing, average nonproductive or benefit hours need to be taken into account, so the unit is properly staffed when staff members are off.

23. Your healthcare organization has a decentralized system for scheduling.

As part of this process, after you have developed a draft schedule, you may need to: a. Seek budgetary approval. b. Balance personal schedules against institutional needs. c. Negotiate the schedule with unit staff. d. Submit the schedule to a centralized staffing office for review.

ANS: D In a decentralized model, you may be completely responsible for approving

all schedule changes and for development of the schedule, or you may need to submit a draft to a centralized office for review and determination of supplemental staff. Balancing personal schedules and negotiation describes staff self-scheduling models.

MULTIPLE RESPONSE 1. In reviewing the job description of a nurse manager, the staff becomes aware that a nurse manager’s role is complex. Which of the following duties are required of a nurse manager? a. Ensure unit productivity reports. b. Develop policy and legislation to protect nurses’ well-being. c. Plan staffing of UNPs only. d. Prepare a unit budget that reflects unit staffing needs. e. Monitor nurse-sensitive indicators such as falls and incidence of infections.

ANS: A, D, E A nurse manager manages financial resources by developing business and staffing plans.

Chapter 15: Selecting, Developing, and Evaluating Staff Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. The nurse manager schedules evaluations of staff members using a newly developed performance appraisal tool. The development of a performance appraisal tool should include: a. Organizational mission, philosophy, and position requirements. b. A generalized overview of the duties of a position. c. A skills checklist and accreditation requirements. d. An ordinal scale that ranks all employees.

ANS: A Performance appraisal tools and processes should reflect the organizational mission and philosophy, as well as position requirements.

2. John, a new graduate, reviews the employee evaluation for his new position. The first section requires that he list his own specific objectives to be accomplished. This is an example of: a. The traditional rating scale. b. Learning goals, or management by objectives. c. A forced distribution scale.

d. A behavior-anchored rating scale.

ANS: B In management by objectives, the employer and the employee jointly establish clear and measurable objectives for the next performance period.

3. John notes that the next section is specific to the organizational philosophy and has a four-point ordinal scale that describes performance from “always meets expectations” to “does not meet expectations.” This type of evaluation is most commonly known as: a. A behavior-anchored rating scale. b. Management by objectives/learning goals. c. The forced distribution scale. d. A graphic rating scale.

ANS: D Graphic rating scales are commonly used in evaluation and reflect generalizations rather than specific behaviors.

4. On your unit, despite efforts to build a strong sense of team, conflict between some of the staff is ongoing. Nonetheless, you want to proceed with developing a systematic and effective performance appraisal system. Which of the following approaches would be most appropriate for you to implement? a. Peer review b. A combination of tools c. Anecdotal notes d. Rating scale ANS: B A combination of tools is likely superior to any one method in any situation.

5. As part of orientation to your unit, you decide to administer Kolb’s Learning Style Inventory (LSI) to new staff. The most likely reason for your decision is that the use of Kolb’s LSI: a. Reduces the cost of orientation. b. Determines if there is fit between learner and organizational values. c. Develops the strengths of the new staff member. d. Enables individualization of learning to the learner’s needs.

ANS: D Administration of Kolb’s LSI enables identification of the learning styles of new employees, which assists in focusing the implementation of orientation

goals and in individualizing learning to the needs and learning style of the employee.

6. Which of the following might best conclude an interview? a. “Thank you for your interest. Someone will be in touch with you soon.” b. “Before you go, we will make sure that we have your contact information.

Thank you for coming.” c. “I will be in contact with all candidates by telephone by next Friday. It has been a pleasure to meet you.” d. “We have several excellent candidates so I am not sure about the outcome of the interview, but I will let you know. Thank you for coming.”

ANS: C An employment interview should always conclude with information as to how and when follow-up to the interview will occur.

7. In determining the fit of a candidate with the culture on your unit, which of the following interview questions might be asked? a. “Could you review your resume for us, highlighting your certifications and experience?” b. “If we were to ask your references, what would they list as your strengths?

Weaknesses?” c. “We have a number of older adult patients on this unit. If you noticed another staff member addressing one of these patients impatiently, how would you respond?” d. “Tell us about your work and academic experiences and qualifications.”

ANS: C The nurse manager wants the most qualified individual for the position who also fits the culture of the organization. Asking behavioral questions in the interview allows you to assess how a candidate may function in real-life situations and to assess if this behavior is compatible with the culture on the unit.

8. The biggest challenge in the recruitment of staff is: a. Finding well-qualified candidates who can function well within your particular work culture. b. Recruiting individuals with the appropriate qualifications and experience. c. Screening out candidates who are unable to function well within a team. d. Determining if candidates have had previous negative experiences in a work environment.

ANS: A Choosing the right individual is the challenge for managers and involves finding qualified candidates who will work well within your culture.

9. Anecdotal notes: a. Should be completed only when there are performance concerns. b. Can be used to support and justify fairness in termination discussions. c. Are unnecessary if the evaluation instrument is thorough. d. Need to be completed at the end of a performance period.

ANS: B Anecdotal notes should be kept consistently throughout the evaluation period and should reflect both negative and positive behaviors if they are to provide an accurate assessment of performance. Anecdotal notes provide documentation to support rating scales and narrative evaluation summaries.

10. An outpatient clinic advertised for RN positions. Before authorizing an open position, the nurse manager should: a. Review the position description and performance expectations for the opening. b. Place an ad in the local newspaper and on the telephone job line. c. Review all current applications on file. d. Look for employees within the system who might best fill the position.

ANS: A The position description provides the basis for this position within the organization and communicates expectations for the role. When applying for a position, researching the facility and position description will help an applicant gain insight into the organization; therefore, the position description should be current and communicate expectations.

11. The turnover rate for RNs in the ICU is high. You discuss this situation with existing staff and you find out that because of the rapid turnover, new staff are frequently required to assume full responsibilities soon into the position and before training is completed. In considering approaches that will reduce turnover rates, the staff and you decide to implement: a. An employee recognition program. b. Coaching for new staff. c. A new performance appraisal system. d. A committed orientation and training program.

ANS: D

Retention of new nursing personnel begins on the day of their hire. This includes an effective, appropriate orientation and training program, which has a measurable impact on reducing turnover.

12. The validity of comments and ratings related to performance is enhanced by: a. Maintenance of anecdotal notes over the entire evaluation period. b. Quantity of information gathered for appraisal purposes. c. Agreement of the employee with the ratings and comments. d. Whether or not other individuals have contributed to the observations.

ANS: A Anecdotal notes compiled consistently over the entire rating period are a much more equitable method of providing an accurate summary of the employee’s performance.

13. A nurse manager in the ICU works with his staff to develop an appraisal instrument that includes quantitative data and respects standards for an RN working on that unit. This type of appraisal is a: a. Rating scale. b. Collaboratively based appraisal system. c. Narrative instrument. d. Behaviorally anchored rating scale.

ANS: D Behaviorally anchored rating scales (BARSs) describe performance quantitatively and qualitatively.

14. You have hired a new RN to replace a well-respected and experienced nurse in your outpatient department. The new RN recently graduated and is nervous about stepping into a role that was previously filled by someone who was so competent. You recognize anxiety and set up regular, frequent meetings during which you explore how she is dealing with her anxiety, provide feedback, and discuss strategies/ideas that will enhance her performance. What development approach are you using? a. Performance appraisal. b. Counseling. c. Empowerment. d. Coaching.

ANS: D The overall evaluative process can be enhanced if the manager employs the

technique of coaching. Coaching is a process that involves the development of individuals within an organization. This coaching process is a personal approach in which the manager and the employee interact on a frequent and regular basis with the ultimate outcome that the employee performs at an optimal level.

15. Sue, a nurse manager, discusses her concerns about the hospital’s employee appraisal system with her work group, noting that it includes only one rating scale and that it means nothing unless the manager has effective relationship skills. Sue’s concerns reflect which best practices associated with performance appraisal? a. Rating scales are too generalized to be considered valid or reliable. b. The effectiveness of appraisal is enhanced by a combination of methods and effective communication skills. c. BARS is considered superior to simple rating scales in terms of performance appraisal. d. Rating scales need to be designed by users to be well accepted.

ANS: B A combination of several methods is probably superior to any one method.

The primary success of any performance appraisal lies in the skills and communication abilities of the manager.

16. During a performance appraisal, Joanne, the nurse manager, indicates that Alysha has difficulty mentoring students on the unit. Alysha responds that this is not her responsibility. In responding to Alysha, Joanne needs to consider: a. Alysha’s level of confidence. b. Whether mentoring is included in the position description. c. Whether mentoring is an essential component of the position description. d. Whether mentoring can be accurately observed and measured.

ANS: B Employees must have clear role expectations, clearly understand what is expected of their performance, and understand the ramifications of not meeting those expectations. Position descriptions provide written guidelines detailing the roles and responsibilities of a specific position within the organizational context.

17. The final section of a performance appraisal is a rating scale. This scale is very detailed and relates to competency standards specific to surgical clients.

The scale is a summary of performance directly observed or documentation reviewed and is specific to client care situations in which the employee has been involved. This type of evaluation is most commonly known as: a. A traditional rating scale. b. Management by objectives/learning goals. c. A forced distribution scale. d. A behaviorally anchored rating scale.

ANS: D BARS contain both quantitative (rating scales) and qualitative data. They are specific to situations and positions.

18. John’s performance was satisfactory during the first month, but after that time, he was found to be very inconsistent in the provision of nursing care.

One month before the end of the rating period, he cared for a very wealthy and influential client, who is best friends with the clinical manager. This client donated new furniture for the staff lounge in John’s name to show appreciation for his care. John’s subsequent performance appraisal resulted in outstanding ratings in all areas. This is an example of: a. A performance rating based on justifiable evidence. b. A bias related to recent events. c. The impact of personality on the appraisal of performance. d. The effective use of a behaviorally anchored rating scale.

ANS: B To gain and to provide an accurate evaluation of performance over time, anecdotal notes need to be maintained throughout the evaluation period. This process assists in avoiding bias related to recent or sensational events that make a particularly strong impression.

19. As a manager, you are interested in developing behavioral questions for an interview. Knowing that there is team conflict at times on your unit, which of the following questions would satisfy your interest in behavioral questions? a. “Tell me about a time you were involved in a conflict related to a project.

What was your role in the conflict? In the resolution of the conflict?” b. “If you were to employ one strategy for managing conflict, what would it be?” c. “What is your preferred style of conflict resolution?” d. “How effective are you in working in a group? In dealing with conflict?”

ANS: A

Behavioral questions seek demonstrated examples of behavior from the candidate’s past experiences; behavioral-based interviewing can be a strong predictor of a future employee.

20. Which of the following strategies might be effective in empowering staff? a. Communication book in which new information on policies and processes is communicated and mistakes are highlighted. b. Monthly staff meetings during which a portion of the agenda is devoted to sharing ideas and presentations on best practices for implementation on the unit. c. Once-yearly summative evaluations based on what the manager best likes about the individual. d. Focus on discussion of errors in care with direction as to how errors are to be prevented in the future.

ANS: B Empowerment is a process that acknowledges the values and judgments of others and trusts their decisions. It allows freedom for making decisions while retaining accountability and provides an environment that is safe in which to explore.

21. The chief nursing officer establishes a shared governance model to help empower the nursing staff, thus empowering the organization. Common characteristics of empowered organizations are: a. Shared values, high salaries, and a human focus. b. Shared values, flexibility, and a human-capital focus. c. Commitment to communication, high salaries, and flexibility for evaluations. d. Creation of community and of effective stress management in the midst of divergent goals.

ANS: B Shared governance involves valuing the contributions of each member of the team, releasing the need to control, and understanding that accountability rests with members of the team.

22. Joanne, a new nurse manager, writes certain assumptions regarding the organization’s objectives into her budget. Her supervisor tells her that the objectives implied in her assumptions are not entirely consistent with the organization, and that she needs to clarify these objectives with her supervisor. Joanne apologizes and says she had more latitude with the budget

where she previously worked. This is an example of: a. Role complexity. b. Role ambiguity. c. Role conflict. d. Time-dependent roles.

ANS: B Role ambiguity in the workplace creates an environment for misunderstanding and hinders effective communication. Without clear expectations of performance, missteps in performance can occur.

23. A survey of staff satisfaction is conducted. The survey indicates that staff members are satisfied, are loyal to the organization, and feel that they have reasonable control in their individual responsibilities. The findings best exemplify: a. Clarity in roles and valuing of contributions. b. Satisfaction but not empowerment. c. Effective coaching of new staff. d. Role attachment.

ANS: A Commitment, a sense of control, and satisfaction are linked to clear role expectations and a feeling that contributions are valued.

24. You have hired Chelsea as a new staff member on your unit. Although she is an experienced ICU nurse, this is her first educator role. A month into her new position, she confides that she feels really incompetent in her new position and bursts into tears. Your response is based on application of your understanding of: a. Role acquisition. b. Role conflict. c. Role complexity. d. Performance appraisal.

ANS: A Acquisition of a role is time dependent and involves application of life experiences to each role and interpretation of the role within one’s own value system. As roles become more complex, an individual may take longer to assimilate the components of each role.

MULTIPLE RESPONSE 1. During the performance appraisal session, the manager should :

a. Maintain a relaxed and professional manner. b. Inquire about the employee’s personal life and how it is affecting performance. c. Allow the employee to express opinions orally and in writing. d. Plan to give specific examples only for poor performance.

ANS: A, C During a performance appraisal, it is important to provide examples of both strong and problematic performance and to provide opportunities to express opinions. The supervisor needs to maintain a relaxed professional manner.

Chapter 16: Strategic Planning, Goal-Setting, and Marketing Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. Planning is a process designed to achieve goals in dynamic, competitive environments. As a new manager, what is the first step you will undertake to develop a strategic plan of action for a congestive heart failure program? a. Search the environment to determine changes that may affect the organization. b. Appraise the organization’s strengths and weaknesses. c. Identify the major opportunities for and threats to the organization. d. Identify and evaluate the various strategies available to the organization.

ANS: A Assessment of the external environment is the first step in the strategic planning process.

2. A community-based pain management program is being planned for your region. As a coordinator of a home care agency, you have been requested to develop a conceptual framework, mission statement, philosophy, and objectives for the program. In what order will you pursue this endeavor? a. Objectives, philosophy, and mission statement b. Philosophy, objectives, and mission statement c. Philosophy, mission statement, and objectives d. Mission statement, philosophy, and objectives ANS: D The development of the mission statement is the first step in defining the purpose and direction of the organization after an assessment has been completed.

3. Northwestern Hospital has decided to implement peer review. As a clinical leader in the Emergency Department, you have overall responsibility for ensuring that this is in place by next month. The most important step in this process is to: a. Provide an educational session for staff on peer review. b. Revise the mission statement, objectives, and performance standards. c. Develop objectives and performance standards with employees. d. Implement objectives and performance standards.

ANS: A Once a strategic plan has been developed, the next step is open communication and execution of the specific plan, which, in this instance, is peer review.

4. The clinic nurse understands that the advantages of planning include: a. Assisting staff in critical thinking and improving decisions. b. Orienting people to react instead of act. c. Forcing managers to be cost-efficient and effective. d. Focusing on activities, not results.

ANS: A Effective planning means that everyone in the organization manages his own work and sees how it relates to organizational goals. Being proactive means “aggressive planning” that ensures that decisions are improved and are oriented toward organizational goals.

5. As a nursing leadership student, you have had the opportunity to develop a palliative care manual that will be utilized by the palliative care network (PCN) in your region for teaching healthcare professionals. The PCN has requested that you provide a prioritized plan of action for marketing the manual on a regional and state basis. What is the first priority? a. Motivate the target market. b. Research the target market. c. Communicate benefits to the target group. d. Package the product.

ANS: B To put a strategic plan into place for marketing, it is necessary to conduct an external assessment.

6. The chief nursing officer has to write a strategic plan. The most difficult stage in the strategic planning process is:

a. Assessment of the external and internal environment. b. Review of mission statement, goals, and objectives. c. Identification of strategies. d. Implementation of strategies.

ANS: A Determination of strengths, weaknesses, opportunities, and threats requires openness to what is being said and observed and is critical to setting the stage for relevant responses in the latter phases of strategic planning.

7. The reasons cited by nursing administrators for not planning in a systematic manner include: a. Lack of understanding of the planning process. b. Lack of knowledge regarding the internal and external operations of the organization. c. Not enough hours in the day for both day-to-day operations and planning. d. Delegation of the task to subordinates.

ANS: A The nurse manager should participate in strategic planning and quality initiatives with the governing body. Lack of knowledge is a common reason for nonparticipation in planning initiatives.

8. From your observation of planning activities in the organization, you have noticed that planning and decision making occur at various levels of the organization. The nurse manager has overall responsibility for which of the following? a. Sending out postcards b. Organizing a telephone follow-up c. Monitoring ongoing activities and projects d. Listing the patient population ANS: C The nurse manager should articulate organizational decision making for the criteria model adopted by the organization and monitor ongoing implementation of the plan.

9. Which of the following represents a well-written objective? a. Hospital-acquired infections are reduced, and procedures to reduce infections are implemented. b. To increase staff satisfaction and to decrease burnout c. To increase the health of the community

d. To implement evidence-based practice on nursing units, as evidenced by adoption of evidence-based processes, by June 1, 2015 ANS: D Objectives are specific (begin with word to followed by an action word; specify single result to be achieved; and specify a target date for attainment) and measurable (provide level of accomplishment at the end).

10. To conduct assessment of the internal environment, the strategic planning team for Pacific Hospital: a. Invites community members and staff of the hospital to an evening focus group session. b. Discusses what it sees as the primary threats and opportunities in demographic shifts affecting the hospital. c. Invites all levels of staff to focus groups on the effectiveness of the hospital environment, including information systems and staffing. d. Asks the board to provide a summary of major opportunities for the future.

ANS: C Assessment of the internal environment should include all levels of staff and facilitates feedback on effectiveness of strengths and weaknesses of systems and processes within the institution.

11. In assessing the internal environment, the strategic planning team at Pacific Hospital discovers that 90% of staff members have no idea what the current mission statement means. This is most likely related to: a. The level of abstraction inherent in mission statements. b. Development of the statement by the administration team with no other staff involvement. c. Outdated goals and objectives contained in the mission statement. d. Failure to provide action statements within the mission statement.

ANS: B A mission statement reflects the beliefs of the organization in relation to those it serves and services it provides, and it communicates the direction of an organization. Covey (1990) believes that the process of developing the mission statement is vital to an organization’s success and should involve everyone.

12. Pacific Hospital’s team develops a process to include staff in development of the mission statement. Which of the following statements would indicate that the staff has been able to develop an effective mission

statement? a. Pacific Hospital will increase its sustainability by increasing revenue streams within the next three years. Revenue streams are important to our hospital and are a driving force in our sustainability in the face of insurer and government funding changes. b. Pacific Hospital has a desire to relate to its community to enable appropriate identification of programming needs by July 2012. c. Pacific Hospital will provide family-centered care to the community of Pacific Rim. It is committed to delivering a full spectrum of services that foster collaborative partnerships among clients, families, and the hospital, and it utilizes evidence-based practice to guide planning and interventions. d. To provide health promotion programs for school-aged children ANS: C An effective mission statement reflects the values and direction of the organization. Included in the statement are beliefs about individuals, health, practitioners, and the relationship of the organization to practice, research, professionalism, and/or education.

13. At the beginning of its strategic planning processes, Pacific Hospital learns that nursing staff members are uncomfortable with utilizing evidencebased practice, and that staff perceives that only limited resources are available to support translation of evidence into their usual practice. Because this issue has been identified, the management team determines that a plan of action is required to address the issue. Who should be involved at this point? a. Nursing unit managers b. Staff nurses c. All staff d. Administration ANS: C The first phase in planning is conducting an assessment of the external and internal environments. Assessment of the internal environment should include all levels of staff and facilitates feedback on effectiveness of strengths and weaknesses of systems and processes within the institution.

14. In implementing the strategic plan for effective utilization of evidence to guide nursing practice at Pacific Hospital, the nursing unit managers take the next step, which is the implementation. Implementation most likely would involve: a. Revisiting the mission statement and objectives.

b. Reevaluating external and internal factors affecting evidence-based practice. c. Preparing a budget to support implementation. d. Developing unit-based objectives related to the plan.

ANS: D The previous planning (assessment of internal and external environments, development of a mission and plan, and allocation of resources) has already been completed. The next step involves adapting the strategic plan to the nursing units.

15. To meet the social and human needs of a target market, it is critical to: a. Assess the needs and priorities of the target market. b. Revise the organization’s mission statement to reflect external needs. c. Assess the internal culture and needs. d. Develop highly sophisticated media.

ANS: A Marketing emphasizes the identification and meeting of human and social needs, which can only be known through assessment of the needs of the consumer (as opposed to the needs of the organization).

16. Assessment of the needs of the consumer or client (in developing a strategic marketing plan) focuses on: a. Present needs only. b. Present and future needs. c. The development of surveys. d. Secondary analysis of existing data.

ANS: B Assessment of needs takes into account needs of the consumer now and for the future, using a variety of data-gathering techniques. Future orientation aids in anticipating how marketing and programs will need to shift to meet those needs.

17. After an extensive campaign to ensure that the community surrounding Pacific Hospital has been exposed to the emphasis of excellence in clinical care that occurs through the use of evidence, the marketing team finds that the public perception has changed little. This determination is made possible through: a. Marketing surveys. b. Focus groups.

c. Informal feedback. d. Comparison of data against benchmarks.

ANS: D Developing benchmark data at the beginning of a project enables comparison of later data against the benchmark to determine if a marketing plan has met its objectives.

18. Nurses are valuable partners in marketing strategies because they: a. Are more likely than other members of the organization to use marketing tools. b. Have a strong background in using evidence to support decisions. c. Have close involvement with patients, who are the target group for marketing. d. Constitute the largest staff group in most healthcare organizations.

ANS: C As nurses are directly involved with patients who use services and who are the target group for marketing efforts, nurses have excellent insights into patient needs.

19. Shifts such as changes in the percentage of seniors in the population, governmental initiatives in health care, and the influence of income on health status are factors in the __________ environment. a. Public b. Macro c. Competitive d. Social ANS: B The external environment in strategic marketing planning includes the public, competitive, and macro environments. Demographic, social, and political factors are included in the macro environments.

20. A private ambulance clinic established a few streets away from Pacific Hospital markets its services as quality-based within caring relationships. The clinic is part of the __________ environment. a. Public b. Macro c. Competitive d. Social ANS: C

The competitive environment includes factors and elements that compete for resources with another organization. These elements may include those in public and macro environments.

21. Which of the following represents an effective goal statement? a. Involve patients and families in planning health care. b. To revise clinical guidelines for incontinence care from evidence within 6 months c. Patients and families are partners first in care planning. d. To acquire $4 million in additional funding within 12 months to support clinical education programs for dementia ANS: A Goal statements formalize targets for an organization. Objectives include the word to and an action word, and specify dates for attainment. Mission statements convey values and beliefs of the organization.

22. After a year, the staff at Pacific Hospital is frustrated, and implementation of evidence-based practice has gone poorly. In responding to this situation, the strategic planning team at Pacific Hospital: a. Recommends that the mission, objectives, and goals of the hospital be reassessed. b. Revises the goal statements in the strategic plan. c. Consults an external team on preparation of materials on evidence-based practice. d. Holds focus groups with staff to determine what kinds of issues, challenges, and obstacles have occurred in implementation.

ANS: D On a consistent basis, the strategic plan is reviewed at all levels to determine whether the execution of goals, objectives, and activities is on target. As stated, a sense of flexibility regarding the objectives is important to consider, and objectives may change as a result of legislation, budget changes, and change in structure or other environmental factors. Involving staff enables development of creative methods to ensure that necessary changes occur.

23. Benchmarks in the strategic marketing planning process are useful in: a. Establishing programs. b. Setting targets. c. Rewarding employees. d. Measuring progress.

ANS: D Establishing benchmarks enables measurement of the interim and final achievements of programs.

24. The executive team at Hospital XYZ develops a polished strategic plan that includes a mission statement, goals, and objectives.. The executive team involves the marketing team, so that the plan can be communicated internally and externally. After 2 years, no significant progress has been made toward any of the goals. What has been omitted in the plan? a. Planning b. Marketing c. Integrated financial planning d. Customer focus ANS: C Without the inclusion of a business plan with the strategic plan and integration of financial planning and allocation of resources execution of the strategic plan can become paralyzed, even with the most effective communication of the strategic plan itself..

MULTIPLE RESPONSE 1. A clinic nurse developed objectives for a diabetic education program. The characteristics of well-written objectives include that they should be what? a. Achievable b. Understandable and specific c. People-oriented d. Manager-oriented e. Means-oriented f. Measurable ANS: A, B, F The S.M.A.R.T. acronym describes the attributes of objectives: specific, measurable, agreed-upon, reasonable (achievable), and time-bound.

Chapter 17: Leading Change Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. When goals/outcomes are somewhat unclear in early preparation for a complex change, the manager and the change management team develop several acceptable goals/outcomes. This change in management approach is termed:

a. Unfreezing. b. Nonlinear. c. Cybernetic. d. Linear.

ANS: B While Lewin’s theory was designed to describe planned or first-order changes, many scholars think the theory is too simplistic to address how unplanned or second-order change occurs. In complex situations with an uncertain change environment, a nonlinear approach that involves flexibility improves overall outcomes. Linear change is appropriate to stable, less complex, and more predictable situations.

2. The home health agency hired an expert in financial management to evaluate and propose a plan for reversing growing expenses and decreasing revenues. The expert is well respected, both personally and professionally, by members living in this small community. To be effective, staff will need to perceive this change agent as: a. Trusted, quiet. b. Flexible, informal. c. Credible, enthusiastic d. Communicative, personable.

ANS: C To influence the decision, the expert must be seen as having knowledge of what matters to the people that they lead and of the change area itself. The expert also must be enthusiastic and communicative and have referent power.

3. The nurse manager frequently interacts with staff and other hospice facility employees. Communication is purposeful because the manager assesses current issues, such as specific satisfactions and dissatisfactions with the newly implemented computerized documentation system. Informally, the manager gathers available staff members to address similar learning needs.

Many times, staff members are found coaching other staff about improving use of the new system. According to Senge (1990), the activities demonstrated in this example are: a. Dialogue, team learning. b. Resilience, personal mastery. c. Shared vision, systems thinking. d. Mental models, teachable moments.

ANS: A

Building shared vision occurs when leaders involve all members in moving personal visions of the future into a consolidated vision common to members and leaders.

4. The clinical coordinator expects the position description of the new wound care specialist to change nurses’ responsibilities in caring for clients with skin integrity problems. The best approach to address this need for change, yet to have the best outcomes for clients, staff nurses, and the organization, is to: a. Select one of the change models. b. Use Lewin’s model and principles of change. c. Apply both planned and complexity theory approaches. d. Form a task force of nursing staff and wound care specialists.

ANS: C In the second stage, the moving or changing stage of Lewin’s theory, planned interventions and strategies, such as education, vision building, and incremental steps towards the change, are executed to support the implementation of the change. This situation potentially also involves complexity theories that recognize that change involves engagement of individuals and subsystems throughout the unit and organization.

5. Complex change situations require that the change leader promote ongoing visioning among staff members. One strategy is to: a. Consciously evaluate invisible mental models. b. Allow for individual outcomes. c. Encourage cooperative activities. d. Operate between order and disorder.

ANS: A Senge’s theory on change suggests that each individual or organization bases activities on a set of assumptions, or a set of beliefs, or mental pictures about the way that the world should work. When these invisible models are uncovered and consciously evaluated, it is possible to determine their influences on work accomplishment.

6. To effectively achieve a change goal/outcome in a change situation, the wound care specialist will: a. Preserve the status quo. b. Diminish facilitators and reinforce barriers. c. Weigh the strength of forces. d. Strengthen facilitating forces.

ANS: D For change to be effective, the facilitators must exceed the force of the barriers; thus, strengthening the facilitating forces would achieve this aim.

7. The wound care nurse decided to involve those to be affected by change early in the change management process. This can positively result in: a. Coordination. b. Resistance. c. Anticipation. d. Participation.

ANS: D Successful change means persistence and advancement of the change, which requires the undivided focus of all team members. Early involvement and participation are critical to capturing the undivided focus of team members.

8. The oncology clinic manager and the educational coordinator asked nursing staff to complete a brief written survey to assess their attitudes and knowledge related to having used the new infusion equipment for 6 weeks.

The stage of change in this situation is: a. Developing awareness. b. Experiencing the change. c. Integrating the change. d. Perceiving awareness.

ANS: C This particular initiative assesses the success with which the change has been integrated into everyday practice after it has been experienced, or the degree to which staff members have accepted using the new infusion equipment.

9. An example of one strategy to improve participation in the change process by staff fitting the behavioral descriptions of laggards, early majority, late majority, and rejecters is to: a. Encourage teamwork. b. Transfer to a different unit. c. Require attendance at staff meetings. d. Delegate the roles and tasks of change.

ANS: D According to Rogers’s work, the individual’s decision-making actions pass through five sequential stages. The decision to not accept the new idea may occur at any stage. However, peer change agents and formal change

managers can facilitate movement through these stages by encouraging the use of the idea and providing information about its benefits and disadvantages.

10. An example of one strategy used to improve participation in the change process by staff fitting the behavioral description of innovators and early adopters is to: a. Repeat the benefits of the change. b. Share change experiences early in the process. c. Initiate frequent interactions among staff. d. Provide select information to the staff.

ANS: B Connecting innovators and early adopters to new ideas and with new peers keeps them at the cutting edge.

11. As a new manager, you are shocked to learn that your unit is still using heparin in heparin locks. You are aware of evidence related to this practice and want to change this practice as quickly as possible on your unit. You are in which stage of Lewin’s stages of change? a. Unfreezing b. Experiencing the change c. Moving d. Refreezing ANS: A Although you may be at a higher level of change in relation to your individual practice and knowledge of the use of change, in this situation, you are recognizing the need for change in relation to practice on the unit that you are managing. This phase is the initial phase in first-order change and will involve listening to staff to see if they perceive a similar problem.

12. To engage your staff in awareness of their current practice and how it is affirmed or not by evidence, you plan a short series of learning presentations on evidence and use of heparin and saline to maintain IV patency. You meet with the educator to plan out the goals for each session with the overall purpose of increasing knowledge and awareness of staff in readiness to consider questions related to the IV practice. This learning approach is an example of which change management approach? a. Linear b. First-order

c. Facilitative d. Integrative ANS: A In the second stage, the moving or changing stage of Lewin’s first-order, planned change process, planned interventions and strategies are executed to support the implementation of the change. One commonly used method is educating staff about the need for the change.

13. To engage your staff in awareness of their current practice and how it is affirmed or not by evidence, you plan a short series of learning presentations on evidence and use of heparin and saline to maintain IV patency. You meet with the educator to plan out the goals for each session with the overall purpose of increasing knowledge and awareness of staff in readiness to consider questions related to the IV practice. Staff nurses who gain information on current IV therapy practices are engaging in which phase of Rogers’ decision-making process? a. Persuasion b. Knowledge c. Confirmation d. Decision ANS: B Rogers’ innovation-decision process involves five stages for change in individuals, the first of which is knowledge.

14. Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because “the unit has been using heparin for years and there has never been any adverse effects.” According to Havelock (1973), this comment may originate from failure in which phase of the six phases of planned change? a. Generating self-renewal b. Choosing the solution c. Diagnosing the problem d. Building a relationship ANS: D The first phase of this model of planned change involves building a relationship as a basis for later phases, which include diagnosing the problem and choosing the solution. At this point, as a new manager, the relationship may not have yet developed sufficiently with Elizabeth.

15. Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because “the unit has been using heparin for years and there has never been any adverse effects.” You follow up with Elizabeth and discover that she is really quite angry about the information sessions because she feels that you are implying that “what she has been doing all these years means that she is incompetent and doesn’t care about her patients.” Your response to her indicates that: a. Elizabeth will never adopt the change. b. Elizabeth is insecure in her practice. c. Elizabeth requires more information about the practice. d. Change involves emotions.

ANS: D Change, whether proactively initiated at the point of change or imposed from external sources, affects people. Responses to all or part of the change process by individuals and groups may vary from full acceptance and willing participation to outright rejection or even rebellion. It is critical to be able to “read” people and to recognize that communication should involve people’s emotions and feelings.

16. Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because “the unit has been using heparin for years and there has never been any adverse effects.” You follow up with Elizabeth and discover that she is really quite angry about the information sessions because she feels that you are implying that “what she has been doing all these years means that she is incompetent and doesn’t care about her patients.” Which of the following would be the most effective response to Elizabeth? a. “I understand how you feel, but you are going to have to change.” b. “It is unfortunate that you feel this way. Others seem quite excited about the new information.” c. “It is difficult sometimes to change what we know very well. Sometimes it can be frightening.” d. “Perhaps I can arrange some more information sessions for you, so you can see just how important this change is to patient safety.”

ANS: C

Dialogue can reveal areas where individuals feel inept or overwhelmed, providing the leader with an understanding of what programs need to be developed to increase personal ability to change and what educational initiatives need to be implemented to support change. To promote dialogue, leaders must serve as facilitators, promoting the sharing of ideas, fears, and honest reactions to the change proposal.

17. Elizabeth is an example of a(n): a. Early adopter. b. Late majority. c. Laggard. d. Resister.

ANS: C Laggards prefer keeping traditions alive (“We have always done it this way”) and openly express their resistance to ideas (speaking out against the change).

Late majority individuals are openly negative but will engage with new ideas when most others adopt the change.

REF: Page 311 TOP: AONE competency: Leadership 18. Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because “the unit has been using heparin for years and there has never been any adverse effects.” You follow up with Elizabeth and discover that she is really quite angry about the information sessions because she feels that you are implying that “what she has been doing all these years means that she is incompetent and doesn’t care about her patients.” After speaking with Elizabeth a few days later you discover that she is now fine with the change but is concerned that other areas of the organization might resist the change because of perceptions related to patient safety and cost. She suggests that it is important to bring pharmacy on board as they have had previous concerns about the use of heparin. In relation to change theory, this is indicative of: a. Systems level thinking. b. Linear thinking. c. Interprofessional collaboration. d. First-order change.

ANS: A Senge’s complexity theory, Bevan’s Seven Change Factors, and general

systems theory all highlight connectivity and the idea that changes are not isolated events.

19. Based on Elizabeth’s insights and suggestions, you involve pharmacy, only to discover that the change in practice involves practice committees, a medical practice committee, and concerns from administration about potential costs and safety of the proposed change to the IV protocols. The change process at this point is: a. Linear. b. Nonlinear. c. Sabotaged. d. Neutralized.

ANS: B Complex change involves nonlinear processes and a variety of strategies to negotiate influences on change. Complexity theories alter the traditional systems thinking approach by asserting that system behavior is unpredictable.

This theory views change as emergent, nonlinear, and highly influenced by all individuals and subsystems in an organization.

20. Resistance is most likely when change: a. Is not well understood. b. Involves many layers in an organization. c. Involves nonprofessional workers. d. Threatens personal security.

ANS: D Resistance and reluctance commonly occur when personal security is threatened and may involve loss of confidence in abilities or loss of job or financial security.

REF: Page 309 TOP: AONE competency: Leadership 21. As the unit manager on the unit that is leading changes to heparin locks, you find that Elizabeth is very valuable in terms of her observations about other units and her knowledge of organizational processes, and now in discussing the new procedure with others. Elizabeth might be considered an: a. Engager. b. Innovator. c. Informal change agent. d. Informant.

ANS: C

Informal change agents are those who do not have formal, positional power but who have credibility through expertise and can model the new way of thinking, or who offer suggestions, ideas, and concerns.

22. As the unit manager, you spend a day performing direct patient care and work with a new system that is designed to capture patient documentation at the bedside. During discussions with staff while giving care, you discover that the number of screens that need to be opened during documentation makes charting more complex and time-consuming than traditional manual charting approaches. On the basis of this feedback, you: a. Assume that the system is doing what it needs to do. b. Provide reassurance to staff that the unit has achieved its goals in implementation of the system. c. Ask some of the staff if they have had similar experiences with the system. d. Consult chart audit data and end user consultation reports to determine if errors and problems are occurring.

ANS: D In Kotter’s eight-step change model, removing obstacles means keeping alert for barriers in structure and processes that limit the ability to change and then removing those barriers once they have been found.

23. You anticipate that your region will soon move towards an e-health record system. You begin to discuss this with your staff and are disappointed that you receive little positive response from the staff about this possibility.

One staff member, in particular, seems to sum it up by saying “e-health?

Won’t happen in my working life! There are too many problems with it, like privacy issues.” This response is most likely motivated by: a. Lack of urgency regarding the need to change. b. Lack of evidence to support importance of technology. c. Deficits in education and experience. d. Lack of organizational support for change.

ANS: C For leaders to inspire change, they must have intimate knowledge of what matters to the people they manage. Kotter (2012) characterizes this as establishing a sense of urgency, and this involves overcoming complacency.

This is especially hard when there doesn’t seem to be any visible crisis, or the crisis seems irrelevant to the people being asked to change (Kotter, 2012).

24. Sarah, RN, is one of your most enthusiastic staff members and has been

to a workshop on preparing educational materials for patients. On the basis of this workshop, she would like to develop an information Website for patients who are being admitted to the ward. An appropriate response to Sarah’s suggestion would be: a. “That is a great suggestion, but we have no resources for such an expensive undertaking right now.” b. “Perhaps you can keep that in mind as we redesign our charting system.” c. “We have too many seniors as patients, and you know that they don’t use technology.” d. “There is a great group here that meets to look at technology pilots. Let’s see if you can join them and discuss your idea further.”

ANS: D Involving Sarah with others who enjoy new ideas and who are able to try out new ideas in pilot projects enables her to remain on the cutting edge and to try out innovative solutions with the least amount of disruption.

25. Edith has been vocal about her negative concerns related to a new charting system and frequently expresses the view that keeping the “old system” would have been “just fine.” In facilitating change, your best approach to Edith would be to: a. Put her in the pilot planning group for the change. b. Determine if she has considered retirement. c. Schedule her work assignment so that it coincides with those of two staff members who are confident with technology and the change. d. Avoid discussion of the change, and trust that with sufficient training and information, she will change.

ANS: C Laggards prefer keeping traditions and openly express their resistance to new ideas. Having a group of change agents and innovators on board to champion an idea builds what Patterson et al. call “social motivation” and “social ability.” This group can help staff, such as laggards, who are less adept at change.

MULTIPLE RESPONSE 1. Which of the following are examples of application of the Leadership Rounding Tool? a. “What is working well for you during bedside reporting?” b. “What has not worked for you today?”

c. “Is there someone on your team who deserves special recognition for her efforts in the implementation?” d. “Did you have a good vacation?”

ANS: A, B, C, D The Leadership Rounding Tool suggests establishing and maintaining rapport and asking what is working well, what was a barrier, and who should be recognized, as well as answering tough questions.

Chapter 18: Building Teams Through Communication and Partnerships Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. A nurse manager is experiencing conflicts between herself and staff members. She had tried to develop a team by using a shared leadership model to empower the staff. Staff members are functioning: a. As a team. b. Independently. c. Interdependently. d. As a group.

ANS: D A group is a collection of interconnected individuals working together, with a high degree of interdependence, for the same purpose. A team is a unified group that is committed to a common purpose, performance goals, and approach, for which they hold themselves mutually accountable. The conflict indicates that the staff may not be united in a common purpose.

2. The nurse manager used a mediator to help resolve conflicts on the unit.

During the mediation process, the nurse manager saw signs of potential teambuilding. One key concept of an effective team is: a. Conflict. b. Task clarity. c. Commitment. d. A designated leader.

ANS: C Team-building involves moving toward a common vision, which requires commitment. Conflict and clarification of tasks are components in the development of this commitment.

3. A mediator suggested that the nurse manager and staff members decide on a method to resolve conflicts. It is important to have agreements about how

team members will work together because: a. If there are no agreements, each member will make up rules about how to handle disagreements and relationships. b. People are naturally difficult and will not work well together without such agreements. c. People will naturally ask for agreements about how to be together. d. A way to eliminate nonproductive team members must be available.

ANS: A People must agree on the goals and mission with which they are involved.

They have to reach some understanding of how they will exist together.

Tenets or agreements such as “I will respectfully speak promptly with any team member with whom I have a problem” go a long way to avoid gossiping, backbiting, bickering, and misinterpreting others. Without agreement, people have implicit permission to behave in any manner they choose toward one another, including angry, hostile, hurtful, and acting-out behavior.

4. By following a shared leadership model, the nurse manager believes that staff members will learn to function synergistically. Some teams function synergistically because members: a. Do not volunteer unwanted information. b. Actively listen to each other. c. Listen to the person who believes he or she is an expert. d. Do not speak unless they are absolutely sure they are correct in their views.

ANS: B Active listening in a group creates synergy in that team members really hear one another’s ideas and share in decision making.

5. The chief nursing officer decided that the nurse managers need a series of staff development programs on team-building through communication and partnerships. She understood that the nurse managers needed to build confidence in ways of handling various situations. The greatest deterrent to confidence is: a. Lack of clarity in the mission. b. Lack of control of the environment. c. Fear that one can’t handle the consequences. d. Fear that the boss will not like one’s work.

ANS: C Fear of not being able to manage consequences undermines confidence and a

sense of competency.

6. The mediator noticed that tension was still evident between the nurse manager and staff members. He informed the chief nursing officer that to begin team-building, it would be important that everyone: a. Work together in a respectful, civil manner. b. Use avoidance techniques when confronted with a conflict. c. Develop a personal friendship with each other. d. Socialize frequently outside of work.

ANS: A For team-building to occur, team members need to be able to listen actively and respect one another’s opinions, while feeling comfortable in openly expressing their own.

7. The state of being emotionally impelled, demonstrated by a sense of passion and dedication to a project or event, describes: a. Commitment. b. Control. c. Willingness to cooperate. d. Communication.

ANS: A Commitment is described as having a sense of passion and commitment to a project without necessarily having a need to control.

8. The mediator suggested to the unit staff that a group agreement needed to be made so meetings could become productive. For example, the group agreement, “We will speak supportively,” prevents: a. Expression of opposing ideas. b. Gossip and making negative comments about absent team members. c. Efforts to ensure that everyone thinks alike. d. Votes that oppose motions.

ANS: B This is an example of a rule that a team can implement to prevent certain negative behaviors such as gossip, backbiting, and bickering that undermine the productivity and functioning of a group.

9. The mediator asked each staff member to reflect on his or her communication style. Which of the following best describes communication?

Communication: a. Is a reflection of self-analysis.

b. Is a result of thoughtful consideration. c. Consists of thoughts, ideas, opinions, emotions, and feelings. d. Focuses on the sender of the message.

ANS: C Communication involves both senders and receivers and may or may not be a reflection of self-analysis and thoughtful consideration. It always, however, involves thoughts, ideas, opinions, emotions, and feelings.

10. The staff development educator developed strategies to help nurse managers actively listen. Guidelines for active listening include which of the following? a. Speed up your internal processes so that you can process more data. b. Realize that the first words of the sender are the most important. c. Be prepared to make an effective judgment of the communication sender. d. Cultivate a desire to learn about the other person.

ANS: D Active listening means suspending judgment about what is about to be said and listening to all that is said (and not just the first or last words). It is motivated by a genuine desire to learn about the other person.

11. The nurse manager was upset with the staff nurse and said, “You did not understand what I said.” Which element in the communication process was she referring to? a. Feedback between receiver and sender b. A message channel c. A receiver who decodes the message d. A set of barriers that may occur between sender and receiver ANS: D Problems can occur at any point in communication and result in miscommunication. In this instance, it can be assumed that there was a sender, a receiver, a channel, and feedback. In this scenario, barriers such as distractions, inadequate knowledge, differences in perceptions, and emotions and personality may have resulted in misunderstanding between the manager and the staff nurse.

12. As the nurse manager on a rehab unit, you are asked to come to the tub room immediately because two nursing assistants are having a loud disagreement in front of a patient. You ask the nursing assistants to meet you outside and after ensuring that a third nursing assistant is able to care for the

patient, you speak with the two nursing assistants. Which of the following would you ask first? a. “How long have you two been working together?” b. “Have you experienced disagreements like this before?” c. “How do you think this patient’s perception of her care has been changed?” d. “What happened to bring on this disagreement today?”

ANS: D Conflicts are usually based on attempts to protect a person’s self-esteem or to alter perceived inequities in power. When a nurse recognizes upset and reaction, the following steps can be helpful (Sportsman, 2005): Identify the triggering event (“What happened to bring on this disagreement today?”).

Discover the historical context for each person.

Assess how interdependent each person is on the other.

Identify the issues, goals, and resources involved in the situation.

13. Sally (RN) and Melissa (RN) have shared an ongoing conflict since the first day that Melissa worked on the unit. Sally has confided to another colleague that she doesn’t even know why the conflict started or what it was about. This is an example of: a. How expectations and objectives need to be made clear in team situations. b. The need to encourage open discussion of disagreements in opinions. c. The importance of involving all staff in discussions in group settings. d. The enduring nature of first impressions.

ANS: D First impressions are lasting and, as Sally indicates to her colleagues, are often an unconscious response.

14. After staff meetings lately, Sharon, the head nurse, observes her staff in small groups, having animated discussions that end abruptly when she approaches. Sharon reflects on this observation and realizes that: a. Two very outspoken members tend to dominate discussions in meetings. b. This behavior is indicative of a high level of communication among her staff. c. Staff members are very committed to the team and have strong opinions. d. Ongoing discussion outside of meetings is conducive to creativity.

ANS: C When team communication is dominated by a few members, leaving others

uninvolved or bored, disagreement is not expressed openly. As a result, team members “stuff” their feelings and wait until after meetings to voice their opinions.

15. You are charged with developing a new nursing curriculum and are committed to developing a curriculum that reflects the needs of the profession and of the workplace. To address deficits that may already be present in nursing curricula related to the workplace, you include more content and skills development related to: a. Therapeutic communication with patients. b. Effective communication in the workplace. c. Increased emphasis on sender-receiver dyads. d. Generational differences in communication.

ANS: B Nursing programs teach therapeutic communications with patients and their families. Little focus, however, is placed on effective communication in the workplace, although communication is essential to building and maintaining smoothly functioning teams.

16. The SBAR system of communications is one of the most used communication systems in health care because: a. It deals with all aspects of communications in patient care except communication with the physician. b. The nurse is on the same communication level as administration. c. It honors a familiar, structured transfer of information among health professionals. d. It honors an unstructured transfer of information.

ANS: C The SBAR system was developed by professionals in the California Kaiser Permanente System and involves direct, respectful communication skills among professionals with the aim of quality patient care.

17. In the cardiac intensive care unit, there has been simmering discontent about the new nurse manager, who avoids any discussion about her scheduling and practice decisions. The staff have begun to sort into “different camps” depending on how they feel about the manager or the decisions.

Which of the following statements MOST accurately describes this situation? a. The tension that has been generated will result in creative solutions. b. Staff will become a cohesive group that takes a stand against the manager.

c. The conflict will result in increased dialogue about practice and scheduling options. d. Patient care may suffer because attention and energy is being diverted toward the unit relationships.

ANS: D Destructive conflict polarizes groups, saps group morale, deepens differences in values, and diverts energy from more important activities, such as patient care. Constructive conflict opens up issues of importance, results in solutions to problems, and enables authentic communication.

18. From the information presented in this chapter, which of the following statements best defines an accomplished team? Effective teams: a. Can create a form of synergism in which the outcome is greater than the sum of the individual performances. b. Do not necessarily need goals, objectives, vision, and a clearly stated purpose. c. Do not always have effective communication patterns. d. May or may not have a clear plan that is followed and revisited and has an ongoing evaluation scheme.

ANS: A Research on team-building over many years has established that highfunctioning teams are characterized by synergy that takes the team from a collection of individuals to an outcome that is greater than the sum of the parts.

19. “I really wish that my supervisor would realize and acknowledge all the things I do well.” In nursing, this has been identified as a problem. Which statement is part of the solution? Focus on: a. New staff. b. Care assignments with which the individual is not familiar. c. Making corrections. d. The strengths of the individual rather than the weaknesses.

ANS: D The research of Rath (2007) included many recommendations, one of which was that focusing on mediocre behaviors and on a person’s weaknesses will not lead to excellence. Focusing on weaknesses tends to decrease the appreciation, and thus the acknowledgements.

20. Trust is an important aspect of helping relationships, therapeutic

communications, and the positive communications model. Which statement does not involve or define trust? Trust: a. Involves decisions to manipulate situations to gain advantage over another. b. Is the basis by which leaders facilitate the activities and progress of a team. c. Is low among members and leaders in poorly performing teams. d. Involves what we say and not necessarily what we do.

ANS: A Trust is high in high-performing teams and involves not consciously taking advantage of others and behaving in a way that inspires trust. It is the basis by which leaders facilitate the activities and progress of a team.

21. Team Member A and Team Member B engage in heated disagreements on a frequent basis in team meetings. Their behavior is characterized by insistence on their points of view and refusal to back down or to negotiate alternative solutions once their ideas have been expressed. This behavior is characteristic of: a. Autocratic leadership. b. Constructive conflict. c. Dualism. d. Creativity.

ANS: C Our society tends to be dualistic in nature. Dualism means that most situations are viewed as right or wrong, black or white. Answers to questions are often reduced to “yes” or “no.” As a result, we sometimes forget a broad spectrum of possibilities actually exists. Exercising creativity and exploring numerous possibilities are important. This allows the team to operate at its optimal level.

22. The unit manager was addressing nursing students in the lounge area and was discussing team leadership and team effectiveness. She stated, “One can agree to disagree with another team member’s perspective even when one doesn’t necessarily see that perspective as being the correct one.” In being creative, what did she mean? a. Championing one’s own opinion. b. Being compassionate c. Being flexible d. Committing to resolution ANS: D

Caregivers must listen to the other person’s perspective, listen to the message accurately, identify differences, and creatively seek resolutions.

23. Which of the following would not be a characteristic of an effective team nurse leader? a. An autocratic perspective b. Excellent communication skills c. Awareness of everyone’s abilities d. A genuine interest in team members ANS: A In ineffective teams, leadership tends to be autocratic and rigid, and the team’s communication style may be overly stiff and formal. Members tend to be uncomfortable with conflict or disagreement, avoiding and suppressing it rather than using it as a catalyst for change. When criticism is offered, it may be destructive, personal, and hurtful rather than constructive and problemcentered. Team members may begin to hide their feelings of resentment or disagreement, sensing that they are “dangerous.” This creates the potential for later eruptions and discord.

24. As a nurse manager, you notice that one of your new nurses has provided exceptional care for a patient with especially complex needs. What would be the MOST effective way of recognizing the nurse’s performance? a. At the next performance review, note specifically what the nurse did to make the patient comfortable. b. To avoid embarrassing the nurse in front of others, find a way to compliment the nurse in private. c. When the nurse comes out of the room, tell the nurse specifically what you appreciated about the care that was provided. d. Encourage the patient to note the care on the patient feedback form so that the institution can recognize the nurse’s efforts.

ANS: C Acknowledgement is most effective when it is specific, timely, given in public, sincere, and on an eye-to-eye basis. The more time that elapses between the event and acknowledgement, the less effective it becomes.

25. What is not a key concept in a well-functioning team? a. Absence of disagreement or conflict b. Special work that is understood and supported by all c. Willingness to work together respectfully

d. Dedication to a mission ANS: A The challenge in teams is not to eliminate disagreement or conflict but to recognize when a breakdown in communication occurs. Singleness of mission, willingness to cooperate, and commitment are all key concepts in a well-functioning team.

MULTIPLE RESPONSE 1. Mobilizing others to accomplish extraordinary things requires what leadership behaviors? a. Celebrating the successes of others b. Demonstrating exceptional technical skills c. Imagining possibilities d. Establishing a sense of “being in this together” ANS: A, C, D Leaders who inspire teams to accomplish extraordinary things or to display synergy model the way, inspire shared vision, challenge the status quo, and encourage the heart by celebration of success.

Chapter 19: Workforce Engagement and Collective Action Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. The staff members in a local Emergency Department are experiencing stress and burnout as the result of excessive overtime. The staff decides to unionize to negotiate for better working conditions. The increase in unionization within health care may be attributed to the: a. Movement from being “blue-collar workers” to being “knowledge workers.” b. Excess profits in health care. c. Level of risk that exists for health care. d. Number of people who are involved in health care.

ANS: D As technology replaces unskilled workers, fewer workers are available for trade-union organizing, which has led to declines in union memberships.

Nurses represent a large pool of workers who may be available for union organizing in the face of the declining pool available elsewhere.

2. The Emergency Department nurses’ decision to organize for the purpose of

collective bargaining is being driven by a desire to: a. Establish the staffing pattern that will be used. b. Determine the hours that one is willing to work. c. Create a professional practice environment. d. Protect against arbitrary discipline and termination.

ANS: C Historically, nurses were reluctant to unionize. However, concern with safety of care and quality of care, especially when tension is present in a work environment, makes unionization more desirable. U.S. Supreme Court rulings have provided for RN-only units and protection to practice according to what the profession and licensure status require nurses to do.

3. The Emergency Department staff decides to use a collective bargaining model for negotiation rather than a traditional trade union model. A traditional trade union model is characterized by: a. Positional conflict. b. Management support of labor’s initiatives. c. A spirit of trust between management and labor. d. An ability to resolve complaints.

ANS: A Collective bargaining encompasses management support of labor’s initiative, a spirit of trust between labor and management, and resolution of problems. It replaces the positional conflict that has been associated with traditional trade unions. Models such as the interest-based problem solving (IBPS) model seek to avoid positional conflicts such as those between labor and management that do not take into account the opposing party in any way.

4. The chief nursing officer utilizes the hospital’s workplace advocacy to help the overwhelmed Emergency Department staff. Workplace Advocacy is designed to assist nurses by: a. Creating professional practice climates in their institutions. b. Equipping them to practice in a rapidly changing environment. c. Negotiating employment contracts. d. Representing them in labor-management disputes.

ANS: B Workplace advocacy encompasses a number of activities that enable nurses to control the practice of nursing and to address challenges that they face in the practice setting. These activities include career development, employment rights, employment opportunities, and the labor-management relationship.

The aim of workplace advocacy is to proactively equip nurses to practice within a rapidly changing environment, rather than to negotiate contracts or provide representation in employment disputes.

5. Nursing labor management partnerships: a. Engage nurses at all levels in problem solving for better patient care. b. Require unions and management to negotiate in good faith regarding hours of work and wages. c. Have been shown to have negligible effects on nurse turnover and patient outcomes. d. Have typically resulted in increased polarization of nurses and management, leading to formation of collective bargaining units.

ANS: A The development of a nursing labor management partnership is an approach that can be used in most professional nursing environments. This process recognizes nurses as leaders on all levels and provides formal and informal mechanisms for professional nurses to work together to achieve shared goals through collaboration and shared decision making or decentralized decision making. A study of a nursing labor management partnership suggested that nurse satisfaction was higher, turnover was lower, and more time was available for patient care.

6. A Magnet™ hospital surveys the staff about job satisfaction. This type of environment, in which nurses have authority and autonomy, is linked with: a. Client satisfaction with the healthcare organization. b. Organizations with a limited number of nurse managers. c. Private, specialty organizations in urban areas. d. Sophisticated academic health sciences universities.

ANS: A Autonomy and authority in decision making that is consistent with scope of practice are linked both to higher job satisfaction and to higher patient satisfaction with care. Job satisfaction is an important indicator of the quality of patient care.

7. In a nurse managers’ meeting, strategies for ways to help retain staff are discussed. One strategy for assisting nurses in developing collective action skills is: a. Accepting the practice of “going along to get along.” b. Attending as many workshops as practical.

c. Spending as much time as possible in clinical settings. d. Taking the opportunity to work with a mentor.

ANS: D Mentoring facilitates development and adoption of positive interaction and other skills that facilitate good decision making. Optimism, trust, and decision making are important in collective action and shared decision making and contribute to job satisfaction and lower turnover in staff.

8. While making rounds, a night supervisor finds a unit with a low census and too many staff members. The night supervisor is performing as a statutory supervisor when he or she: a. Assigns nurses to care for specific clients. b. Develops a protocol for unlicensed personnel. c. Recommends transferring a nurse to another service. d. Teaches a nurse to use a new piece of equipment.

ANS: C The night supervisor is acting in accordance with the National Labor Relations Act, which would enable the supervisor to assign nurses to care.

9. The Emergency Department staff members are concerned that working long hours without rest puts patient safety at risk. One staff member decides that she will risk her job and become a whistleblower. Whistle-blowing is an appropriate recourse when management: a. Disregards due process when disciplining a nurse. b. Delays responding to repeated efforts to provide safe care. c. Hires nurses who are not a part of the union during a strike. d. Refuses to bargain in good faith with the elected bargaining agent.

ANS: B Whistle-blowing is often a result of organizational failure, including failure of the organization to respond to serious danger or wrongdoing created within the environment, which, in this instance, involves conditions that put the patient at risk.

10. As a new nurse manager who has “inherited” a unit with high nurse turnover and complaints of patient dissatisfaction, your first course of action would be to: a. Determine levels of nurse engagement on the unit. b. Review the personnel files of nurses who have resigned. c. Interview upper management about their vision for the unit.

d. Meet with your staff to clarify your vision for the unit.

ANS: A Multiple studies demonstrate that a healthcare organization that provides a climate in which nurses have authority and autonomy has better patient outcomes, retains nurses at a higher rate, is more cost-effective, and has evidence of greater patient satisfaction than an organization in which such a climate does not exist (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Dunton, Gajewski, Klaus, & Pierson, 2007). Organizational assessment assists in identifying the reasons for high nurse turnover and patient complaints.

11. In an inner-city area, a group of nurses meet and develop a plan to negotiate with local businesses to support a breakfast program for young elementary schoolchildren. This is an example of: a. Community development. b. Collective bargaining. c. Collective action. d. Shared governance.

ANS: C Collective action refers to activities undertaken by a group of people with common interests and, in this example, by a group of nurses who are interested in the welfare of children in their community.

12. In accomplishing the goal of breakfast for children in elementary school, Leanne is particularly effective in approaching businesses with the needs that the group has determined and articulating the ways that the group has found for businesses to participate. Leanne is exemplifying: a. Leadership. b. Followership. c. Professionalism. d. Knowledge of context.

ANS: B Effective followership involves active and loyal involvement in an agenda that has been established. In this role, Leanne is supporting and operationalizing the agenda and strategies that have been established within the group.

13. Awareness and use of power have been challenging for nurses in general because of:

a. Incidences of punishment by authority figures. b. Too little time in the workplace to collectively develop power strategies. c. Lack of cohesiveness and unity among nurses. d. A tradition of obedience to authority.

ANS: D Rituals and traditions such as the Nightingale Pledge have emphasized the need for the “good nurse” to be obedient to authority. This prevailing attitude has made it difficult for nurses, who typically spend considerable time in the workplace and who have opportunity through their work in teams to develop cohesiveness and unity, to develop awareness and use of power.

14. Collective action is effective in: a. Ensuring that needs of nurses are placed ahead of other disciplines. b. Defining nursing as a profession. c. Advising patients of the needs of nurses. d. Amplifying the influence of individuals.

ANS: D Individuals may have limited influence in achieving various purposes such as advancement of quality care or of the profession, whereas collective action helps to define and sustain individuals in achieving the desired purposes.

15. Nurses on the dialysis unit notice that changes in labeling of fluids have meant several alarming near misses in terms of wrong administration of fluids. They take this concern to the unit manager. As an advocate of nurse autonomy, the most appropriate response in this situation would be to: a. Ensure that the nurses are aware of the reasons for the change and how the decision was made about the new labels. b. Discuss concerns about the labels and develop potential solutions that take into account changes that can be made at the local level and those that need system intervention. c. Suggest that the staff wait until they have become more familiar with the labels before taking further action. d. Tell the staff that you will notify the pharmacy about these concerns and leave it up to the pharmacy to decide what should be done.

ANS: B Participation in decision making regarding one’s practice is an appropriate expectation for professional nurses, provides for greater autonomy and authority over practice decisions, contributes to supporting the professional nurse, and is a major component of job satisfaction (Kramer et al., 2008;

Pittman, 2007). Autonomy is encouraged through supportive management and through unit-level support of changes without the need for complex, multilevel approval of changes that can be made locally.

16. Martin, the unit manager, receives complaints from community agencies that patients who have been discharged from his unit seem to lack understanding about their disorder and immediate strategies for managing elements of their care. Martin checks the patient teaching sheets and notes that the sheets are initialed by staff. He calls the agencies and indicates that teaching has been done. Martin’s follow-up to complaints from the community is: a. Appropriate and indicates that he has assumed accountability for the actions of his staff. b. Indicative that he does not clearly understand the concept of accountability. c. Indicative of strong support for his staff and their autonomy. d. Important in clarifying the difference between his accountability and that of the community in patient care.

ANS: B Accountability refers to the achievement of desired outcomes. If community agencies are noticing that limited or no change in patient behavior has occurred despite teaching on the unit, then the staff has not achieved accountability, and he is not holding his unit responsible for the outcomes.

Martin is also demonstrating lack of accountability.

17. Sarah determines, in partnership with her patient, that current medications are not enabling her patient, a married account executive with fibromyalgia, to continue with her employment and family responsibilities. After searching for additional information on fibromyalgia, Sarah finds nonpharmacologic interventions that are supported through credible evidence. Sarah suggests that the patient, her physician, and she meet to discuss the medications and possible options and a plan of care for the patient’s discharge. This action exemplifies which of the four historical concepts identified by Lewis and Batey? a. Authority b. Responsibility c. Communication of conflict d. Autonomy ANS: A

Authority refers to the use of professional status and power to act in the patient’s best interests. In this example, Sarah is using her professional status and power to set up a conference in which her patient, the prescribing physician, and she can discuss what is not working for the patient and potential options.

18. In looking at an organizational chart for her institution, Jennifer notes that nursing is led at the senior level by a non-nurse executive. Jennifer expresses concern that this is a reflection of how nursing is viewed within the organization. Jennifer’s comments reflect: a. A concern that resource allocation will be made on a business and not a professional model. b. The dissatisfaction that occurs when lack of autonomy is given to nurses. c. Concern with the nonadvancement of nursing practice in the institution. d. An awareness of how organizational culture is reflected in organizational structure.

ANS: D The organizational chart reflects the formal structure of the organization and can reflect predominant beliefs, values, and relationships in the organization.

Exclusion at senior executive levels of nurse leaders may reflect institutional beliefs about how resources are allocated, the degree of autonomy given to staff, and involvement of key groups in decision making.

19. Government and third-party payers announce reduction of compensation for the delivery of patient services. Hospital STV has a flat organizational structure. After the funding announcements, senior officials at the hospital meet and make decisions regarding cost containment of new revenue streams.

This action is consistent with: a. The practice of leaving financial decisions with senior officials who understand the total context of funding. b. A tendency to concentrate decision making during economic downturns at the top administrative level. c. A need to make expedient decisions that are likely to be poorly received by staff. d. Ensuring that decisions with regard to cost are made equitably across all departments.

ANS: B During times of economic downturn, decisions tend to become very centralized to avoid risk. History demonstrates that increasing the breadth of

input during these times is more effective than narrowing it.

20. In Hospital STV, senior administration is strongly oriented toward fiscal and social conservatism. The nursing department is deeply concerned with the provision of quality to the community, which includes a high number of poor and unemployed. To accomplish the goals of the nursing department, resources need to be allocated that administration is not able to allocate.

Nursing and administration: a. Are engaged in shared governance. b. Are involved in an irreconcilable conflict of interests. c. Represent separate subcultures in the institution. d. Represent union and nonunion conflict.

ANS: C Institutions can have several subcultures, which are represented by unique features and distinct ideologies. Subcultures can be congruent and can support healthy relationships in the organization, or they may be separated and characterized by tensions that may be irreconcilable and destructive.

From the information given in this scenario, it is not evident that shared governance, union presence, or irreconcilable differences are present.

21. On Unit 62, the nurses and the unit manager have been involved in shared decision making related to the model of nursing care delivery that the unit will adopt. All individuals have participated and been involved in decision making and implementation of changes. When issues arise during implementation, it is expected that: a. Accountability resides entirely with the unit manager. b. Individual expertise will be utilized to provide solutions, but that responsibility for the change is shared. c. No one really has any accountability or responsibility for the changes. d. This will contribute to widespread skepticism among the staff about the probability of success.

ANS: B High-performing organizations provide for participation by all stakeholders, and each stakeholder shares responsibility and risk. This kind of environment is more satisfying for nurses and is characterized by optimism and trust.

22. Senior executives at Hospital A determine that the hospital will engage in a strategic planning process after changes in healthcare funding and concerns expressed in the community about care that is being delivered at the hospital.

The senior executives decide on a participatory process in which staff are widely consulted regarding input about the organization and the external environment and are actively invited to be part of decisions related to the mission statement, goals, and objectives. For true shared governance to be seen as part of this approach: a. It must be evident in the outcomes of the process that staff and senior executives have partnered on the decisions. b. Stakeholders must be assured of the value of their input even though final decisions rest with senior executives. c. Publications must clearly outline how staff input was solicited and obtained. d. Staff must be reassured that significant concerns will be kept in mind even if they have not been addressed in planning documents.

ANS: A Shared governance demands participation in decision making. When partnership, equity, and ownership are not involved, then shared governance has not occurred, and publication and expressions of appreciation for input will not be seen as representative of shared governance.

23. Nurses in an Emergency Department, in an inner-city neighborhood characterized by high levels of violence, are concerned with low levels of security presence in their department. Security levels have recently been decreased and the nurses question why this has occurred. An appropriate action would be to: a. Provide nurses with information about rationale for recent changes in security staffing. b. Refer the matter to the head of security and let her deal with it. c. Provide mentors who can help nurses diffuse aggressiveness. d. Accept the security levels as a consequence of funding realities.

ANS: A Workplace advocacy is an umbrella term encompassing activities within the practice setting. Workplace advocacy includes an array of activities undertaken to address the challenges faced by nurses in their practice settings. The focus of these activities is on career development, employment opportunities, terms and conditions of employment, employment rights and protections, control of practice, labor-management relations, occupational health and safety, and employee assistance. The objective of workplace advocacy is to equip nurses to practice in a rapidly changing environment.

One manifestation of workplace advocacy is ensuring that relevant information is shared about decisions that affect practice so that further data gathering and decision making (in this instance about security levels and nurse safety) is informed.

24. You are hired as a new manager. When the offer of employment is made, you agree to at-will employment. Later, you become very concerned about the policies and practices of your organization and their impact on patient care. You speak with your supervisor several times about your concerns, but no action is taken. In considering your next steps, you: a. Consider your increased vulnerability under the terms of your employment. b. Recognize that your supervisor is more vulnerable than you are because of her more senior position. c. Are more likely as a leader to take action because you are well protected from repercussions by federal and state regulations. d. Contact your union to discuss your concerns and review your options.

ANS: A Managers of at-will employees have greater latitude in selecting disciplinary measures for specific infractions. State and federal laws do provide a level of protection; however, an at-will employee may be terminated at any time for any reason except discrimination. At-will employees, in essence, work at the will of the employer. Nurses in these positions need to know their rights and accountability.

25. Sandra, an RN on the surgery unit, is assisting with a procedure in the patient examination room. The physician orders a medication to be given through IV. Sandra questions the order, based on her knowledge of the patient’s history and of other medications that the patient has been given. The physician reiterates the order and Sandra refuses to give it. In this instance, Sandra is demonstrating: a. Autonomy. b. Accountability. c. Authority. d. Best practice.

ANS: A In this situation, Sandra is exemplifying autonomy, which is the act of making independent decisions in the best interests of the patient, based on her knowledge and experience. This is analogous to the example in the text where the workers on the manufacturing floor have the independence to say

“Stop the line” when something is wrong. Key to the concept of autonomy is decision making and the level of independence that is given. Accountability refers to achievement of outcomes, and authority refers to the capacity to make decisions.

MULTIPLE RESPONSE 1. Martin, the unit manager, receives complaints from community agencies that patients who have been discharged from his unit seem to lack understanding about their disorder and immediate strategies for managing elements of their care. Martin checks the patient teaching sheets and notes that the sheets are initialed by staff. He calls the agencies and indicates that teaching has been done. Potential outcomes of Martin’s actions include : a. Poor morale on the unit. b. Disruption in community relationships. c. Corruption of patient-staff relationships. d. Patient outcomes for quality care are met.

ANS: A, B, C Kupperschmidt (2004) points out that when accountability is not accepted, then relationships suffer, professional practice is diminished, and self-esteem suffers.

Chapter 20: Managing Quality and Risk Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. A new graduate is asked to serve on the hospital’s quality improvement (QI) committee. The nurse understands that the first step in quality improvement is to: a. Collect data to determine whether standards are being met. b. Implement a plan to correct the problem. c. Identify the standard. d. Determine whether the findings warrant correction.

ANS: C Before further action (data collection, decision making related to correction, and implementation of a plan) can occur, it is necessary to identify the standards against which data collection and decision making will occur.

Institutions may or may not adopt standards that are already established by organizations such as the ANA.

2. The chief executive officer asks the nurse manager of the telemetry unit to justify the disproportionately high number of registered nurses on the telemetry unit. The nurse manager explains that nursing research has validated which statement about a low nurse-to-patient ratio? It: a. Promotes teamwork among healthcare providers. b. Increases adverse events. c. Improves outcomes. d. Contributes to duplication of services.

ANS: C Studies related to staffing and patient outcomes suggest that patient outcomes are improved with a low nurse-to-patient ratio and especially with a low registered nurse-to-patient ratio.

3. A nurse manager wants to decrease the number of medication errors that occur in her department. The manager arranges a meeting with the staff to discuss the issue. The manager conveys a total quality management philosophy by: a. Explaining to the staff that disciplinary action will be taken in cases of additional errors. b. Recommending that a multidisciplinary team should assess the root cause of errors in medication. c. Suggesting that the pharmacy department should explore its role in the problem. d. Changing the unit policy to allow a certain number of medication errors per year without penalty.

ANS: B Quality management stresses improving the system, and the detection of staff errors is not stressed. If errors occur, reeducation of staff is emphasized rather than imposition of punitive measures such as disciplinary action or blaming.

4. The nurse educator of the pediatric unit determines that vital signs are frequently not being documented when children return from surgery.

According to quality improvement (QI), to correct the problem, the educator, in consultation with the patient care manager, would initially do which of the following? a. Talk to the staff individually to determine why this is occurring. b. Call a meeting of all staff to discuss this issue. c. Have a group of staff nurses review the established standards of care for postoperative patients.

d. Document which staff members are not recording vital signs, and write them up.

ANS: B Leadership must identify safety shortcomings and must locate resources at patient care levels to identify and reduce risks. One method of doing this is to invite all staff into a discussion related to solutions to an identified concern.

This approach encourages teamwork.

5. A nurse is explaining the pediatric unit’s quality improvement (QI) program to a newly employed nurse. Which of the following would the nurse include as the primary purpose of QI programs? a. Evaluation of staff members’ performances b. Determination of the appropriateness of standards c. Improvement in patient outcomes d. Preparation for accreditation of the organization by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) ANS: C The primary purpose of QI is improvement of patient outcomes, which relates to prevention of error, quality patient care, and patient satisfaction.

6. Before beginning a continuous quality improvement project, a nurse should determine the minimal safety level of care by referring to the: a. Procedure manual. b. Nursing care standards. c. Litigation rate of unsafe practice. d. Job descriptions of the organization.

ANS: B Standards establish the minimal safety level of care. Procedure manuals provide information about how standards are to be achieved.

7. The nurse gives an inaccurate dose of medication to a patient. After assessment of the patient, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication understands that: a. The error will result in suspension. b. An incident report is optional for an event that does not result in injury. c. The error will be documented in her personnel file. d. Risk management programs are not designed to assign blame.

ANS: D QM stresses improving the system, and the detection of staff errors is not stressed. If errors occur, reeducation of staff is emphasized rather than imposition of punitive measures such as disciplinary action or blaming.

8. The nurse manager is concerned about the negative ratings her unit has received on patient satisfaction surveys. The first step in addressing this issue from the point of view of quality improvement is to: a. Assemble a team. b. Establish a benchmark. c. Identify a clinical activity for review. d. Establish outcomes.

ANS: C In theory, any and all aspects of clinical activity could be improved through the QI process. However, QI efforts should be concentrated on changes to patient care that will have the greatest effect.

9. With the rise of violence in the psychiatric department, the nurse manager decides that she should work with the risk manager in violence prevention.

The nurse manager should: a. Request all staff to accept new risk management practices. b. Hold staff accountable for safe practices. c. Document inappropriate behavior. d. Hire more police security.

ANS: B Active involvement of staff in risk management activities is key to prevention of adverse events. Nursing has a primary role in leadership in optimizing patient outcomes, preventing patient care issues, and mitigating adverse events. Accountability for safety can be one aspect of performance evaluations.

10. A new RN staff member asks you about the difference between QA and QI. You explain the difference by giving an example of QI. a. “Last year, the management team established new outcomes that addressed issues such as medication errors.” b. “At a staff meeting last year, two of our staff commented on the number of recent falls and asked, ‘What can we do about it?’” c. “A process audit was done recently to determine how much time was being spent on patient documentation.”

d. “Errors are reported on our new computerized forms, and I follow up with staff to make sure that they understand the seriousness of their error.”

ANS: B In QI, followers invest in the process by continually asking “What makes this indicator important to measure?” “What has been done to improve it?” “What can I do to improve it?”

11. Healthcare organization X is committed to improving patient outcomes and, as part of the QI process, examines its executive structure and organizational design. This approach recognizes: a. The importance of decentralized structure in QA. b. That structure influences nurse burnout and participation in quality improvement initiatives. c. The need to ensure sufficient supervisory staff to respond in a corrective manner when mistakes occur. d. That a narrow hierarchy ensures accountability for errors and outcomes.

ANS: B Common organizational characteristics of Magnet™ hospitals include structure factors (e.g., decentralized organizational structure, participative management style, and influential nurse executives) and process factors (e.g., professional autonomy and decision making, ongoing professional development/education, active quality improvement initiatives). ANCC Magnet™ designated hospitals and other high-reliability organizations in the United States and Europe generally have lower burnout rates, higher levels of job satisfaction, and provide higher levels of quality care resulting in greater levels of patient satisfaction (Aiken et al., 2012; Kelly, McHugh, & Aiken, 2011).

12. Hospital ABCD is a Magnet™ hospital. This designation has been applied to Hospital ABCD because it: a. Facilitates active staff participation in decision making related to quality nursing care. b. Has implemented a graduate nurse orientation program. c. Espouses commitment to excellence in patient care. d. Is establishing career ladders for nurses.

ANS: A Magnet™ hospitals are particularly successful in implementing excellence in patient care through use of standards, evidence, and participatory decision making in quality improvement. Organizations that cannot pursue Magnet™

status can implement strategies such as career ladders.

13. A nursing-led classification system that has led to greater reliability and standardization in data utilized for QI processes is: a. NANDA. b. AHRQ. c. NIOSH. d. Nursing process.

ANS: A NANDA has been developed by nurses and uses standardized terminology that enables study of health problems across populations, settings, and caregivers.

14. In determining the relationship between injury-producing falls and proposed preventive measures as part of the QI process, a QI team might turn to which of the following for confirmatory evidence? a. NDNQI b. NANDA c. NIOSH d. AHRQ ANS: A The National Database of Nursing Quality Indicators is a national, nursing quality measurement program from the American Nurses Association that provides hospitals with unit-level performance reports with comparisons to national averages and rankings.

15. A method commonly used in Quality Assurance to monitor adherence to established standards is: a. A Pareto chart. b. Brainstorming. c. Patient interviews. d. Chart audit.

ANS: D Chart audits are a common method of addressing process standards. Chart audits over time yield trend charts.

16. Hospital Magnet™ decides against creating a separate department to lead and monitor quality activities because: a. Total organizational involvement is critical to QI. b. Data generated by a single, separate department are generally flawed.

c. Monitoring and commitment to QI can come only from senior-level managers. d. Staff resent suggestions for improvement that originate outside of their unit.

ANS: A Decentralized approaches are effective in developing unit-level solutions, as well as commitment to strategies and implementation of changes.

17. As a nurse manager, you know that the satisfaction of patients is critical in making QI decisions. You propose to circulate a questionnaire to discharged patients, asking about their experiences on your unit. Your supervisor cautions you to also consider other sources of data for decisions because: a. The return rate on patient questionnaires is frequently low. b. Patients are rarely reliable sources about their own hospital experiences. c. Hospital experiences are frequently obscured by pain, analgesics, and other factors affecting awareness. d. Patients are reliable sources about their own experiences but are limited in their ability to gauge clinical competence of staff.

ANS: D Patients are reliable and motivated sources of their own experience but often do not have sufficient knowledge of clinical procedures to provide feedback about clinical competence.

18. An example of an effective patient outcome statement is: a. Eighty percent of all patients admitted to the Emergency Department will be seen by a nurse practitioner within 3 hours of presentation in the Emergency Department. b. Patients with cardiac diagnoses will be referred to cardiac rehabilitation programs. c. The hospital will reduce costs by 3% through the annual budget process. d. Quality is a desired element in patient transactions.

ANS: A Patient outcomes must be measurable, specific, and patient-centered.

19. Patient perceptions are useful in: a. Determining disciplinary actions in QI. b. Establishing the competitive advantage of QI decisions. c. Providing one source of data for QI initiatives.

d. Establishing blame for poor-quality care.

ANS: C Customers define quality and patient dissatisfaction as useful indicators of which areas are of greatest concern to patients and of what matters then to nurses and organizations. Patient perceptions guide areas of inquiry; however, they do not establish what disciplinary decisions will be made.

20. Through the QI process, the need to transform and change the admissions process across administrative and patient care units is identified. In this particular situation, what method of data organization will be most effective? a. Flowchart b. Histogram c. Narrative d. Line graphs ANS: A Flowcharts are useful in identifying and visualizing sequential steps, such as the admissions process.

21. A nursing unit is interested in refining its self-medication processes. In beginning this process, the team is interested in how frequently errors occur with different patients. To assist with visualizing this question, which organizational tool is most appropriate? a. Histogram b. Flowchart c. Fishbone diagram d. Pareto chart ANS: A Histograms are bar graphs that are useful in outlining and identifying frequency.

22. The outcome statement “Patients will experience a ten percent reduction in urinary tract infections as a result of enhanced staff training related to catheterization and prompted voiding” is: a. Physician-sensitive and nonmeasurable. b. Measurable and nursing-sensitive. c. Precise, measurable, and physician-sensitive. d. Patient care–centered and nonmeasurable.

ANS: B Nursing-sensitive outcomes refer to outcomes that are affected by nursing

activity and are precise, measurable, and patient-centered.

23. Your institution has identified a recent rise in postsurgical infection rates.

As part of your QI analysis, you are interested in determining how your infection rates compare with those of institutions of similar size and patient demographics. This is known as: a. Quality assurance. b. Sentinel data. c. Benchmarking. d. Statistical analysis.

ANS: C Benchmarking is a widespread search to identify the best performance against which to measure practices and processes.

24. At Hospital Ajax, there has been a 20% increase in instruments and sponges being left in patients during surgery and surgeries on the wrong limbs. These are known as: a. Sentinel events. b. Medically sensitive events. c. Nurse-sensitive events. d. Never events.

ANS: D The NQF and CMS define never events as errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients and that indicate a real problem in the safety and credibility of a healthcare facility. Examples of never events include surgery on the wrong body part, foreign body left in a patient after surgery, mismatched blood transfusion, major medication error, severe pressure ulcer acquired in the hospital, and preventable postoperative deaths.

MULTIPLE RESPONSE 1. Examples of sentinel events include : a. Forceps left in an abdominal cavity. b. Patient fall, with injury. c. Short staffing. d. Administration of morphine overdose. e. Death of patient related to postpartum hemorrhage.

ANS: A, B, D, E Sentinel events are serious, unexpected occurrences involving death or

physical or psychological harm.

Chapter 21: Translating Research into Practice Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. The chief nursing officer at a local hospital seeking Magnet™ status creates staff development classes concerning translation of research into practice (TRIP). What best describes TRIP? a. Conducting an integrative review of the literature b. Searching the literature for a systematic review c. Providing the results of research studies to practitioners d. Applying strategies that aid in adoption of research in practice ANS: D The science of how research is adopted is known as translation science, the science of translating research into practice (TRIP). The primary aim of research utilization is to activate the change process to move research findings into practice to improve patient outcomes.

2. The chief nursing officer at a local hospital seeking Magnet™ status creates staff development classes about incorporating evidence-based practice in nursing. What best describes evidence-based practice? a. Applying best research evidence to care of patients b. Using research-based information to develop practice guidelines c. Conducting a randomized control trial to determine effectiveness of handwashing techniques d. Developing standards for practice ANS: A Evidence-based medicine is derived from evidence-based medicine and involves integration of the best research evidence with clinical expertise and the patient’s unique values and circumstances in making decisions about the care of individual patients. It is focused on searching for, appraising, and synthesizing the best evidence to address a particular clinical practice problem.

3. The nurse manager decides to change staffing schedules in the intensive care unit. She chooses to use Rogers’ diffusion of innovations theory to implement the change. What are the elements of Rogers’ diffusion of innovations theory? a. Assessment, planning, intervention, and evaluation

b. Preparation, validation, synthesis, and evaluation c. Knowledge, persuasion, decision, implementation, and evaluation d. Scanning, diagnosis, decision making, application, and reevaluation ANS: C Nurse managers disseminate research findings to patient care team members.

Rogers’ diffusion of innovations theory provides a useful model for integration of evidence into practice.

4. As a nurse manager, you trial a new pain scale on your unit that is supported by numerous research studies. You compare the patient outcomes with the new scale against the existing scale. Feedback from staff suggests that the new scale is too difficult for patients who have limited language skills and who are already under duress to understand. The difficulty in implementing the new scale refers to testing: a. Efficacy. b. Effectiveness. c. Practice failure. d. Comparative error.

ANS: B Comparing the effectiveness of interventions can help to address the needs of clinicians in determining best practices for their patients. Comparative effectiveness research (CER) is the “generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care” (Institute of Medicine, 2009, p. 29). Efficacy is testing an intervention or treatment in a traditional randomized clinical trial under carefully controlled conditions and is used to determine whether an intervention or treatment works, whereas effectiveness is testing whether the intervention or treatment works in the real world of practice.

5. The nurse manager wants to use evidence-based recommendations to prevent ventilator-associated pneumonia. In order to effectively gather evidence to guide practice, what is the critical first step? a. Develop the clinical question. b. Identify the databases to be used. c. Appraise the evidence. d. Integrate available evidence with unit expertise.

ANS: A Identifying the question may be the most challenging part of the process.

Once the clinical question has been identified, writing it down will help in moving on to the next step of gathering evidence.

6. A strategic goal developed by the chief nursing officer is to implement an evidence-based practice program. What is an appropriate strategy that can be used by a nurse manager who is beginning to implement an evidence-based practice program? a. Conducting a review of adverse events and incident reports b. Soliciting input from staff members c. Reviewing specialty organization guidelines d. Identifying patients with extended lengths of stay ANS: B Stakeholders need to be involved early, and staff members need to be involved when initiatives involve direct patient care. Involvement assists in understanding issues and concerns, motivations, and unmet needs.

7. The nurse manager of an ICU wants to implement the revised policy and procedure on central line catheter care. What would be the most effective method of getting the staff nurses to incorporate a new evidence-based practice into their care? a. Conducting an interactive educational workshop b. Distributing educational materials on clinical units c. Sharing the results of a chart audit with staff d. Providing staff with a short DVD on the topic ANS: A Dobbins et al. suggest that effective strategies for promoting behavioral change in health professionals include active involvement strategies such as face-to-face information sessions in small groups and one-to-one interactions.

Other approaches have mixed or few results.

8. Before implementation of the new policy and procedure on central line catheter care, the nurse manager uses an appraisal system to evaluate the evidence. What is important in using an appraisal system to evaluate the evidence gathered in preparation for development of a new protocol? a. Limiting the search to randomized clinical trials b. Matching the appraisal tool to the type of evidence c. Eliminating qualitative research studies d. Using only pre-processed evidence ANS: B

Appraisal tools are specific to the number of studies, as well as to the study design (type of evidence), type of review, and strategy for determining the applicability of evidence to your practice.

9. To help staff nurses adjust to using research in practice, what strategy would the nurse manager use? a. Attendance at a regional research conference b. Formal classes in electronic search techniques c. Establishing a journal club d. Issuing reports on the adverse consequences of outdated practices ANS: C Journal clubs provide opportunities for engagement in reading research and considering how it might be applied to clinical practice problems, which is considered very effective in behavioral change.

10. What is a strategy that can be used by a small community hospital with limited resources to develop an evidence-based nursing practice program? a. Hiring a nurse researcher b. Partnering with nurse researchers at a local university c. Subscribing to journals devoted to evidence-based nursing d. Including research competencies in managers’ job descriptions ANS: B Partnering with nurse researchers assists in providing nurse researcher expertise and leadership to organizations that do not have the size or the resources to hire nurse researchers.

11. Tara, the unit manager, is telling her colleague about her recent project, which involves seeking the most effective approaches to incontinence care, with the intention of adopting evidence-supported approaches on her dementia care unit. Her colleague suggests that translation of research into practice is: a. Less important than knowledge-generating research, which is required to advance the nursing profession. b. A priority of all healthcare practitioners to improve patient care. c. Characterized by lack of knowledge about how to use evidence to guide practice. d. So difficult that it is useless to begin the query in the first place.

ANS: B The National Institutes of Health identified translational research, or getting

research into the hands of practitioners to improve patient care, as a priority.

12. After searching the literature, Tara, the unit manager develops a table that outlines the findings of studies on management of incontinence. She then examines the studies in terms of risk and whether the findings fit within her practice context and for her population of moderately to severely cognitively impaired patients. This is which phase of Stetler’s research utilization model? a. Preparatory b. Validation c. Evaluation d. Application ANS: C The third phase, comparative evaluation and decision making, involves making a decision about the applicability of the studies by synthesizing cumulative findings; evaluating the degree and nature of other criteria, such as risk, feasibility, and readiness of the finding; and actually making a recommendation about using the findings of the studies.

REF: Page 386 TOP: AONE competency: Knowledge of the Health Care Environment 13. The clinical guidelines for management of incontinence developed by the Registered Nurses Association of Ontario (RNAO): a. Reflect practice that is fiscally directed and sound. b. Articulate practice recommendations developed from synthesis and review of evidence. c. Are intended to increase awareness of issues in incontinence management. d. Reflect a compilation of information from a variety and range of sources related to incontinence.

ANS: B The evidence-based practice (EBP) movement has grown exponentially with scientific publications, establishment of collaboration centers, resources on the Web, and grants focused specifically on translating of research into practice. A number of evidence-based nursing centers have been established around the world. These centers have teams of researchers who critically appraise evidence and then disseminate protocols for the use of evidence in practice. In this example, clinical guidelines have been developed by a professional nursing organization on the basis of best possible evidence on incontinence management. Although issues may be raised in the

recommendations, the purpose is to guide practice for the purposes of better patient care.

14. Marie is a long-term staff nurse on the rehab floor. Her unit manager has been eager to adopt evidence-based recommendations related to familycentered care on the unit. Marie’s response has been that she rarely has time to provide care to patients, let alone families, and that there is no good reason to do anything different than what she is already doing. An approach that may gain Marie’s support of the idea is to: a. Invite Marie to review the studies for herself. b. Suggest that she does not need to provide family-centered care. c. Avoid discussion of the idea with her until she initiates it. d. Secure the support of her closest colleagues on the unit.

ANS: D As a skeptic, Marie, who is a late majority adopter, needs pressure from colleagues to move her towards support of the recommendations. The translation of research into practice requires that nurse leaders and managers understand group dynamics, individual responses to innovation and change (such as the response of late majority adopters), and the culture of their healthcare organization.

15. You are excited by evidence supporting the use of PDAs at the bedside to improve documentation and patient outcomes. You have disseminated the information through discussions and e-mails and are now ready to begin the process of considering implementation on the unit. To develop positive attitudes toward the use and implementation of the technology, you would discuss your ideas with (Rogers’ diffusion of innovations theory): a. Harvey, RN, a technology guru, who enthusiastically tries on all new software. b. Berta, RN, who thoughtfully considers evidence and regularly uses it to try new approaches in her practice. c. Carol, LPN, who is positive about new ideas but looks to her friends for their ideas about whether or not to try something new. d. Ben, a 10-year veteran of the unit, who wonders why technology should be used at all. He says that he will use it when there is no chance of security breaks.

ANS: B Berta is the one with whom you should now have informed conversations, because she is an early adopter who is respected for her thoughtful

acquisition and critique of knowledge and application of knowledge to practice. Berta, an early adopter (Rogers’ characteristics of innovation adopters), is more effective in this stage than Harvey, an innovator who may be seen as open to all new ideas regardless of merit.

16. The implementation of saline flushes for capped angiocatheters is an example of: a. How multilevel and interprofessional application of a procedure can slow adoption of EBP. b. How competition among disciplines can lead to negative patient outcomes. c. The reluctance of hospital administrators to act on recommendations from EBP. d. How a safe, well-known practice outweighs the benefits of adopting a newer practice.

ANS: A The translation of research into practice operates at four levels: The individual healthcare professional, healthcare groups or teams, organizations, and the larger healthcare system or environment. The adoption of saline flushes illustrates the challenges of communicating EBP to other disciplines and organizations and of the involvement of different levels. This particular innovation needed endorsement by nurses, physicians, and pharmacists, as well as by administrators who needed evidence of lost savings to support adoption.

17. Which of the following would be most effective in implementing the findings of Dobbins et al. on treating problems associated with bowel motility? a. Lecture by a nurse practitioner b. Workshop for surgical nurses that involves discussion of case studies and application of evidence c. Discussion of the findings on the bulletin boards at the workstation d. Education of unit opinion leaders regarding the evidence presented in the studies ANS: B Work by Dobbins et al. suggests that translation of research into practice is best facilitated through interactive learning such as workshops. Least effective strategies included didactic learning and distribution of learning materials.

18. Which of the following is an effective approach in the appraisal of research studies? a. Accept only studies that use a RCT design. b. When ranking research studies, choose RCTs over qualitative studies. c. Select only studies with a large sample size. d. Evaluate the quality of the research against the standards for that type of research.

ANS: D While randomized controlled trials (RCTs) are generally considered the gold standard for research, it is important to assess not only the method but the quality of the study and its applicability to the question that is being asked.

The quality of all studies should be appraised against the standards accepted for that that type of research.

19. Within a multisite healthcare system, the most appropriate strategy for translation of research would be: a. Widespread development of protocols using EBP at unit levels. b. Dissemination of EBP and recommendations to individuals, units, and the organization. c. Development of the skills of individual managers on how to build guidelines based on EBP. d. Establishment of an interdisciplinary center to guide and lead the translation of research findings into practice.

ANS: D At a systems level, the most appropriate approach would be establishing a center that leads in, guides, and promotes EDP across and at various levels.

20. At an organizational level, which of the following strategies would assist in ensuring that EBP is incorporated into nursing care? a. Formation of nursing-only implementation teams b. Restriction of evidence to RCTs c. Formation of a network of individuals doing research and/or interested in research utilization d. Avoidance of partnership with experienced researchers ANS: C Collaboration, partnerships, and consideration of a variety of evidence appropriate to the clinical questions are important in ensuring translation of evidence into practice. Collaboration is considered particularly critical and can occur through practice-based networks.

21. Which of the following is most accurate regarding evidence-based practice? a. Evidence-based practice replaces continuous quality improvement. b. Evidence-based practice began with medicine and assists in determining which medical models can be applied in nursing practice. c. Effective and efficient care can already be demonstrated, which means that EBP will soon become redundant. d. EBP is generally recognized across disciplines and by policymakers as state-of-the-art clinical practice.

ANS: D EBP is recognized across nursing and other disciplines as reflective of stateof-the-art clinical practice, as it is based on best available evidence.

22. Which of the following is a meta-analysis? a. Review of 35 studies on nurse work satisfaction to determine the significance of the aggregated research findings b. Review of multiple chart audits to determine which errors are being reduced through implementation of evidence-based guidelines c. RCT comparing the effectiveness of a local anesthetic in reducing the pain of venipuncture in young children d. Analysis of factors contributing to nurse burnout and dissatisfaction at emergency room sites ANS: A Meta-analysis statistically combines the results of several similar studies to determine whether aggregate findings are significant.

23. Once evidence related to the use of prompted voiding in patients with cognitive impairment has been appraised and integrated with practice, it is important to: a. Consider whether patients’ families see this as necessary for the well-being of family members. b. Search large databases such as CINAHL to amass further evidence. c. Clarify the clinical practice question. d. Solicit input regarding integration with practice.

ANS: A EBP is the integration of best research evidence with clinical expertise and the patients’ unique values and circumstances. In this situation, the family’s values and preferences would be considered. Search of databases,

clarification of the question, and gaining staff input would occur in the process.

24. As the unit manager, you are interested in determining whether patient autonomy is preserved through informed consent in surgical settings. You determine that participatory action research is the best method to address this question. Which of the following is consistent with a participatory action research design? a. You interview 125 patients who have recently undergone surgery and transcribe the interviews to determine themes. Themes are validated with an expert in informed consent. b. You circulate a questionnaire to patients who recently underwent surgery and ask for their opinions regarding consent. Data are analyzed and the findings distributed to administration and other groups. c. An audit is undertaken of signed consents for treatment, to determine if the consent is properly witnessed and signed. Findings are used to inform changes in policies. d. You meet with a patient group to determine which questions should be asked about patient informed consent and what issues might be encountered and addressed during the research.

ANS: D In participatory action research (PAR), the members of the community being studied are integral members of the research team and are involved in identifying the questions and addressing the issues involved in the implementation of the research project (Chevalier & Buckles, 2013).

25. Volunteers in a study are assigned randomly to groups. Some of the volunteers receive an herbal supplement that is reputed to control nausea, and some of the volunteers are assigned to a control group where a placebo is administered. This is an example of a(n): a. Longitudinal study. b. RCT. c. Meta-analysis. d. Appraisal tool.

ANS: B RCTs, or randomized controlled trials, always involve testing of a treatment through the random assignment of subjects in the study to an experimental or treatment group or to a control group that receives a placebo.

MULTIPLE RESPONSE 1. A nurse manager introduces prompted voiding into nursing practice on a unit, which is supported by clinical guidelines based on evidence-based practice. The nurses on the unit resist implementation, indicating that the bathroom facilities are too far away for efficient implementation of the guidelines, and that resources are too few to accomplish the initial voiding observations. For the nurse manager in this situation, it is important to have further discussion with the staff regarding : a. Compatibility of this intervention with the values of staff on the unit. b. Advantages of prompted voiding over incontinence products and catheterizations. c. Usefulness of prompted voiding with the particular population of patients on the unit. d. Feasibility of the program with respect to unit design.

ANS: A, B, C, D Various theories related to the translation of evidence into practice point to strategies for success in introducing innovation and EBP on units, including determination of how well the innovation fits with the values of the staff; benefits of this practice or innovation over current practice; appropriateness of the innovation or practice for the target group for which the practice is intended; and the feasibility of the innovation from a variety of perspectives, including the physical design or layout of a unit.

Chapter 22: Consumer Relationships Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. The chief nursing officer decides to establish a client advocacy position in an oncology unit. Advocacy is best represented by: a. Establishing private and professional networking systems. b. Asking social services to handle clients’ concerns. c. Identifying community support groups. d. Empowering others by promoting self-determination.

ANS: D Advocacy involves empowering and promoting self-determination in others.

2. As part of performance appraisal, the nurse manager designs strategies to acknowledge staff members. What practices by the nurse manager best acknowledge staff accountability and contribution?

a. Providing new and varied learning experiences for staff members b. Fostering group cohesiveness through standardization of unit activities c. Allowing professionals greater influence over their practices d. Giving recognition for success and support for failure to staff members ANS: C Facilitating greater control over practices implies trust and acknowledges expertise and performance.

3. The nurse manager understands that the three Ps associated with client education are philosophy, priority, and performance. Effective client education programs start with a shared philosophy that such programs are worth the investment. Evidence of a philosophic commitment to client teaching is best represented by: a. Investing time and energy in teaching clients. b. Developing teaching skills among the nursing staff. c. Assuming that clients lack the knowledge they need. d. Having a teaching checklist on clients’ charts.

ANS: A A philosophy that patient education is an investment with a significant positive return is one of the three Ps of a successful consumer education focus. Money invested in teaching is money well spent.

4. The nurse manager on a pediatric intensive care unit wants to evaluate patient satisfaction. The nurse manager understands that ultimately, positive relationships with consumers of care are evaluated by the: a. Cultural sensitivity of staff. b. Cost-effectiveness of care delivery. c. Economic value of service. d. Outcomes for clients and their perceptions of care.

ANS: D Trend-setting organizations such as MagnetTM organizations need to demonstrate excellence in outcome data such as patient satisfaction. Patient satisfaction and perception of the quality of care are affected by the quality of the nurse-patient relationship. Valid measurement of patient satisfaction is an evolving science; nurses do not always accurately gauge what factors are most important to patients. Satisfaction measures are often skewed in a positive direction with scores clustered at the top of the scale.

5. The nurse manager has to develop a patient satisfaction survey. What is

one of the critical elements in selecting a patient satisfaction instrument? a. Being able to use the same instrument for all clinical units b. Including items that are important from the patient’s perspective c. Being able to administer the instrument before a patient’s discharge from the hospital d. Being sure that the reading level is no higher than third grade ANS: B Because satisfaction is a measure of service and service is a measure of perception of what matters to the patient, to measure satisfaction, surveys must include items that reflect the perspective of the patient. The quality of human contacts becomes the measure by which the consumer forms perceptions and judgments about nursing and the health agency. Consumers may not be able to evaluate the quality of interventions, but they always can evaluate the quality of the relationship with the person delivering the service.

6. In writing the patient satisfaction survey, the nurse manager is aware of the education levels of the families. What is the most critical element in the concept of health literacy? a. Providing instructional materials at appropriate reading levels b. Facilitating access to translators for persons with language barriers c. Obtaining, processing, and understanding basic health information so appropriate decisions can be made d. Knowing that most people have limited health literacy skills ANS: C The definition of health literacy used by the federal government is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (U.S. Department of Health and Human Services, 2010).

7. The nurse manager analyzes the data from the patient satisfaction surveys.

What can a nurse manager do to strengthen service recovery and improve consumer relationships? a. Post comparisons of patient satisfaction scores with those of other units on a monthly basis. b. Involve the staff in resolving consumer issues quickly and effectively. c. Ensure that staff members apologize to patients when they complain about services. d. Ask that patients with complaints about services place them in a written format.

ANS: B Consumers need to be treated with fairness, given explanation, and provided with information about how errors will be prevented in the future. Staff can be assisted to respond to patient concerns through scripting, support, and an atmosphere that places an emphasis on learning and solutions rather than on blaming.

8. Based on data from the patient satisfaction survey, the nurse manager decides that a change should be made in communication with family members. What would be important for a nurse manager to consider when instituting a change to improve customer service? a. Assess the perceptions of the nursing staff regarding the particular service problem. b. Include community representatives on a planning committee to address the change. c. Involve physicians, other healthcare professionals, and ancillary staff. d. Review all patient complaints with the nursing staff.

ANS: A Nurses are the healthcare providers who spend the most time with the consumer and are in an opportune position to understand the issues, structures, and processes that affect patients. The nurse acts as the primary person to be alert to circumstances that may prevent a successful outcome for the patient and to intervene on the patient’s behalf. As a nurse manager, it is important to support staff in their use of power to be in control and to make decisions at the consumer-staff level of interaction.

9. The chief nursing officer is pleased with the nurse manager’s strategy of improving patient satisfaction in the pediatric intensive care unit. She decides to implement these changes throughout the hospital. What would be important to consider in implementing a new program focused on improving relationships with consumers? a. Recognition of the nursing staff for excellence in promoting consumer relationships b. Holding the staff accountable for resolving patient complaints c. Selecting a staff nurse leader to implement the program d. Identifying key staff members who have already demonstrated excellence in consumer relationships ANS: A The nurse leader should allow professionals more influence over their

practice;give staff opportunities to learn new and varied skills; give recognition and reward for success and support and consolation for lack of success; and foster motivation and belief in the importance of each individual and the value of his or her contribution.

10. In orienting new staff nurses to a pediatric intensive care unit, the nurse manager asks the staff nurses to answer the following question: “What is an important consideration in providing information to parents of a critically ill child?” a. Making sure that they receive complete information during each encounter with a member of the nursing staff b. Assessing parents’ preferences for the amount of information desired c. Allowing parents to observe key aspects of their child’s nursing care d. Making sure that patient education brochures explaining ICU protocols are readily available ANS: B Consultation with the parents regarding the amount of information that they desire reflects a service orientation, in which preferences and needs of the consumer are placed first. The other answers reflect nurse-directed decisions in which the nurse decides what information and how much information is needed and how it is to be delivered.

11. In designing a program for young adults regarding safe sexual practices, which of the following might reach the greatest number in your target group? a. Web-based applications b. Print-based media such as newspapers c. Television advertisements d. Brochures in kiosks in malls ANS: A Mobile technology is changing the digital divide, with young adults, minorities, those with no college experience, and those with lower household incomes being more likely to indicate that phones are their main source of Internet access (Zickuhr & Smith).

12. A nurse is admitted to a psychiatric unit. The staff expresses frustration with her because they have explained several times her medication regimen, and yet, when she goes on passes, she fails to follow it. The staff believe that, as a nurse, she should be able to understand what is expected. The nurse’s failure to follow the regimen indicates:

a. Early cognitive impairment. b. Lack of motivation. c. Lack of health literacy. d. Worsening health state.

ANS: C What is evident from the response is that she lacks health literacy or the capacity to obtain, process, and understand basic health information and services. Using a Health Literate Care Model involves weaving health literacy strategies into care by assuming that patients do not understand their health conditions or what to do about them, and then, subsequently assessing patients’ understanding (Koh, Brach, Harris, & Parchman, 2013). For example, a nurse who is an expert clinician in a specialty practice area, when diagnosed with a serious chronic illness, may not have the appropriate background to make informed healthcare decisions.

13. John is an older adult patient who comes regularly to the multigroup practice in which you are a nurse practitioner. He says that he doesn’t understand what he is supposed to be doing about his medications, because every time he comes to the clinic, he sees someone else who has different ideas. John’s experience represents what aspect of the current consumer experience? a. Nurses are well-trusted members of the healthcare team. b. Fragmentation of care results in lack of respect and trust. c. Care providers often have conflicting ideas about care. d. The public does not trust care providers other than nurses.

ANS: B When consumers visit a multigroup practice, they do not have the option of selecting a specific healthcare provider, and thus, there is less opportunity to build a trusting relationship with a provider.

14. The complexity of the healthcare environment for consumers is increased by: a. Falling levels of education among the public. b. Increased levels of poverty. c. Complex compensatory systems and a variety of delivery systems. d. Increased numbers of uninsured or underinsured.

ANS: C The complexity of options in health care and the processes and policies involved in funding health services for patients, as well as fragmented

relationships with a growing variety of healthcare providers, contribute to the complexity of the system for patients, especially for those who might need it most, such as the poor, uninsured or underinsured, and homeless.

15. Corrine, a student nurse, often hears that nurses are gatekeepers and wonders what that term means. As a nurse leader, you explain that this is a reference to the: a. Assessment and admission of patients into care. b. Orientation of patients to services once they are admitted. c. Function of controlling which patients see the physician and which do not. d. Coordination of care, services, advocacy, and access for patients within the healthcare system.

ANS: D As gatekeepers to the system, nurses advocate for and coordinate care, services, and access for patients across all providers, settings, and levels of care.

16. A 27-year old woman is admitted to your ICU in a coma, following an accident. The family of the patient, who is a Native American, places a medicine pouch in the bed with the young woman. As the nurse in this situation, it is important to: a. Explain to the family that the medicine pouch may contain herbs that may bother other patients. b. Ask the family about the significance of the medicine pouch for them. c. Remove the pouch when the family is not present. d. Put the medicine pouch on the shelf beside the bed.

ANS: B Diversity encompasses more than differences in nationality or ethnicity and may include a variety of ways that patients are different from their healthcare providers. Nurses need to recognize the culture of their work setting, realizing that it may differ markedly from the culture of the consumer, and move beyond ethnocentrism to provide culturally competent care. This competence includes cultural knowledge, which involves actively learning about a community; cultural sensitivity, which entails valuing and respecting beliefs, norms, and practices of the people being served; and collaboration within a community (Flaskerud, 2007). In this instance, it is important to understand the meaning of the pouch for the family; removal from the bed without discussion does not demonstrate respect for the values and beliefs of this family.

17. You are involved in designing a clinic for women in an inner-city neighborhood. A goal of this clinic might be: a. Development of services that are identified in various studies as important for this target group. b. Partnership with area city councilors and health professionals to provide services that are consistent with their vision and funding sources. c. Provision of immunization and addictions services and health screening services for women in the area. d. Development of services that have been identified by the women and neighborhood advocates as necessary for their health care.

ANS: D Involvement of persons in their own health care is a cornerstone of healthcare reform and is important for improving health outcomes and patient experiences. While studies and partnership with key informants are important sources of information in the design of services, engagement of the women through their neighborhood advocates may increase activation and resulting behavior. Patient activation refers to patients’ willingness and ability to take independent actions to manage their health and care.

18. Which of the following exemplifies a service orientation? a. Staff members on the unit are encouraged to chart details about family support networks. b. Chart audit reveals that details related to assessment of family history are missing. c. The palliative care unit organizes a “tree of light” fundraiser each year to highlight the importance of palliative care. d. A children’s preoperative holding area is initiated in response to requests from families and nurses who care for them..

ANS: D A service orntation needs to translate caring into appropriate, timely action that meets the needs of patients. Activities such as documentation of details or promotion of services may remain at the technical or conceptual level without a commitment to caring interactions. The institution of a holding area where families can be with children represents a caring action that arises out of interactions and knowledge of patient needs and thus, is service oriented.

19. As a head nurse, you are concerned about the service orientation on your unit. Which of the following findings and approaches might provide useful information for you?

a. Patients find nurses friendly and accessible; data are aggregated for the institution as a whole. b. Data indicate that nurses are responsive to requests for assistance; data are available for the unit and the institution. c. Specific questions related to management of comfort are included for the institution as a whole. d. The survey asks for a range of responses for the unit and the organization, with a focus on facilities, such as cleanliness and responsiveness of administrative services.

ANS: B The National Database of Nursing Quality Indicators (NDNQI®) is a national repository for unit-based quality data that can be used by organizations to benchmark the outcomes of care against those of other institutions (ANA, n.d.). Unit-based quality indicators, including satisfaction with nursing care, are a key feature of the NDNQI®. In addition to hospitals being provided with their own and comparison data, researchers are able to access deidentified data in order to answer important questions about nursing care quality. Pain management, the discharge process, and post-discharge patient callbacks are specific areas where nurses can make significant improvement in patient satisfaction. Because patients and nurses may differ in what they see as factors that produce satisfaction, total reliance on nursing perceptions of patient satisfaction may not provide a complete picture.

20. As a nurse manager, you see an opportunity for patients to be well serviced through the medical home concept. You recognize that the concept of medical homes: a. Currently does not include nurses in its vision of multifaceted primary care. b. Includes nurses as part of an interdisciplinary and multidisciplinary team. c. Restricts nurses to services related to direct care and procedures. d. Cannot encompass nurses within this framework.

ANS: A The concept of medical homes encompasses the idea of multifaceted medical homes that provide a usual source of health care. Current discussions have focused on physician-directed care even though nurses in advanced practice are well suited to lead teams in this model.

21. Technology is integral to a cardiac ICU. Sue, the nurse manager, implements a patient-centered approach that focuses on the meaning of the

experience for the patient and family, primary nursing, and a health literacy approach. Sue is: a. Using high-tech–low-touch approaches. b. Using high-tech–high-touch approaches. c. Providing products. d. Providing tangible products of satisfaction.

ANS: B The provision of humanistic care within a high-tech environment is characteristic of high tech–high touch approaches and reflects the idea that the more that high-tech is used, the more patients also desire high-touch.

22. Which of the following actions best exemplifies advocacy? a. Developing a list of agencies that will provide free services for the homeless b. Working in a needle exchange program for individuals in an inner-city environment c. Acting on behalf of a patient to promote end-of-life wishes to an ethics committee d. Working in a free clinic for immigrant workers ANS: C Advocacy means making known and defending and protecting the rights and interests of others, as well as ensuring the dignity and respect due to others.

Simply being employed in an environment where this might be a focus of practice does not necessarily ensure that advocacy is actually occurring.

23. During review of a patient’s progress, the healthcare team determines that a patient requires treatment that is generally accepted at that time in the usual illness trajectory of a patient. The patient is unable to pay. As the head nurse, you persist in ensuring that this patient receives the treatment. You are: a. Empowering the patient. b. Avoiding litigation. c. Advocating for the patient. d. Supporting the clinical pathway.

ANS: C Advocacy means defending the rights and interests of others and, in this situation, the right of a patient to receive care, as determined by standards utilized in a critical pathway.

24. A nurse makes a medication error that is not serious and does not cause

harm to the patient. As the head nurse, your best action would be to: a. Call attention to it by posting the critical incidents report at the nursing station. b. Include the mistake on the nurse’s performance appraisal. c. Apologize to the patient for the error, and indicate that discipline has occurred. d. Educate the nurse on how to provide an apology to the patient.

ANS: D Service recovery ensures responsiveness to the patient, and as part of service recovery, it is important to address an error in the most productive way, which also includes the nurse who made the error offering an apology to the patient.

25. An example of a factor that would impede a patient’s learning is: a. Poverty. b. Limited health insurance. c. Being an older adult. d. Heavy sedation.

ANS: D Nurses need to be sensitive to the teaching needs of those at risk for disparities in health care: persons of a different race or ethnic group, women, children, older adults, rural residents, and those with limited or no health insurance, low health literacy, and/or low socioeconomic status. It is important that lower expectations for persons who are disadvantaged, have a low literacy level, or have limited English proficiency are not unintentionally communicated.

MULTIPLE RESPONSE 1. Which of the following activities would represent a customer-friendly approach in a healthcare setting? a. Using a local anesthetic before inserting a needle into a child’s arm b. Repeating patient history information to the admitting clerk, the admitting nurse, and the ultrasound technician c. Ensuring that birthing preferences are on file and available when a laboring mother comes in d. Providing support to families when a family member is brought into trauma ANS: A, C, D

A service orientation means delivering services in a manner that is least disruptive. When possible, services should come to the patient and should be as easy, comfortable, pleasant, and effective as possible. Meeting the emotional, psychosocial, and spiritual needs of the patient is important.

Chapter 23: Conflict: The Cutting Edge of Change Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. A group of staff nurses is dissatisfied with the new ideas presented by the newly hired nurse manager. The staff wants to keep their old procedures, and they resist the changes. Conflict arises from: a. Group decision-making options. b. Perceptions of incompatibility. c. Increases in group cohesiveness. d. Debates, negotiations, and compromises.

ANS: B Conflict involves disagreement in values or beliefs within oneself or between people that causes harm or has the potential to cause harm. Folger, Poole, and Stutman (2012) add that conflict results from the interaction of interdependent people who perceive incompatibility and the potential for interference.

2. Two staff nurses are arguing about whose turn it is to work on the upcoming holiday. In trying to resolve this conflict, the nurse manager understands that interpersonal conflict arises when: a. Risk taking seems to be unavoidable. b. People see events differently. c. Personal and professional priorities do not match. d. The ways in which people should act do not match the ways in which they do act.

ANS: B By definition, conflict involves a difference in perception between two or more individuals.

3. The nurse manager is aware that conflict is occurring on her unit; however, she is focused on preparing for a state health department visit, so she ignores

the problem. A factor that can increase stress and escalate conflict is: a. The use of avoidance. b. An enhanced nursing workforce. c. Accepting that some conflict is normal. d. Managing the effects of fatigue and error.

ANS: A Avoidance as a conflict-management style prolongs conflict and has a tendency to escalate conflict.

4. The nurse manager decides to use a mediator to help resolve the staff’s conflict. A basic strategy for truly addressing this conflict is to: a. Identify the conflicting facts. b. Be determined to resolve the conflict. c. Schedule a meeting time for resolution. d. Have a clear understanding of the differences between the parties in conflict.

ANS: D It is important for each person in the conflict to clarify the conflict as “I see it” and how “it makes me respond” before all the persons involved in the conflict can define the conflict, develop a shared conceptualization, and resolve their differences.

5. Sarah, a staff nurse on your unit, witnesses another nurse striking a patient.

Sarah wants to remain friends with her colleague and worries that confrontation with her colleague or reporting her colleague will destroy their relationship. Sarah is experiencing which type of conflict? a. Intrapersonal b. Interpersonal c. Organizational d. Professional ANS: A Intrapersonal conflict occurs within a person when confronted with the need to think or act in a way that seems at odds with that person’s sense of self.

Questions often arise that create a conflict over priorities, ethical standards, and values. Some issues present a conflict over comfortably maintaining the status quo and taking risks to confront people when needed, which can lead to interpersonal conflict.

6. The chief nursing officer plans a series of staff development workshops for

the nurse managers to help them deal with conflicts. The first workshop introduces the four stages of conflict, which are: a. Frustration, competition, negotiation, and action. b. Frustration, conceptualization, action, and outcomes. c. Frustration, cooperation, collaboration, and action outcomes. d. Frustration, conceptualization, negotiation, and action outcomes.

ANS: B Thomas (1992) determined that conflict proceeds through these four stages in this particular order.

7. After using a mediator to resolve a conflict between the nurse manager and two staff nurses, the chief nursing officer decides to: a. Observe to make sure the conflict has been resolved. b. Fire both staff nurses. c. Reassign both staff nurses. d. Reassign the nurse manager.

ANS: A The nurse leader should follow up to determine if the conflict has been resolved because, in professional practice environments, unresolved conflict among nurses is a significant issue that results in job dissatisfaction, absenteeism, and turnover, as well as in decreased patient satisfaction and poorer quality in patient care.

8. A nursing instructor is teaching a class on conflict and conflict resolution.

She relates to the class that conflict in an organization is important, and that an optimal level of conflict will generate: a. Creativity, a problem-solving atmosphere, a weak team spirit, and motivation of its workers. b. Creativity, a staid atmosphere, a weak team spirit, and motivation of its workers. c. Creativity, a problem-solving atmosphere, a strong team spirit, and motivation for its workers. d. A bureaucratic atmosphere, a strong team spirit, and motivation for its workers.

ANS: C Differences in ideas, perceptions, and approaches, when managed well, can lead to creative solutions and deepened human relationships. Work on conflict suggests that complete resolution of conflict is counterproductive to

the achievement of organizational goals, organizational change, and cohesiveness of employees.

9. Jane has transferred from the ICU to the CCU. She is very set in the way she makes assignments and encourages her new peers to adopt this method without sharing the rationale for why it is better. This is a good example of a process and procedure that creates which type of conflict? a. Organizational b. Intrapersonal c. Interpersonal d. Disruptive ANS: C Interpersonal conflict transpires between and among nurses, physicians, members of other departments, and patients.

10. Two nurses on a psychiatric unit come from different backgrounds and have graduated from different universities. They are given a set of new orders from the unit manager. Each nurse displays different emotions in response to the orders. Nurse A indicates that the new orders include too many changes; Nurse B disagrees and verbally indicates why. This step in the process is which of the following in Thomas’ Stages of Conflict? a. Frustration b. Conceptualization c. Action d. Outcomes ANS: B Thomas’ Stages of Conflict include conceptualization, which involves different ideas and emphasis on what is important or not or about what should occur.

11. Mrs. Hill, aged 68, was hospitalized after a stroke. The speech therapist recommended that oral feeding be stopped because of her dysplasia. During visiting hours, Mr. Hill fed his wife some noodles. The nurse noticed this and stopped Mr. Hill from feeding his wife, telling him it was the doctor’s decision. An hour later, the nurse returned and found Mr. Hill feeding his wife again. The nurse tried to stop him again. Mr. Hill refused and claimed that the clinical staff was trying to starve his wife; he also threatened to get violent with the nurse. The nurse decided to walk away and documented the event in Mrs. Hill’s chart. According to Thomas’ Four Stages of Conflict, in

which stage could the nurse have been more effective? a. Frustration b. Conceptualizing c. Action d. Outcomes ANS: C By walking away, the nurse is engaged in an action or a behavioral response, which is the action stage of conflict that is outlined in the four stages of conflict (Thomas, 1992). In this stage, the nurse might have used more effective strategies, such as clarifying Mr. Hill’s views on feeding his wife and engaging in dialogue with Mr. Hill to clarify his concerns and attempt to reach a common goal.

12. Mrs. Hill, aged 68, was hospitalized after a stroke. The speech therapist recommended that oral feeding be stopped because of her dysplasia. During visiting hours, Mr. Hill fed his wife some noodles. The nurse noticed this and stopped Mr. Hill from feeding his wife, telling him it was the doctor’s decision. An hour later, the nurse returned and found Mr. Hill feeding his wife again. The nurse tried to stop him again. Mr. Hill refused and claimed that the clinical staff was trying to starve his wife; he also threatened to get violent with the nurse. The nurse decided to walk away and documented the event in Mrs. Hill’s chart. The outcome as depicted by Thomas’ conflict stages can be considered to be: a. Compromising. b. Confronting. c. Constructive. d. Destructive.

ANS: D Resolution was absent because the nurse did not have time to effectively deal with the issues in the conflict. This can lead to negativity, increased frustration, and further distancing between individuals or groups, including between patients and nurses.

13. Jill is the head nurse on a unit in a large hospital. Two of the staff nurses are constantly arguing and blaming each other, and a resolution has not occurred in months. To solve the existing conflict, which is the most creative conflict resolution? a. Avoiding b. Competing

c. Compromising d. Collaborating ANS: D Collaboration, although time-consuming, is the most creative stance. The collaboration technique involves both sides in the conflict working together to develop an optimal outcome. This results in a win-win solution.

14. A nurse educator is giving a workshop on conflict. During the sessions, he makes various statements regarding conflict. All of the statements are true except: a. Conflict can decrease creativity, thus acting as a deterrent for the development of new ideas. b. Horizontal violence involves those with similar status but little power in the larger context. c. Interprofessional collaboration reduces unresolved conflicts. d. All conflicts involve some level of disagreement.

ANS: A The opposite is true because research has shown that conflict, like change, increases creativity and allows for the development of new ideas.

15. Sarah is a nurse manager in a surgical unit. She is concerned about a conflict between Lucy (a staff nurse) and one of the maintenance personnel.

Sarah explains to Lucy that unsatisfactory resolution of the conflict is typically destructive and will result in: a. Decreased frustration between the maintenance worker and her. b. A good relationship with the maintenance department. c. Eventual resolution of the problem without further intervention. d. Decreased productivity on her part.

ANS: D Research by Saltman et al. (2006) determined that productivity decreases with destructive conflict, whereas constructive conflict strengthens relationships.

16. Staff at Valley Hospital are concerned that recent staffing cuts will affect their ability to provide quality patient care, and they express their concerns to senior management. The CEO of Valley Hospital makes the following statement: “We need to contain costs because our funding has been decreased.” This is a good example of which of the following conditions that propel a situation toward conflict?

a. Incompatible goals b. Role conflicts c. Structural conflict d. Competition for resources ANS: A Conflicts arise in four areas: goals, facts, approaches, and values. Conflicts among goals arise from competing priorities such as the provision of quality patient care and containment of costs.

17. Kala, a unit manager, in discussing a role the CEO would like her to perform, makes the following statement, “I will sit on the hospital taskforce on improving morale if you send me to the hospital’s leadership training classes next week, so I can further develop my skills and thus be more effective.” Which of the following conflict management styles is Kala using? a. Collaborating b. Avoiding c. Negotiating d. Accommodating ANS: C Negotiation involves an exchange of concessions (membership on a committee in return for attendance at a workshop) or trading. This strategy supports a balance of power.

18. John is a circulating nurse in the operating room. He is usually assigned to general surgery, but on this day he is assigned to the orthopedic room. He is unfamiliar with the routines and studies the doctor’s preference cards before each patient. The fourth patient comes into the room and John prepares a site for a biopsy using a Betadine solution. The surgeon prefers another solution. He notices what John has done and immediately corrects him by rudely insulting John. Which of the following is the most appropriate approach to conflict resolution in this example? a. Collaboration b. Compromising c. Avoiding d. Withdraw ANS: B Compromise involves negotiation or an exchange of concessions and supports a balance of power.

19. Factors that influence the ease with which conflict is resolved include all except which of the following? a. Level of interdependence of the parties b. Interprofessional collaboration. c. Expression of one’s own needs and ideas. d. Avoidance of the issue or concern.

ANS: D Conflict involves a level of interdependence and is a condition for conflict but not necessarily for continuance of the conflict. Expression of one’s ideas and concerns is considered assertive and effective in resolving conflict if the concerns and needs of the other are also considered. Interprofessional collaboration has been shown to be effective in resolving conflict. Avoidance tends to prolong and sometimes escalate conflict.

20. The head nurse and a staff nurse are having a conflict over how to use and apply a new procedure for dressings in the medical/surgical unit. The staff nurse wishes to use the new procedure based on newly released nursing research. The head nurse wishes to use a protocol that has been used in the department for a number of years. The head nurse later makes comments to other staff on her unit about the credibility of the staff nurse. This behavior is associated with: a. Lateral violence. b. Horizontal violence. c. Confrontation. d. Bullying.

ANS: D Bullying involves aggressive or destructive behavior or psychological harassment of a recipient who is in a position of power differential with the perpetrator (the head nurse). Bullying is closely related to lateral or horizontal violence and involves such behaviors as incivility or intimidation.

21. Which of the following exemplifies the predominant conflict management style of nurse managers? a. Elizabeth, the head nurse on neurology, finds that Tom, the RN nurse on nights, is irritable in relation to any suggestions or new ideas, and so she comes in to work after Tom leaves the unit. b. The technology committee has recommended a clinical system for implementation on the nursing unit. Staff is anxious about the change. Tim, the head nurse, asks staff for ideas on how to meet the technology goals and

to meet staff needs. c. During management meetings, George, the head nurse on nephrology, dominates meetings and decisions. Lee, the head nurse on the cardiac stepdown unit, begins to miss the management meetings. d. Ann, RN, asks her head nurse if she can go on the permanent evening shift.

The head nurse, Rajib, agrees, as long as Ann agrees to be involved in assisting to mentor evening staff in the use of the new clinical information system.

ANS: D Compromise involves trading and negotiation and is the predominant conflict management style of managers.

22. Lee, the head nurse in ER, has attempted to meet Jillian, one of her staff RNs, for several days to discuss concerns about Jillian’s relationships with her team members. Lee hopes to offer Jillian coaching so that Jillian’s relationships can be more satisfying for Jillian and her team members. Each time Lee and Jillian set a time to meet, Jillian phones in sick. In this situation, Lee and Jillian are demonstrating: a. Similar conflict management strategies. b. Escalation of conflict. c. Avoidance and compromise strategies. d. Competing and compromise strategies.

ANS: C Jillian is demonstrating avoidance by staying away from meetings to discuss her team relationships, and Lee is demonstrating compromise by offering coaching in return for Jillian’s being able to engage in more satisfying relationships.

23. Which of the following best exemplifies the predominant style of conflict management for staff nurses? a. Sarah and Jonas, two RNs, disagree about the best approach to assisting a family that has complex needs. They decide that they will consult with family and together will decide what is best. b. Jennifer needs to switch a shift to attend a family function. She arranges to trade with Nancy, who wants a day off next to a 3-day break. c. Lindsay asks Melody to stay late for the third day in a row. Melody refuses, stating that she has already helped out for two days by staying late for Lindsay. d. Lara asks Stacey to switch shifts with her because Lara wants to attend a

concert. Stacey would prefer not to but does to enable Lara, who is new in town, to be with her friends.

ANS: D Avoidance and accommodation are the predominant conflict management styles of nurses. Accommodating involves neglecting one’s own needs while trying to satisfy the needs of another.

24. In trying to achieve Magnet™ status, the chief nursing officer establishes a shared governance model to help nurses experience job satisfaction.

However, some nurses who have enjoyed working with less autonomy resist this change and begin to criticize and make rude comments about managers who embrace this model, as well as colleagues who support it. The comments are largely ignored because those who are making them are well established nurses who are often vocal about their displeasure with the organization.

Organizational conflict is arising from which of the following? a. Staffing practices b. Increased participation in decision making c. Allocation of resources d. Tolerance of incivility ANS: D Organizational conflict arises from discord related to policies and procedures (such as staffing policies and practices and allocation of resources), personnel codes or conduct or accepted norms of behavior (such as incivility), and patterns of communication. A major source conflict in organizations stems from strategies that promote more participation and autonomy of staff nurses.

MULTIPLE RESPONSE 1. Nurses entering into the workforce today are faced with which of the following relationships that could create organizational conflict? a. Nurse-physician relationship b. Nurse-nurse relationship c. Nurse-patient relationship d. Nurse-chief nursing officer relationship e. Nurse-auxiliary personnel relationships ANS: A, B, C, D, E By nature, conflict is potentially present in all interpersonal situations. The nurse manager should create an environment that recognizes and values differences in staff, physicians, patients, and communities.

Chapter 24: Managing Personal/Personnel Problems Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. The most important approach that a nurse manager can take with an emotionally troubled employee is to: a. Act as a therapist for the employee. b. Adjust the standard of care to assist the employee. c. Assist the employee in obtaining professional help. d. Adjust the employee’s work schedule to decrease stress.

ANS: C Emotional difficulties are usually beyond the scope of skills that a nurse manager would normally employ. A referral needs to be made to a professional who is specifically prepared to deal with this kind of difficulty.

2. The nurse manager knows that the most serious effect that absenteeism has on the nursing unit is that: a. Using replacement personnel with new ideas may be beneficial. b. Salary costs are lower because personnel are fewer, and outcome is favorable. c. Absence on the part of the rest of the staff is decreased. d. Unacceptable patient care may result.

ANS: D Reduced staffing adversely affects patient care. Employee morale suffers, care standards may be lowered, and additional stress is placed on working staff.

3. In keeping with guidelines of the organization, the nurse manager documents staff problems. Documentation of disciplinary problems should: a. Include a plan to correct them and to prevent future occurrences. b. State a detailed history of past problems that are related to the current one. c. Be written at the convenience of the manager. d. Not be discussed until the formal performance evaluation.

ANS: A In documenting staff problems, it is important to identify the incident with an objective statement of facts and record actions taken to correct/prevent future problems.

4. Before terminating an employee, a nurse manager must: a. Be an expert in all legal aspects of termination and discipline practices.

b. Follow the organization’s specific policies for addressing disciplinary problems and termination. c. Function as a counselor for problem employees. d. Do everything to assist and protect the employee by adjusting standards and policies.

ANS: B It is important to know the policies of the organization to address disciplinary issues fairly and equitably, as well as to know the model that is employed to address employee problems. Human resource departments and legal departments are important sources for consultation, advice, and support.

5. A nurse manager understands that the typical first step in handling an employee with a disciplinary problem is a: a. Verbal reprimand. b. Written reprimand. c. Reminder of employment standards. d. Day off without pay.

ANS: C The progressive model of discipline advocates that the first step of the disciplinary process is the informal reprimand or verbal admonishment. The nonpunitive discipline model advocates reminding the employee of the employment policies and procedures of the agency.

6. The chief nursing officer understands that clinical incompetence is best prevented by a(n): a. Flexible protocol for evaluating competency skills. b. Standardized clinical skills checklist. c. Administration of personality tests and competency assessments at point of hire. d. Formalized competency program with established standards for practice.

ANS: D The competency program with established standards of practice outlines what the nurse must do to achieve desired competencies in her current position.

Competency assessment and goal-setting should help the nurse identify how to excel and which competencies the nurse wants to achieve in the future.

7. A nurse manager understands that the second step in handling an employee with a disciplinary problem is to document the incident. Which of the following is best for documentation of personnel problems?

a. Use of the performance appraisal on an annual basis b. Notes made immediately after an incident that include a description of the incident, actions taken, plans, and follow-up c. A tally sheet of medication errors and other specific problems that will be used at annual review d. Copies of reports, placed in his or her file, of all unusual occurrences involving the employee ANS: B In documenting staff problems, it is important to specifically indicate what rules were broken or violated, consequences if behavior is not altered, employee’s explanation of the incidents, and the plan of action to achieve and to reach new goals.

8. The nurse manager places a staff member on probation because of reports of chemical dependency. The nurse manager should be aware that which of the following statements is true regarding chemical dependency? a. The chemically dependent employee usually hides any changes in behavior. b. When confronted with the issue, the affected employee is usually relieved to have someone to talk to about the problem. c. The chemically impaired nurse affects the entire healthcare organization. d. Hospital policy, state laws, and nurse practice acts address procedures for the chemically dependent employee in the most general terms.

ANS: C A chemically impaired nurse jeopardizes patient care through impaired skills and judgment. She or he also compromises teamwork and continuity as peers attempt to cover deficiencies in work performance for their impaired team member.

9. The chief nursing officer reviews the policy about “progressive discipline process.” The progressive discipline process includes which of the following?

The manager: a. Is a counselor and friend to the employee. b. Should reprimand and suspend the employee as a last resort. c. Should rehire the employee after a reasonable length of time. d. Should terminate the employee if the problem persists.

ANS: D Termination can be defined as the discharge of an employee who is performing at an unsatisfactory level or who is not a good match for the

organization. Termination is always considered the last resort when dealing with poor performance.

10. A nurse manager must be familiar with the agency’s policies regarding termination. Termination procedures include which of the following? a. Following specific procedures from other organizations b. Having an attorney present at the termination meeting c. Having adequate written documentation to support the action d. Having a friend present during the termination meeting ANS: C All steps should be followed, including full appropriate detailed documentation and following the procedures of the organization.

11. Nathan has been on the cardiac unit for 6 months and has found it difficult to adjust to the expectations of his team. Which of the following behaviors would most likely signal that Nathan is intending to resign from his position on the unit? a. Increased absenteeism over the past month b. Increased attempts to discuss his concerns with his colleagues c. Testing of workplace guidelines d. Frequent defensiveness ANS: A Many employees increase their absenteeism just before submitting their resignation. If the healthcare worker is experiencing some form of role stress, it might be manifested through absenteeism. Role strain may be reflected by (1) withdrawal from interaction; (2) reduced involvement with colleagues and the organization; (3) decreased commitment to the mission and the team; and (4) job dissatisfaction. Testing of workplace guidelines and defensiveness are associated with immaturity.

12. All of the following are grounds for immediate dismissal except: a. Failing to pursue further medical help for a patient; patient dies. b. Selling narcotics obtained from the unit supply of narcotics. c. Restraining a patient in bed for 7 hours, unsupervised, as punishment for hitting a staff member. d. Grabbing the unit manager and threatening further physical harm after a poor performance appraisal.

ANS: A Situations that may warrant immediate dismissal include theft, violence in the

workplace, willful abuse of the patient, harassment, and chemical abuse.

13. The unit manager on 4E is concerned about the performance of Jean, a staff nurse. She is not involved directly with Jean, so she has not been able to determine whether the problem is one of motivation, ability, or both. If Jean lacks ability, which of the following strategies might the head nurse use? a. Dismiss or transfer Jean. b. Document all problem areas and then discuss them with Jean. c. Develop appropriate solutions and make recommendations to Human Resources. d. Smooth over the problems if they are minor in nature.

ANS: B For the employee to change and grow, specific corrective measures need to be taken. Consultation with the employee is necessary, and documentation is key to determining the issues.

14. Nurses generally experience difficulty in identifying behaviors and actions that could signal chemical dependency in a co-worker. Which of the following is not a behavioral change that occurs with chemical dependency? a. Personality and behavioral changes b. Job performance changes c. Changes in educational involvement and pursuit d. Absenteeism ANS: C A manager needs to be alerted when suspicions of chemical dependency are raised by behavioral changes in the employee. These include mood swings, changes in hygiene and appearance, heightened interest in the pain control of patients, frequent changes in shifts, increases in absenteeism, and increases in tardiness.

15. Nurse Stacey is a self-admitted drug addict and has been a heavy abuser of codeine. Stacey and the unit manager decide that changes have to occur.

Stacey enrolls in an addiction program, and the manager has her transferred to a drug-free area. What other strategies might be appropriate? a. The manager could refer Stacey to the Human Resources Department. b. The manager could assist in monitoring Stacey’s progress. c. The manager could counsel Stacey if Stacey has formed a trusting relationship with her. d. Stacey needs to be asked not to involve her family in the recovery program

because this is a work-related situation.

ANS: B Effective management demands that the organization take an active role in helping employees with special needs. Humanistic strategies that counsel and assist employees are cost-effective and necessary.

16. Incivility is a disruptive behavior or communication that creates a negative environment and interferes with quality patient care and safety. The manager can implement steps that help to alleviate uncivil behavior on a unit.

Which of the following would not be an appropriate first step? a. Suspending the staff member from work b. Providing written admonishment that is discussed and placed in the employee’s file c. Providing verbal admonishment d. Terminating the staff member ANS: D Dismissal does not enable the present organization to attempt remediation of the behavior and is not consistent with first steps in progressive discipline.

17. Incivility is a disruptive behavior or communication that creates a negative environment and interferes with quality patient care and safety. The manager can implement the following steps that help to alleviate uncivil behavior on a unit. A) Suspending the staff member from work, B) Providing written admonishment that is discussed and placed in the employee’s file, C) Providing verbal admonishment, D) Terminating the staff member a. A, B, C, D b. B, A, C, D c. C, B, A, D d. C, A, B, D ANS: C The steps in progressive discipline are followed from the least severe (counseling the employee) to the most severe (termination). Studies have shown that following this sequence provides a fair and effective plan for discipline and remediation.

18. When progressive discipline is used, the steps are followed progressively only for repeated infractions of the same rule. On some occasions, rules that are broken are so serious that the employee is: a. Transferred to another unit.

b. Suspended indefinitely. c. Asked to attend a union grievance meeting. d. Terminated after the first infraction.

ANS: D Behaviors that include violence, theft, and purposeful abuse of a client are sufficiently serious to warrant immediate dismissal with the first incident.

19. During unit staff meetings, you observe that Marg rolls her eyes and snorts whenever Julia makes a comment. Your first response as a unit manager is to: a. Discuss what you have observed with Marg. b. File immediate documentation in Marg’s personnel file. c. Ask Julie to monitor Marg’s behavior during meetings. d. Ignore the behavior, as Marg is one of your strongest nurses.

ANS: A Incivility must be addressed. The initial step in addressing it is discussion with Marg, and if the behavior continues, then written documentation should be filed in Marg’s personnel file. Monitoring and follow-up are your responsibility as the unit manager.

20. Ellen is a novice nurse on your unit. Even though she has come to you highly recommended, as her supervisor, you have noticed some knowledge and skill deficiencies. These deficiencies have been noticed by her peers as well, who cover for her because she is new and they like her. Which of the following is likely to be the greatest asset to Ellen in improving her performance? a. Ignore Ellen’s errors until she has more experience. b. Instruct staff to avoid working with Ellen until she learns to how do things herself. c. Ask Ellen to complete a self-assessment, using a standard skills checklist. d. Encourage staff to report every behavior of Ellen’s that is different from theirs.

ANS: D When other employees are engaged in enabling behavior by covering for the mistakes of one of their peers, the nurse leader may be surprised to discover that the employee does not know or cannot do what is expected of him or her.

The nurse leader must remind employees that part of professional responsibility is to maintain quality care and thus they are obligated to report instances of clinical incompetence, even when it means reporting a co-

worker. Ignoring violations of a safety rule or poor practice is unprofessional and cannot be tolerated. The employee may be asked to do a self-assessment of the listed skills or competencies and then have performance of the skills validated by a peer or co-worker. This is a very effective method for the leader to assess the skill level of employees and to determine whether additional education and training may be necessary.

21. Susan, a new graduate, is upset that so many staff have been absent lately from the unit. She declares to you that all absenteeism could be eliminated with proper management. Your response is based on understanding that: a. Not all absenteeism is voluntary. b. High personal control contributes to absenteeism. c. Direct discussions with employees who have high levels of absenteeism are not recommended. d. All absenteeism is related to personal issues and needs.

ANS: A Not all absenteeism is voluntary or preventable, which means that absenteeism can never be fully eliminated. Absenteeism can result from personal issues and needs, work dissatisfaction, and involuntary reasons such as jury duty.

22. The nursing director calls a meeting with one of the new unit managers.

She is very concerned about a report of substance abuse on the manager’s unit, and she reviews the procedures involved in dealing with chemically dependent staff. Which of the following statements would NOT be included in the discussion? “As a manager, you: a. Need to be aware of ADA issues.” b. Should check with Human Resources regarding chemically dependent employees and employment practices.” c. Check the nurse practice acts for the state in which the nurse resides.” d. Should realize that the nurse is a professional embarrassment and should be kept out of sight of other staff.”

ANS: D As a manager, you need to be familiar with state and professional regulatory and reporting requirements regarding chemical use and abuse, as well with Human Resource practices and guidelines.

23. The education consultant for the hospital is presenting a workshop titled “Documentation: A Manager’s Responsibility.” Which of the following

points would she not include in her PowerPoint presentation?

Documentation: a. Cannot be left to memory. A notation must be placed in the personnel file. b. Should avoid discussion of the problem. c. Should include what was done about the problem when it occurred. d. Needs to include date, time, and place.

ANS: B Documentation of personnel problems is one of the most important aspects of the nursing manager’s role. Through carefully detailed and timely documentation of the problem and plan, the manager decreases the burdensome problems that can ensue from improper or inadequate documentation.

MULTIPLE RESPONSE 1. The unit manager discusses absenteeism with the unit clerk. She indicates that it is a serious problem on the unit. Which of the following points would they have likely discussed? a. Employee morale is at a high level. b. Care will suffer and standards will be lowered. c. Existing staff have experienced little effect from the absenteeism. d. Replacement staff usually needs little supervision. e. Unit costs have increased because of staff replacements and overtime.

ANS: B, E Absenteeism puts a strain on staff, produces morale problems, can jeopardize patient safety, and increases unit costs.

2. Clinical incompetence is one of the more serious problems facing a nurse manager. Joyce, the nurse manager, is not aware of the problems of Sarah, a novice nurse. After she investigates, it is obvious that Sarah’s peers are covering for her. Which of the following might Joyce include in her meeting with the nurses? a. “It is a nurse’s professional responsibility to maintain quality control.” b. “All instances of clinical incompetence are to be reported.” c. “It is not considered being disloyal when one nurse reports another for poor care.” d. “Patient care is the number one concern. Meeting standards is mandatory and necessary.”

ANS: A, B, C, D

The nurse leader must remind employees that professional responsibility is to maintain quality care, and thus they are obligated to report instances of clinical incompetence, even when it means reporting a co-worker. Ignoring safety violations or poor practice is unprofessional and jeopardizes patient care.

Chapter 25: Workplace Violence and Incivility Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. Your healthcare organization places a high value on workplace safety and integrates this into all aspects of administrative and patient care processes. As a unit manager, you thoroughly endorse this direction, and during the selection and hiring of new staff, you consistently: a. Refuse to hire applicants who are pushy during interviews. b. Thoroughly follow up with all references before offering a position. c. Ask applicants during the interview if drug or alcohol abuse is a problem. d. Refuse to interview applicants with sporadic work histories.

ANS: B Determining if current employees pose a danger in the workplace is a critical factor that is often overlooked. In addition to personal and psychological factors, behaviors can be observed in employees that may be related to violence or aggression in the workplace (Paludi, Nydegger, & Paludi, 2006).

The most obvious indicator is a previous history of aggression and substance abuse. Screening potential employees through drug testing, background checks, and references can help reduce the risk of hiring someone who may pose a danger in the workplace.

2. You need to terminate Gregory, who has had a long-standing history of conflict with you and the staff, and who recently was charged with theft of patient belongings. You consult Human Resources, and together, you develop a plan, which includes: a. A private meeting with Gregory, a Human Resources representative, and you to deliver the news and deliver the termination notice and all other documents that are related. b. Planning an opportunity for Gregory to return and be recognized at a staff farewell. c. Calling Gregory at home to tell him that he is fired and that his paperwork will be sent to him at a future date.

d. Calling him into a meeting in your office on the ward, where assistance is available, should he become upset or agitated.

ANS: A Termination requires careful planning as to timing, privacy, safety, and how to preserve the employee’s dignity and avoid humiliation. Choosing a private location where colleagues are not present, and organizing all documentation that is required to be given to Gregory, achieves these goals and prevents his having to come to the organization at a future date.

3. In which of the following situations would you, as the head nurse, be concerned about potential safety issues? a. Jordan comes to your office to complain about inadequate staffing on the unit. He says that he is concerned because he attributes a recent incident to the staffing levels. b. Henry, a long-standing RN on the unit, has begun to miss work regularly.

He calls in but is vague about his reasons for the absences. c. Carla, RN, has just ended an abusive relationship with Jake, RN, and he will not leave her alone. You are meeting with Jake today because colleagues on nights have reported that Jake seems to have been intoxicated last night and the previous night. d. Sarah is very quiet and says almost nothing in team meetings. Lately, she has been much more animated since becoming friendly with a couple of other RNs on the unit.

ANS: C Jake seems at most risk for violence because of his alcohol use and history of aggression. In the other situations, Jordan is expressing a legitimate concern and is behaving assertively; Henry may have health concerns or other issues that are private and interfering with his work life; and Sarah’s change in behavior is likely related to a higher level of comfort with work and colleagues.

4. Delaney, one of your staff nurses, confides that Marjorie, another nurse, has been actively telling others that you are incompetent and do not know what you are doing in relation to patient care, and that you lie to the staff about attempts to get more staffing. Delaney says that Marjorie is derogatory towards her in front of others and tells her “that she better shape up.”

Through telephone calls and conversations during breaks, she is recruiting other staff to her position. Delaney confides that most of the staff find you fair, honest, and knowledgeable. Marjorie’s behavior can best be

characterized as: a. Political action. b. Bullying. c. Building alliances. d. Disgruntlement.

ANS: B Workplace bullying involves aggressive and destructive behaviors such as running a smear campaign, engaging in put-downs, and excluding team members from socialization opportunities.

5. During coffee and other breaks, Rosalie, the new RN, is shut out of conversations with the other staff. When she approaches other staff on the unit to ask questions, they turn and walk off in the other direction. The behavior of the staff is characteristic of: a. Dislike. b. Lack of trust in Rosalie’s abilities. c. Horizontal violence. d. Cultural incompetence.

ANS: C Horizontal or lateral violence and bullying are terms used to describe destructive behaviors towards co-workers, such as the “silent treatment” and shutting others out of socializing.

6. While working with an aggressive patient, it is important for the nurse to: a. Speak firmly. b. Call the individual by name. c. Place herself between the patient and the door. d. Ignore threats against her.

ANS: C In situations where a patient may become aggressive, it is important to ensure that you are not trapped in the room.

7. Caroline asks family members to leave while she cares for the 16-year-old victim of a recent car accident. The father screams at her and tells her that she has no right to ask his family to leave, and that if she continues to do so, he will “throw her out of the room.” Caroline is shaken and tells her head nurse, who tells her that this kind of thing is just part of the job. The guidance of the head nurse: a. Is reasonable. No physical violence was involved.

b. Is related to why statistics on violence in health care are likely underreported. c. Acknowledges the deep distress and fear of the family. d. Acknowledges the concern of the nurse.

ANS: B A common perception is that incidences such as these, which do not involve physical injury or harm, but rather threats, are part of the job. Because of underreporting, data related to violence and aggression in the workplace may not be reflective of its true incidence.

8. You are part of a multidisciplinary team that is charged with designing a workplace safety plan for your healthcare organization. This team has been established in response to increases in reports of violence and aggression.

You begin by: a. Surveying staff about levels of satisfaction with the workplace and management, collegial, and patient relations. b. Offering training sessions in self-defense. c. Developing a policy that outlines zero tolerance for bullying. d. Offering education sessions on recognizing behaviors with potential for violence.

ANS: A Violence and aggression and a toxic workplace can lead to staff dissatisfaction and high staff turnover rates. Surveying staff provides a useful starting place in identifying problems such as employee dissatisfaction, bullying, and other forms of violence.

9. In the Emergency Department waiting room, you notice a patient sitting, with his head in his hands, who has been waiting for about 5 hours for relief of his headache. When you approach him to ask him how he is doing, he says, “I can’t believe that I have to wait this long for help! Do you know what it is like to be in pain for 10 hours?” Your response to him would be: a. “It is frustrating to wait when you are in pain and when you are expecting to receive relief right away.” b. “Don’t talk to me. If you are going to be rude, then you will not receive treatment here.” c. “We are very busy and don’t have enough staff to deal with problems such as yours.” d. “Perhaps you should go elsewhere. We do not have time for you here, as many more sick patients are waiting.”

ANS: A Empathizing helps the other person to know and feel that he has been understood and is powerful in de-escalating a situation that has potential for aggression and violence.

10. At 3 AM, a man walks into your emergency department. He paces back and forth in the waiting area before he approaches staff to ask if he can see his wife, who is a patient on another floor. He speaks rapidly, his face is flushed, he glances around often, and he keeps his hand in his jacket pocket.

A best initial response would be to: a. Assess your situation and your surroundings. b. Ask two or three staff to assist in confronting the individual. c. Ask what floor his wife is on and remind him that visiting hours are closed. d. Remain calm as there is no potential for violence here.

ANS: A The behavior of the individual (flushed appearance, furtive glances, speed of speech) and the hand in his pocket suggest the potential for violence or aggression. The first step is to quickly assess your surroundings for others who might assist and for safety alarms.

11. Linda, a staff nurse on nights, yells at Ali, another RN, and tells Ali that she is stupid and can’t get anything right. In responding to this situation as head nurse, it is critical that you: a. Require that Linda attend anger management classes. b. Investigate to see if Ali did anything to aggravate Linda. c. Call both immediately into the office to discuss the situation. d. Respond to Linda in a way that is consistent with organizational processes and with similar situations.

ANS: D Erratic or arbitrary discipline, favoritism, or behavior that undermines the dignity of either individual undermines efforts at curbing workplace violence.

Disciplinary actions must be proportionate, consistent, reasonable, and fair.

12. Residents in a new long-term care facility attend a large dining hall for meals. In reviewing reports of aggression and violence, you note that behaviors such as hitting, or attempting, to hit staff are increasing. Further investigation suggests that this behavior occurs most often at mealtimes. A possible intervention would be to: a. Seat residents with the highest potential for violence next to those with the

lowest potential for aggression. b. Feed residents earlier in the day. c. Restrain residents who are violent or aggressive during mealtimes. d. Establish a smaller dining area that is away from the main area that is for residents who have potential for aggression/violence.

ANS: D Violence and aggression are more likely during times of increased activity, such as mealtimes. Reducing activity levels through interventions such as a separate dining area may reduce incidents of violence and aggression.

13. You note that Unit 64 has had a high turnover rate of staff during the past year. In investigating this situation, an important source of data might include: a. Employee evaluations. b. Level of experience of staff. c. Exit interviews with staff. d. Selection processes and decisions.

ANS: C Exit interviews may assist in identifying issues such as workplace violence, bullying, and intimidation by managers.

REF: Page 471 | Page 472 TOP: AONE competency: Business Skills 14. You note that Unit 64 has had a high turnover rate of staff during the past year. In selecting the appropriate action, it is important that: a. All documentation is reviewed. b. Usual processes for discipline are followed. c. Confidentiality is assured. d. An incident report is filed.

ANS: C Confidentiality is important if an employee fears intimidation or retribution from a manager.

15. You note that Unit 64 has had a high turnover rate of staff during the past year. In addressing the staff turnover rate, you are: a. Confirming the high correlation between managerial incompetence and violence. b. Demonstrating awareness that workplace violence, if present, has significant costs. c. Aware that staff and manager experiences contribute to high turnover.

d. Aware that violence is a rare but present factor in the workplace.

ANS: B Workplace violence and aggression contribute to staff turnover and toxic work environments. Loss of the organizational investment required to train new staff and departure of experienced staff can increase operating costs and reduce the quality of care.

16. A patient who has a history of involvement with drugs and weapons comes up to you in the hallway and asks you a question regarding directions in treatment. When you respond, he moves closer in to you and puts both hands up on either side of your neck. No one else is in the hallway. Your best response at this point is to: a. Yell at him to stop. b. Calmly ask the patient to remove his hands. c. Hit the patient in the midsection. d. Use pepper spray.

ANS: B In a potentially violent situation, it is important to look and behave in a calm and confident manner, even if you do not feel calm or confident. The person that you are de-escalating will notice and take his cues from you.

17. Jenny tells you that she is always able to tell when others are about to become violent because they yell. Your response to Jenny is based on your understanding that: a. Her perception is accurate. b. Yelling is more likely associated with aggression. c. Violence is signaled by a variety of behaviors. d. She is mostly accurate in her thinking.

ANS: C The STAMP Assessment Components and Cues outline a wide variety of verbal and nonverbal cues that might signal the potential for violence.

18. Joe and Carol, two of the RNs on Unit 22, are discussing recent incidents on the unit that have involved patients and visitors uttering threats or making demeaning remarks to staff during evening hours. Joe observes that unless someone shoots at him, he is not concerned because “words can’t hurt you.”

Joe’s remarks: a. Illustrate common misperceptions about the nature of violence. b. Accurately depict the difference between violence and aggression.

c. Are partially correct because verbal remarks do not cause injury. d. Reveal possible issues that Joe relates to violence in his personal life.

ANS: A Violence and aggression involve verbal and nonverbal and covert and overt behaviors, and all forms are capable of producing short- and long-term injury that may have an impact on productivity, work performance, work attendance, and patient care.

19. Becky, RN, works as a staff nurse in mental health; Sharon works as a data entry clerk in Admissions; Sarah is an emergency room physician; and Donna is a housekeeper in geriatrics. Which of these four is most at risk for violence and aggression? a. Becky b. Sarah c. Sharon d. Donna ANS: A Healthcare workers, especially nurses, experience a disproportionately high rate of violence, compared to personnel in other industries. Nurses are the primary target of violence in healthcare settings, especially those who work in emergency room, mental health, and geriatrics. Hader (2008) found that nurses experienced their colleagues as primary targets of violence 79.7% of the time.

20. Which of the following healthcare employees is MOST at risk for violence? a. Becky, working in a well-lit area with stable psychiatric patients and other staff members nearby. b. Sarah, who works in a busy emergency room. Access to the emergency patient units is allowed by security staff and alarm systems are in place in patient units. c. Sharon, who works evening shifts. Workstation is behind a shatterproof glass, and an alarm can be reached easily from her computer. d. Donna, who works the evening shift, cleans rooms each night in the administrative wing and business offices, which are largely empty. The wing is near an outside access door.

ANS: D Staff who work in isolated, poorly lit areas are at higher risk of violence, which would describe Donna’s work conditions. In addition, if the business

office contains money, this could make it a desirable target for criminals.

While Becky and Sarah work in high-risk areas (mental health and the emergency room), the nearby presence of colleagues, the availability of alarms, and good lighting help to reduce the risk.

21. A safety and security plan is important to a healthcare organization because it: a. Lays out preventive measures in relation to violence. b. Provides direction as to changes in facilities that protect staff. c. Establishes expectations in relation to behavior and tolerance of violence. d. Establishes policies and practices that guide prevention of violence and expectations in the workplace.

ANS: D A safety plan provides overall direction in relation to what is expected, how violence is prevented, and what will occur when violence happens.

22. Sarah is involved in intervening when a patient attempts to harm herself on the unit. During the interaction, the patient slaps Sarah across the face. As a head nurse, it is important that you: a. Offer Sarah immediate education and training in self-defense. b. Assist with follow-up documentation and offer access to counseling. c. Provide access to a lawyer. d. Encourage Sarah to see the incident as a normal part of care.

ANS: B Training should be conducted on a regular basis and cover a variety of topics, including policies and procedures for reporting, record-keeping, and for obtaining medical care, counseling, workers’ compensation, or legal assistance after a violent episode or injury.

23. Which of the following is NOT a factor in patient- and/or familygenerated violence in healthcare settings? a. Feelings of vulnerability b. Anxiety about treatments or diagnoses c. Feelings of powerlessness or loss of control d. Staff rudeness ANS: D Unlike in other settings, hospital violence differs in that it is usually the result of patients or their family members feeling frustration or anger. This is usually related to feelings of vulnerability, stress, and loss of control that

accompany illness. Other factors such as the location, size of the facility, and type of care provided also increase the risk for violence.

24. As a nurse manager, you realize that your unit has become a toxic environment in which horizontal violence and incivility has become common. In addressing the problem, you decide to implement which of the following? a. Increased education in clinical skills b. Follow-up of all reports of violence c. Training in conflict resolution and team-building d. Posting of the institutional policy on violence at the nursing station ANS: C Encouragement to report violence in all its forms is crucial to understanding the root of the problem and implementing plans to eradicate it. Acts of good faith by organizational management in supporting staff include a policy of non-retaliation for reporting. Making sure that reporting is easier and doing an impartial investigation are critical. Addressing a toxic culture also requires training in conflict management, leadership, communication, and teambuilding.

25. As a senior manager, you notice that there have been several resignations on a unit where a new charge nurse has been hired. You suspect that the new charge nurse may be demonstrating bullying behaviors, but staff say little about their relationship with the charge nurse. Your decisions about intervention would be based on which assumptions? a. The staff nurses would tell you if the charge nurse was engaging in relational violence. b. It would be unusual for leaders to engage in violence and bullying behavior. c. Bullying is primarily related to feelings of marginalization and jealousy among peers. d. Initiating confidential exit interviews will assist in determining if leader violence or bullying is occurring.

ANS: D To understand if violence or intimidation is a reason for leaving, organizations should conduct exit interviews with the assurance that the information will remain confidential if an employee fears retaliation. This is an important step in gauging if the problem is bullying or intimidation by managers. Johnson (2009) found that 50% of respondents indicated that they

were bullied by their manager or director. The researcher suggested that when management is part of the problem, victims have a harder time feeling they have adequate support to end the negative cycle of violence. Lack of support leads many victims of bullying to decide that the best alternative is to leave the organization and to give this advice to others who find themselves in similar situations (Johnson, 2009).

MULTIPLE RESPONSE 1. In designing a new healthcare facility, it is particularly important to pay close attention to safety elements related to violence and aggression in which of the following settings? a. Emergency b. Psychiatry c. Gerontology d. Maternal-child ANS: A, B, C Although the potential for violence and aggression exists in all healthcare settings, emergency, psychiatric, and geriatric settings are at particular risk for violence.

Chapter 26: Delegation: An Art of Professional Nursing Practice Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. You are a member of a team assigned to care for 15 general medical/surgical clients. You have all worked well together in the past in this same type of care. If you are assigned to coordinate this team’s work, your best strategy, based on the Hersey and Blanchard model, would be to: a. Have a list of tasks to be accomplished and tell each member of the team what he or she must do. b. Encourage people to discuss their frustrations in providing this care. c. Ignore them—they’ve done it before. d. Provide minimal direction and let them come to you with questions.

ANS: D According to the Hersey and Blanchard model, when ability (skills, job knowledge) and willingness are strong, the role of the delegator is less (“delegating behavior”).

2. The nurse manager is setting up the room assignments for the unit. She has

one critical patient on the unit, who is going to require more care than the others. Before delegating a task, a nurse manager should: a. Delegate the admission assessment to the LPN. b. Review the employee’s performance assessment for the most recent period. c. Assess the amount of guidance and support needed in a particular situation. d. Create a task analysis of critical behaviors for the individual.

ANS: C To delegate effectively, the nurse manager must assess the abilities required in the situation and the abilities that staff have to anticipate the amount of direction, monitoring, explanation, and independence that can be assumed.

3. A key advantage that a nurse manager has in terms of delegating is that: a. Clients receive less attention because too many staff make it difficult to coordinate care. b. Nurses report less pressure to perform necessary tasks themselves. c. Administration can predict overtime more accurately. d. Team skills can be used more effectively.

ANS: D The use of multilevel healthcare providers enables healthcare organizations and nursing to provide patient-centered care, with a focus on abilities and skills that can be employed to perform “what is needed now.” As tasks become more complicated, delegating skills to others enables the nurse to effectively deliver a complex level of care.

4. The nurse on the 7-7 shift is assigning a component of care to an unlicensed nursing personnel (UNP) employee. The night nurse should remain: a. Accountable. b. Responsible. c. Authoritative and liable. d. Responsible and task-oriented.

ANS: A When a registered nurse delegates care to a UNP, responsibility is transferred; however, accountability for patient care is not transferred. Thus, “accountability rests within the decision to delegate while responsibility rests within the performance of the task” (Anthony and Vidal, 2010, p. 3).

5. The night nurse understands that certain factors need to be considered

before delegating tasks to others. These factors include the: a. Complexity of the task and the age of the delegatee. b. Potential for benefit and the complexity of the task. c. Potential for benefit and the number of staff. d. Complexity of the task and the potential for harm.

ANS: D In delegating tasks to others, the nurse considers factors such as stability of the patient, safety of the situation and of the patient, time and intensity involved, and level of critical thinking required to achieve desired outcomes.

6. During a fire drill, the nurse manager becomes very assertive and directive in her communications with staff. This type of situational leadership depends on: a. Supportive behavior by the leader and immature followers. b. The development level of the followers and the type of behavior of the leader. c. Well-developed followers combined with a strong leader who acts quickly. d. The leader’s ability to evaluate personnel and communicate that evaluation.

ANS: B When abilities, relationships, and/or time is limited (as in a crisis situation), the leader assumes a bigger role in guiding and in making decisions (Hersey and Blanchard and “telling” behavior).

7. The unit manager is working in a large metropolitan facility and is told that two UNPs are to be assigned to work with her. Delegation begins with: a. Acknowledging the arrival of the second UNP on the unit. b. Providing clear directions to both UNPs. c. Matching tasks with qualified persons. d. Receiving reports from the prior shift.

ANS: C In delegating to the UNPs, the nurse must consider what cannot be delegated, as well as the factors of safety, time, critical thinking, and stability of patients.

8. During staff development programs, staff nurses verbalize their frustration about their workloads and having to delegate so many tasks to others. One of the main reasons that delegation has emerged as an issue is because of: a. The amount of paperwork required to complete care.

b. The complexity of client care. c. Earlier discharge practices. d. The numbers of other disciplines present on a given unit.

ANS: B Complexity of client care, a multilevel nursing model (registered nurses, mixed with LPNs/LVNs, and UNPs), and community-based care provide many challenges in determining the care required and outcomes desired and/or mandated, and in matching needs with various abilities and authority of regulated and unregulated healthcare providers. The nurse manager should ensure that staff is clinically competent and trained in their roles in patient safety.

9. The day shift nurse asks an LPN/LVN to complete a component of care for a client. The day shift nurse is engaging in what function? a. Delegating b. Assigning c. Sharing d. Authorizing ANS: B Delegation refers to transfer of responsibility for work; the day shift nurse retains accountability for the outcomes of patient care.

10. You are working in a home health service and have three unlicensed nursing personnel (UNPs) assigned to your team. You have worked with two of them for 2 years; the third is new. The two experienced UNPs have patients with complex illnesses for whom they provide basic care. The third member of the team has been assigned to patients with less complex illnesses.

Your best approach to supervising their care is to: a. Remain in the office and ask each UNP to check in with you upon arrival at their first patient care site. b. Ask another RN to supervise the two experienced assistants so you can be with the new person full time. c. Meet the new staff member at the first patient care site and ask the others to call if anything is unusual. d. Meet the new staff member at the first patient care site and call the others with questions to determine whether anything is unusual.

ANS: D When ability and willingness are strong, the involvement of the delegator is less (Hersey and Blanchard).

11. With delegation, responsibility and accountability remain with the: a. Physician. b. Professional who delegates. c. Individual who receives the delegation. d. Individual who previously performed the task.

ANS: B Even though the delegatee (the one who receives the delegation) receives direction from the professional who delegates a task and must have the authority to complete it, the delegator retains accountability for the overall outcome and completion of the activity. The delegatee has responsibility (obligation to engage in the task) and authority for the task.

12. Which of the following exemplifies accountability? Karen, the nurse manager on 5E: a. Consistently submits her budgets on time. b. Gets along well with her staff and with other managers. c. Outlines her rationale for reduction of RN coverage on nights to the Nursing Practice Committee after serious patient injury. d. Actively solicits ideas regarding scheduling from her staff.

ANS: C Reliability, dependability, and obligation to fulfill the roles and responsibilities of the nurse manager are consistent with responsibility.

Accountability refers to being answerable for actions and results.

13. Which of the following indicates safe delegation? a. The nurse supervisor for a large urban acute care department asks the unit manager to accept two new acutely ill patients, which the manager does. The unit is short two staff, and the replacement is inexperienced. b. A unit manager agrees to release a staff from her unit to Unit B. The staff member she agrees to release is experienced on Unit B and is agreeable to the change. The unit manager’s unit is fully staffed and patients are stable. c. The nurse supervisor asks the head nurse for Unit A to make do without a replacement for an ill staff member because Unit A was originally overstaffed anyway. Patient acuity levels are very high on Unit A and two staff are orientating. d. The nurse supervisor asks the charge nurse on Unit B to cover Unit F, which is two floors up, because the charge nurse for Unit F is ill. The charge nurse for Unit B is an experienced manager but has no experience with the nursing care required on Unit F.

ANS: B When span of control (number of individuals for whom a manager is responsible) is compromised by geographic factors such as lack of proximity, instability in patients’ conditions, or lack of experience, the span of control that is being delegated may lead to unsafe care.

14. Which of the following would be most in line with Hersey and Blanchard’s concepts? a. The team of caregivers on day shift are familiar with their roles and with the patients. The nurse manager decides to work on the unit budget in her office. b. After a year of working on the unit, Shari, an LPN, is still hesitant about many policies and procedures. The charge nurse decides to challenge Shari with more difficult patients. c. The nursing supervisor asks one of her charge nurses to lead a technology integration project. The supervisor continuously demands involvement in decisions that the charge nurse is making in the project. d. Team members complain that Alysha, an RN, is unmotivated, and that she refuses assignments that are complex or difficult. The charge nurse suggests that Alysha is relatively new and that she needs time to adjust.

ANS: A The Hersey and Blanchard framework suggests that when ability (skills, job knowledge) and willingness are strong, the involvement of the delegator is less.

15. In delegating to a UNP in a home health setting, which of the following represents the most appropriate delegation communication? a. “You will be taking care of Mrs. S., who needs assistance with her bath.” b. “You will need to help Mrs. S. get into and out of her shower. Ensure that you check the condition of her feet, and let me know if you have any concerns when you check in.” c. “I am not sure that you know how to do this, but I am giving you Mrs. S. She is quite obese and needs skin care.” d. “Mrs. S. needs help to get into and out of her bathtub. Her bath will need to be completed by 10:00. When you are helping her to dry, please check between her toes and toenails, and phone me by 10:30 if you notice nail discoloration or redness.”

ANS: D Delegation communication includes what is being delegated (and what is

not), outcomes, specific deadlines (if applicable), specific reporting guidelines (what, when), and who may be consulted. Communication also includes conveying recognition of the authority to do what is expected.

16. An RN colleague, who is a long-standing and collaborative member of your team, is performing a complex and novel dressing for the first time for the patient to whom she has been assigned. Which of the following would be the most appropriate communication with her? a. “How do you usually do this kind of dressing?” b. “The dressing needs to be done today and tomorrow with the supplies on this cart.” c. “Here is what you need for the dressing, and I will show you what needs to be done.” d. “I know you know what you are doing. Let me know if you have any problems.”

ANS: C If a situation involves a new task and the relationship is ongoing (two individuals who will usually continue to work together), the delegator explains what to do and how to do it. Hersey described the leader’s behavior as explaining or persuading, which, is characterized as “selling.” The RN who is assigned to the patient is an experienced nurse and team member, but is new to this specific situation. In situations where the nurse is experienced but the task is new, explain (and demonstrate) what needs to be done.

17. Sally is an experienced nurse on the unit and is very experienced with ICP monitoring. She is assigned David, a patient who has been admitted with a severe head injury. In communicating with Sally, you would: a. Provide a detailed explanation of what she needs to do with ICP monitoring. b. Tell her when she needs to provide an update about David’s status. c. Ask her to tell you what she knows about ICP monitoring and share expectations about reporting. d. Advise her that you are available if she needs you.

ANS: D You and Sally have a well-established relationship and Sally has the expertise to work effectively with David; therefore, you would need to provide little guidance but would need to communicate that you are available if needed.

Hersey refers to this leader behavior as “delegating.”

18. You ask Evelyn, a new UNP, to check what is left in Mrs. N.’s inhaler when Evelyn makes visits to Mrs. N. and also to check whether Mrs. N. is receiving any positive effect from the medication. Evelyn reports for 3 weeks that Mrs. N. is using the inhaler and that there is enough medication left in the device. The day of her last visit to Mrs. N., Mrs. N. is admitted to the hospital in severe respiratory distress. When she is admitted, she tells the physician that she has not been using the inhaler for 4 weeks. This incident is an example of: a. Incompetence of the UNP. b. Failure to follow through. c. Skills but no motivation. d. Lack of accountability.

ANS: B The nurse should maintain open lines of communication and seek information, and the UNP should know how, when, and what to report.

Communication of delegation of tasks includes specific information about what is being delegated, expected outcomes, and deviations (which includes what immediate action needs to be taken). This two-way communication and follow-through allows patient care to be altered, if necessary, in a timely manner.

19. You ask Evelyn, a new UNP, to check what is left in Mrs. N.’s inhaler when Evelyn makes visits to Mrs. N. and also to check whether Mrs. N. is receiving any positive effect from the medication. Evelyn reports for 3 weeks that Mrs. N. is using the inhaler and that there is enough medication left in the device. The day of her last visit to Mrs. N., Mrs. N. is admitted to the hospital in severe respiratory distress. When she is admitted, she tells the physician that she has not been using the inhaler for 4 weeks. Before assigning Evelyn to Mrs. N.’s care, the most appropriate action of the care coordinator would have been to: a. Determine Evelyn’s educational background and preparation for this role. b. Ask Evelyn if she has worked with inhalers before and to describe what she knows about them. c. Advise that if Evelyn has any questions about what to do with the inhaler, she should come to the coordinator. d. Advise Evelyn that working the inhaler is not really complicated and that she should ask the patient how to check medication levels in the inhaler.

ANS: B

When delegating tasks, in addition to specifying the task to be completed, outcomes, priorities, timelines, deviations, report time frames, monitoring, and resources, asking the delegatee to give examples of each is helpful in ensuring that communication is clear and has been understood. Preparation of UNPs lacks consistency; therefore, the safest practice is to determine the knowledge and skill level of the UNP in relation to the skill and the patient before delegating.

20. You ask Evelyn, a new UNP, to check what is left in Mrs. N.’s inhaler when Evelyn makes visits to Mrs. N. and also to check whether Mrs. N. is receiving any positive effect from the medication. Evelyn reports for 3 weeks that Mrs. N. is using the inhaler and that there is enough medication left in the device. The day of her last visit to Mrs. N., Mrs. N. is admitted to the hospital in severe respiratory distress. When she is admitted, she tells the physician that she has not been using the inhaler for 4 weeks. Determination of Evelyn’s educational preparation and certification is related to the concept of: a. Accountability. b. Authority. c. Role performance. d. Assignment.

ANS: B Authority refers to the right to do and may be designated by law, educational preparation, or job description.

21. County Hospital has position descriptions for all staff, including RN Team Leaders. Sarah, a team leader on the rehab unit, assesses the needs of the patients in her area, assesses the skills and backgrounds of each of the individuals on her team, and then assigns and delegates the appropriate care provider to each patient and task. Sarah’s activity in the example described is termed: a. Passive delegation. b. Passive accountability. c. Active delegation. d. Active responsibility.

ANS: C When a position description contains functions that are considered to be the normal practice of the person in that role, then it is considered a passive

delegation act. When Sarah decides what is best for the patients in her care in terms of who should perform the care and then holds the person accountable, she is engaging in active delegation.

22. Functions such as “delegates tasks to assistive personnel” that are outlined in a position description for an RN Team Leader would be considered: a. Active delegation. b. Passive delegation. c. Passive accountability. d. Active responsibility.

ANS: B Delegation of functions that are normally considered part of or an essential part of the practice of a licensed person through a position description is considered passive delegation.

23. County Hospital has position descriptions for all staff, including RN Team Leaders. Sarah, a team leader on the rehab unit, assesses the needs of the patients in her area, assesses the skills and backgrounds of each of the individuals on her team, and then assigns and delegates the appropriate care provider to each patient and task. Sarah provides Colleen, her RN colleague with details regarding the patients to whom Colleen has been assigned on the day shift. This is an example of: a. Accountability. b. Responsibility. c. Assignment. d. Delegation.

ANS: C When an RN assigns care to another RN, it is termed an assignment and not delegation, because both accountability and responsibility are transferred.

24. Leslie, a UNP, transfers a patient while using improper technique. The patient is injured, and as a result, a suit is launched in which both Sarah (the delegator) and Leslie (the delegatee) are named. Sarah is named in the suit because she: a. Retains accountability for the care of the patient. b. Worked the same shift as Leslie. c. Has passive accountability for delegation. d. Retains accountability for the outcomes of care for the patient.

ANS: D Whenever care is provided by someone other than a registered nurse, accountability for care remains with the manager/delegator even though others provide aspects of care.

25. Ali, an RN on your unit, is consistently late to work and makes remarks such as “Do you really want me to do that?” when patients and care are assigned to her. You have spoken with her frequently about her: a. Ability. b. Skills. c. Attitude. d. Personal issues.

ANS: C Hersey and Blanchard explained followership in terms of ability and willingness. Attitude refers to willingness or reluctance to perform work.

MULTIPLE RESPONSE 1. An example of a care activity that would likely not be delegated by an RN to a UNP is : a. Teaching self-catheterization to a patient with paraplegia who has limited English. b. Basic care for a patient with a head injury who is rapidly deteriorating. c. One-to-one observation with a suicidal patient. d. Assessment of patients being admitted through the Emergency Department. e. Basic hygienic care for a patient who is post MI and stable.

ANS: A, B, D Functions such as assessment, diagnosis, planning, and evaluation cannot be delegated. In addition, stability, critical thinking, time, and safety are factors that are considered in assessing whether or not to delegate care to a UNP. Teaching self-catheterization to a patient with limited English requires critical thinking; basic care for a patient who is rapidly deteriorating exemplifies concern with stability; and assessment of patients through Emergency is related to the factor of time. An exception to safety and stability in which patients may be delegated to UNPs is when patients are placed on suicide precautions.

Chapter 27: Role Transition Leading and Managing in Nursing, 6th Edition

MULTIPLE CHOICE 1. The unit leader on an inpatient psychiatric unit of a large hospital has been in the position for 3 months. The unit leader is frustrated by how little time is available to work with clients and how few changes have been implemented in that time. The phase of role transition being experienced is the role of: a. Acceptance. b. Negotiation. c. Discrepancy. d. Internalization.

ANS: C Role discrepancy is an experience that includes a gap between what is expected and what is occurring and can lead to disillusionment, discomfort, and frustration. If the unit manager values the relationship and sees the differences between performance and expectations as correctable, then the manager is likely to stay in the role.

2. An interviewee for a nurse manager position asks for a copy of the organizational chart. Organizational charts provide information about the role component of: a. Expectations. b. Opportunities. c. Responsibilities. d. Lines of communication.

ANS: D No matter what role an individual is in, multiple relationships exist with individuals including supervisors and peers. Roles incorporate patterns of structured interactions between the manager and people in these groups.

Organizational charts provide information about relationships and lines of communication in the organization.

3. During an employment interview for the manager’s position in a home health agency, the applicant asks questions about the medical director and about retention of staff. The nurse executive assures the applicant that the agency has few personnel problems and receives excellent support from the medical director. The applicant knows that the agency has a 50% turnover rate and has had three medical directors in the past year. The nurse executive is: a. Unaware of the turnover rate and difficulties with the medical director.

b. Lying about the problems and hoping to resolve them by hiring the applicant. c. Denying that the agency has a turnover problem with staff or medical directors. d. Minimizing the challenges of the position to make a positive impression on the applicant.

ANS: D During the dating phase or preview period in the role transition process, the potential employer attempts to make a favorable impression, which may result in minimizing the challenges of the position.

4. The new head nurse on telemetry has been in the position for 3 months.

The head nurse and the administrator disagree on how much time the head nurse should allot to various aspects of the role. Staff members on the unit complain that the head nurse is unavailable for clinical concerns because of being off the unit while attending meetings. To facilitate the process of role transition, the head nurse should: a. Develop policies consistent with the head nurse’s prior workplace. b. Attend a workshop on how to deal with difficult people. c. Decide to give the position 3 more months and then leave if things do not improve. d. Schedule a series of meetings with staff and the administrator to clarify expectations.

ANS: D During role transition, it is important for the manager to negotiate the role by writing down the manager’s expectations of the role and determining the expectations of others (staff, supervisors) in order to clarify expectations and reduce or ameliorate role ambiguity and role strain. Weinstock (2011) suggests that it takes up to a year to understand the role, system, and boundaries in a new position.

5. A nurse manager in one hospital values a colleague who is a few years older and has more experience in nursing management. The colleague works in another hospital, but they meet for lunch once a month. In these meetings, they share their feelings about nursing management and their lives. The function of a mentor that is missing in the relationship is: a. Sponsorship. b. Role modeling. c. Social interaction.

d. Mutual positive regard.

ANS: A Sponsorship involves building the competency of the mentee through exposure or by creating opportunities for achievement in order for the mentee to develop a reputation of competence.

6. The new nurse manager feels pulled between the expectations of staff, the demands of hospital administrators, and family obligations. According to Hardy (1978), unrelieved role stress and strain will lead to: a. Frustration and anger. b. Alienation of family and friends. c. Low productivity and performance. d. Physical symptoms and acute illness.

ANS: C Unrelieved role stress and strain leads to focusing energy into negative thoughts and feelings, which can leave the manager fatigued and therefore less likely to be productive or to perform well.

7. The nurse manager of a unit was demoted to staff nurse 6 months ago.

Because of being near retirement, the former nurse manager wanted to be employed at the hospital and was offered a position on the same unit. The former nurse manager complains often about how infrequently the current nurse manager is available on the unit and argues with physicians and coworkers. Clients have complained about the attitude of the nurse. The behavior of the former nurse manager can be best explained as being caused by: a. Overwork in the staff nurse position. b. Inadequate mentoring in the new role. c. Anger as a stage of the grieving process. d. Demotion as a threat to personal identity.

ANS: C When an employment relationship ends or changes unexpectedly, grieving occurs. One of the phases in grieving is anger.

8. A nurse is interviewing for a manager’s position. Which of the following actions is considered a role preview? a. Formal commitment of the employment contract b. Improving role performance c. Touring the unit

d. Disillusionment about the expectations of the job ANS: C Touring the unit enables the candidate to assess further whether this organization will assist in growth and also to make a positive impression on the potential employer.

9. The chief nursing officer develops a mentoring program to help new staff members adjust to their new jobs. The main purpose of mentoring is: a. Promoting staff retention. b. Promoting staff attrition. c. Developing new role expectations. d. Promoting staff supervision.

ANS: A Mentoring has been identified as important to staff retention.

10. A nurse manager notices that Nathan, an RN who has been on the unit for approximately 3 years, has a particular interest in technology and seems to be very enthused about working with software and hardware at home. She speaks with Nathan and asks him if he would lead investigation of software applications on the unit. This is an example of: a. Opportunity. b. Delegation. c. Role negotiation. d. Role transition.

ANS: A Nathan’s nurse manager recognizes Nathan’s interest in technology as an opportunity for the unit and as an untapped resource that can be used to meet unit goals.

11. Sarah is a nursing graduate of 5 years who is very confident in her clinical skills. She has taken some certificate courses in leadership and management and has considered beginning a graduate degree with this focus.

She is excited about being able to use her knowledge and interest by being hired as a nurse manager. Before beginning her new position, Sarah spends time with her nurse executive to clarify the executive’s expectations of her and of the unit that she has been hired to manage. Sarah’s actions are important in avoiding role: a. Ambiguity. b. Transition.

c. Development. d. Negotiation.

ANS: A Clarification of implicit and explicit expectations regarding the role assists in avoiding role ambiguity and role strain.

12. Sarah is a nursing graduate of 5 years who is very confident in her clinical skills. She has taken some certificate courses in leadership and management and has considered beginning a graduate degree with this focus.

She is excited about being able to use her knowledge and interest by being hired as a nurse manager. Before beginning her new position, Sarah spends time with her nurse executive to clarify the executive’s expectations of her and of the unit that she has been hired to manage. After beginning her new position, Sarah finds that she spends a great deal of time in direct patient care.

Her staff begins to complain that they are never able to find her when they need her, and that some aspects of her responsibilities fall behind, such as scheduling. Sarah is most likely: a. Lacking an understanding of the nurse management role. b. Attempting to prove her clinical skills to the nursing staff. c. Experiencing difficulty in unlearning old roles. d. Lacking enjoyment in her new role.

ANS: C Role transition involves transforming one’s identity. Although any of the answers listed might be correct, as a new manager, her confidence in her clinical skills suggests that she is having difficulty in the transformation process and in unlearning her role as a clinician.

13. Sarah is a nursing graduate of 5 years who is very confident in her clinical skills. She has taken some certificate courses in leadership and management and has considered beginning a graduate degree with this focus.

She is excited about being able to use her knowledge and interest by being hired as a nurse manager. Before beginning her new position, Sarah spends time with her nurse executive to clarify the executive’s expectations of her and of the unit that she has been hired to manage. A strategy that may help to make the transition to her management role and to respond to relationships and situations in her new position is: a. Avoiding discussion of her personal beliefs with staff until she is ready to do so. b. Finding a network of clinicians with interests similar to her own.

c. Researching clinical literature to maintain her clinical assessment skills for the unit. d. Recognizing her strong commitment to care in the management process through journaling.

ANS: D During the transition period, it is important to recognize, use, and strengthen values and beliefs, translate these for staff, and adapt behaviors to the situation. Understanding personal and professional beliefs and values assists in helping the manager respond to situations and relationships.

14. Sarah is a nursing graduate of 5 years who is very confident in her clinical skills. She has taken some certificate courses in leadership and management and has considered beginning a graduate degree with this focus.

She is excited about being able to use her knowledge and interest by being hired as a nurse manager. Before beginning her new position, Sarah spends time with her nurse executive to clarify the executive’s expectations of her and of the unit that she has been hired to manage. Sarah finds that she has begun to think negatively about the way nursing care is delivered on her nursing unit. She often wishes that she was back on her old unit and in her familiar staff nurse role. This behavior: a. Is natural when assuming a new position. b. Diverts energy from internalization of Sarah’s new role. c. Is justified if practices are deficient on the new unit. d. Reflects Sarah’s astuteness as a clinician.

ANS: B By focusing on the weaknesses of the unit, Sarah may lack the energy to internalize the new role—a step that is critical to being an effective leader. As a new manager, Sarah must learn how to access resources in the organization.

Approaching the organization as a foreign culture, Sarah can keenly observe the rituals, accepted practices, and patterns of communication within the organization. This ongoing assessment promotes a speedier transition into the role of manager.

15. Sarah is a nursing graduate of 5 years who is very confident in her clinical skills. She has taken some certificate courses in leadership and management and has considered beginning a graduate degree with this focus.

She is excited about being able to use her knowledge and interest by being hired as a nurse manager. Before beginning her new position, Sarah spends time with her nurse executive to clarify the executive’s expectations of her

and of the unit that she has been hired to manage. Sarah finds a mentor, Amy, who has been in the role of unit manager for 3 years and has a similar interest in clinical excellence. During their frequent meetings, Amy provides assistance with learning aspects of the manager’s role, including technical aspects, such as how to interpret budget printouts and to achieve budget outcomes. The success of Amy’s coaching depends on: a. Clarity of Amy’s information. b. Organizational support for the mentor relationship. c. The congruence of Amy’s beliefs with Sarah’s beliefs. d. Willingness of Sarah to receive feedback.

ANS: D Coaching provides information about how to improve performance and learning aspects of the role. Coaching requires willingness on the part of the mentee to accept feedback.

16. In addition to providing coaching, a nurse mentor may provide counseling to the mentee. For counseling to be successful, the mentor must: a. Provide a quiet environment away from the unit. b. Keep the focus on technical and management responsibilities. c. Assure confidentiality. d. Present assignments that stretch the intellectual and technical ability of the mentee.

ANS: C Counseling provides opportunity for the mentee to share personal concerns.

For counseling to be successful, confidentiality must be assured.

17. Sarah is a nursing graduate of 5 years who is very confident in her clinical skills. She has taken some certificate courses in leadership and management and has considered beginning a graduate degree with this focus.

She is excited about being able to use her knowledge and interest by being hired as a nurse manager. Before beginning her new position, Sarah spends time with her nurse executive to clarify the executive’s expectations of her and of the unit that she has been hired to manage. After a year, Sarah successfully transitions into the nurse manager role and considers taking the examination to become a certified nurse executive. Amy advises her that this is not possible because Sarah will need: a. A graduate degree. b. At least a nursing diploma.

c. 24 months of experience. d. 5 years of successful experience.

ANS: C Nurses with baccalaureate preparation and holding a nurse executive position with at least 24 months of experience can take the examination to become a certified nurse executive.

18. Sarah is a nursing graduate of 5 years who is very confident in her clinical skills. She has taken some certificate courses in leadership and management and has considered beginning a graduate degree with this focus.

She is excited about being able to use her knowledge and interest by being hired as a nurse manager. Before beginning her new position, Sarah spends time with her nurse executive to clarify the executive’s expectations of her and of the unit that she has been hired to manage. Sarah finds that she is comfortable with the expectations of staff and her supervisor regarding her management role and responsibilities and has been able to effect a strong commitment to quality clinical care on the unit. At this point, Sarah has likely attained this role: a. Development. b. Acceptance. c. Symmetry. d. Internalization.

ANS: D Role internalization is achieved when the manager experiences performance of the role as being congruent with his or her own beliefs. Role acceptance refers to accepting the contract and making a public announcement of the acceptance.

19. As a new manager, you reflect on what professional development would be most valuable to assist you in taking on this role. Which of the following would you most likely identify? a. Opportunities to hone clinical skills that are used most often on the unit that you will manage. b. A workshop on conflict management and communication skills. c. Attendance at a conference on global health care economics. d. Attendance at a workshop on survey tool development and statistical measurement.

ANS: B Patrician et al. (2012), in a qualitative descriptive study that explored the

professional development needs of nursing leaders, developed a number of recommendations that were based on what charge nurses indicated about their needs. The recommendations included education and orientation to the role, managing performance and development of staff, and communication skills. Additional education should be focused on unit finances and patient relations. Leadership support was found to be pivotal for charge nurses to feel successful or hinder their work.

20. John, a new nurse manager, complains to his colleague that he feels very uncomfortable with the conflict between what he thinks he should be doing as the manager and what his supervisor thinks he should be doing. According to Hardy’s role theory, John is experiencing: a. Stress. b. Role stress. c. Role strain. d. Role exploration.

ANS: C According to Hardy, role strain is the subjective feeling of distress that occurs when role stress or a social condition of conflicting demands or difficult conditions is present.

21. Seth is hired as the nurse manager for a surgical unit. After a year, the hospital reorganizes, and his position is lost. In leaving the unit, it is important for Seth to: a. Engage in clarifying why the hospital did not state its expectations for the unit at the time of hiring. b. Hire a lawyer to represent his interests during this unexpected role transition. c. Seek counseling to deal with his shock and anger. d. Negotiate a reasonable settlement.

ANS: D When role transition occurs as a result of restructuring, the unit manager should request and negotiate reasonable compensation and assistance, even if it is not offered initially by the employer.

22. After several months in the role of manager of a dialysis unit, Maryanne finds herself still questioning the gap in expectations between her and her staff and management and is also questioning if she can reconcile her concerns about quality care with the strong cost containment orientation of

the facility. At this point, Maryanne is in which stage of role transition? a. Internalization b. Acceptance c. Development d. Discrepancy ANS: D At this point, Maryanne is still experiencing discomfort and disillusionment with the gap between what she expected and what others expect of her in the performance of her role as manager. She is considering the significance and fit of the relationship for her, which is consistent with role discrepancy.

23. In assisting new graduates to make the role transition to graduate nurse, Ted, the unit manager initiates which of the following? a. Self-check list to assess competencies that have been strengthened b. Discussions that focus on what the new graduates have yet to learn c. Fixed target dates for acquisition of competency and transition to RN role d. Frequent formal meetings to provide feedback on performance and areas to be strengthened ANS: A Transition to the new role is facilitated through reflection and ongoing development of awareness of strengths (as compared with a focus on weaknesses) and of weaknesses. The value of the employee may not depend on quickness in making the role transition.

24. Who of the following might be the BEST mentor for Becky, a new nurse manager on the cardiac unit who has 4 years of previous clinical experience? a. Sam, near retirement. He has 20 years of clinical nursing and recently assumed role of head nurse in an interim capacity because of the incumbent’s illness. b. Leslie, who has been a clinical educator at the institution for a number of years. She has tired of her role and aspires to become a nurse manager. She looks at mentorship as an opportunity to understand the role better. c. Courtney, who has been a nurse manager for 3 years. Her staff and supervisor value her skills and her leadership acumen and championship of innovation. d. Ben, who was nurse manager for 3 years, soon after graduation. He left the role because he was uncomfortable with the expectations and has been a team leader on surgery for 15 years.

ANS: C

A mentor needs to have sufficient professional experience and organizational authority so that he or she can mentor the career of the mentee. Mentors need competencies that include interpersonal and communication effectiveness, risk taking and creativity, and ability to inspire change.

MULTIPLE RESPONSE 1. As a result of Amy’s coaching, Sarah, a nursing graduate of 5 years, completes a ROLES assessment. This assessment is helpful in : a. Identifying her clinical knowledge. b. Role development. c. Areas of conflict in expectations. d. Expected work time commitments.

ANS: B, C, D A ROLES assessment is useful in identifying, confirming, and visualizing responsibilities, opportunities, lines of communication, expectations of self and others for the position, and support. This is particularly useful in identifying areas of conflict in expectations, including conflict between the manager’s own expectations and those of staff and supervisors and in negotiating role expectations.

Chapter 28: Self-Management: Stress and Time Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. As a nurse manager, you observe a staff nurse who over the past few weeks has become withdrawn and has had several absences due to minor ailments. Your best action would be to: a. Ask the nurse if she is okay during report. b. Refer the nurse to the employee assistance program. c. Ask the nurse to meet with you for a few minutes before she leaves for the day. d. Write a note to the nurse advising her that her work attendance must improve.

ANS: C Stress can lead to emotional symptoms such as depression and a variety of ailments. Meeting with the nurse privately may assist in identifying stress and possible solutions.

2. The nurse manager of a unit has lost many staff members, and the unit is

now staffed with a large number of agency and traveling nurses. She knows that the agency and traveling nurses are all contracted to stay on the unit for the next 3 months. One way to improve morale and decrease stress in the unit would be to: a. Plan a social event and include the agency and traveling nurse staff members. b. Plan unit-based social events for your remaining permanent staff members. c. Request hospital-based “floating” nurses to substitute for the temporary staff. d. Implement team nursing.

ANS: A Social support, in the form of positive work relationships, can be an important way to buffer the effects of a stressful work environment.

Including all staff in the social event enables those who are not normally part of the team to experience this support and provides an opportunity for the staff as a whole to develop supportive relationships.

3. As a nurse manager, the one activity you should not overlook is: a. Posting the yearly rotation schedule. b. Reviewing vacation requests. c. Scheduling staffing for holidays 6 months in advance. d. Anticipating staff sick days.

ANS: B Free time and vacation time are needed for individuals to recharge. If time for work is more than 60% of wake time, or when self-time is less than 10% of wake time, stress levels increase.

4. A nurse manager has decided that she must institute some personal time management steps to survive work and home life. Her first step should be to: a. Determine what takes up so much of her time and energy. b. Organize her personal and work spaces. c. Purchase a handheld personal digital assistant to help remind her of important meetings. d. Determine her personal and professional goals.

ANS: D Personal time management refers, in part, to “the knowing of self.” Selfawareness is a critical leadership skill, and being self-aware and setting goals helps managers determine how their time is best spent.

5. A hospice nurse has been feeling very stressed at work because of both the physical strain and the emotional drain of working with clients with AIDS. She tries to walk 1 to 2 miles three times a week and to talk regularly with her husband about her work-related feelings. One reasonable stress management strategy would be to: a. Start taking yoga lessons. b. Make an appointment to meet with a psychiatrist. c. Start jogging 5 to 6 miles every day. d. Plan to go out for a drink with fellow nurses after work every day.

ANS: A Stress relief techniques include 30 minutes of exercise five times a week, as well as techniques such as yoga that relieve mental stress.

6. The nurse manager is implementing a shared governance model to help with communication and decision making. Although staff members like the concept, change is difficult. Staff nurses feel: a. More empowered. b. More communicative. c. Less stressed. d. More powerless and devalued.

ANS: D Change can lead to feelings of being overwhelmed and powerless, especially if complexity compression or rapid, intense changes have been involved.

7. The chief nursing officer listens to nurse managers verbalize their feelings of internal stress. One common source of internal stress seems to be: a. The death of a loved one. b. Perfectionism. c. Getting married. d. Losing a job.

ANS: B Losing a job, the death of a loved one, and getting married are examples of external stress.

8. The staff development educator presents a series of programs on stress management to the nurse managers. Research has indicated that an individual’s ability to deal with stress is moderated by psychological hardiness. Psychological hardiness is a composite of: a. Commitment, control, and challenge.

b. Commitment, powerlessness, and passivity. c. Commitment, control, and passivity. d. Decreased isolation, challenge, and passivity.

ANS: A Some people have the capacity to accept changes in life with good humor and resilience, which, in turn, influences behavior that prevents illness. Hardiness involves the capacity to manage time and stress, to reframe situations positively, and to commit.

9. The chief nursing officer understands that a nurse manager can exhibit stress that is related to trying to keep up with the number of electronic messages that arrive, as well as trying to remain accessible to staff. What is a strategy that would assist the manager to manage the information overload effectively? a. Ignore messages unless they are labeled as important. b. Determine who is most likely to send useful or important information or requests. c. Check e-mail messages once a day. d. Encourage face-to-face meetings rather than e-mail.

ANS: B Reduction of stress related to information overload requires the development of information-receiving and information-sending skills. Information-sending skills include determining most common sources of useful data, labeling files and folders to which e-mail messages can be directed, deletion of e-mails, and focusing on the most important pieces. Information-sending skills include keeping e-mail messages short (and calling if the message needs to be long) and considering the most appropriate medium for messages (telephone, fax, face-to-face).

10. In helping nurse managers to manage their time, the chief nursing officer suggests that they: a. Maintain a perfectionistic attitude. b. Set up a complaint list. c. Have good negotiation skills. d. Have good information literacy skills.

ANS: D Time can be saved by using information technology effectively, as it assists with effective data retrieval and information gathering and with

communication related to a variety of needs in the management setting.

11. Which of the following statements would best define stress? Stress is: a. The comfortable gap between how we like our life to be and how it actually is. b. Everyday life, both the highs and the lows. c. A consequence or response to an event or stimulus that can be positive or negative. d. Identical to distress.

ANS: C Stress is defined as a gap between how we would like our lives to be and how they actually are and as a consequence or response to an event or stimulus. It is not inherently bad (distress), and whether highs and lows are seen as distress or eustress is dependent on each individual’s interpretation of the event.

12. In a job interview for a nursing position, Marley can be assured that which of the following will occur? a. Both eustress and distress b. Only eustress c. Only distress d. Neither eustress nor distress ANS: A Eustress is defined as stress that is pleasant in nature, and distress is defined as stress of an unpleasant nature. One can assume that every interview has both of these stresses.

13. Which one of the following statements has been proven to be true? a. Recent research has found that women do not have a unique physiologic response to stress. b. Both men and women interpret the same stressor in the same manner without regard to past experiences. c. Stress influences the immune system in one complex manner. d. Stressors that are identical do not necessarily have similar effects on each individual.

ANS: D Stressors may be unique to certain environments, situations, and persons or groups, and individuals may respond to the same stressor in different ways.

14. An example of role stress occurs when:

a. The director of the ICU and the manager of the surgical unit wish to hire the same new employee. b. Two part-time staff members are hired to work in a unit, but the job expectations for them are not clear, and the head nurse expresses disappointment in their performance. c. The nurse manager for the ICU wants to advocate for more staff and finds it difficult to find data to substantiate his proposal. d. Line managers believe that support staff use their technical knowledge to intrude on their authority.

ANS: B Role stress is an additional stressor for nurses. Viewed as the incongruence between perceived role expectations and achievement, role stress is particularly acute for new graduates. Failure to comply with expectations can lead to role conflict. Role conflict and role ambiguity are major sources of conflict for nurses.

15. A staff nurse approaches the unit manager and indicates to her that because of her father’s death in the previous month, she is now finding it very difficult to do her work effectively. This would be considered a(n) ________ stress. a. Internal source b. Familial c. Burnout d. External ANS: D External stress is outside and removed from the work setting, but it is considered work-related stress because of the impact it has on the worker.

16. Sources of occupational stress in nursing include all except which of the following? a. Authoritarian leadership b. Concern about moral wrongdoing by colleagues c. Multiple changes in a short time d. Rotating shifts ANS: A Ethical distress, complexity compression, rotating shifts, high acuity levels, rotating shifts, and workload are all sources of work-related stress for nurses.

17. Mr. T. Jones and Mr. R. Smith are both going to become residents in

Sunny Haven Lodge. Mr. Jones views it as an opportunity to socialize and meet new friends. Mr. Smith views this as abandonment by his family and is worried that the care will be inadequate. Each senior perceives the situation differently. This is a good example of stress that is: a. Both a positive stressor and a negative stressor. b. Occurring only because of age. c. Positive in both cases. d. Harmful in both cases.

ANS: A Some researchers have determined that stress is a person-environment process in which the person appraises the situation as taxing or not. Appraisal is an important concept that explains why two people react in different ways to the same situation. Stress can be viewed as positive (eustress) or negative (distress).

18. Jeff, an RN in his 30s, has lost a parent, just purchased a new home, and is laid off with 6 months’ severance pay. At the same time, Jerry, an RN in his 50s, is financially secure and is asked to take early retirement with a buyout. How will the two men react to the emotional and physical influences and the sequence of stress? a. The younger man will feel more stress. b. The two men may or may not feel the same amount of stress. c. The older man will feel more stress. d. Neither man will experience any stress.

ANS: B The response to similar stressors does not always result in a similar experience of stress in individuals. Responses are mediated by the appraisal of the event as well as by factors such as gender, personality, lifestyle, and age.

19. Social stressors are considered a major factor in the stress nurses experience in the healthcare system. Which of the following is not considered to be a social stressor? a. High amounts of stress in the nursing home environment b. Changes in the current healthcare system such as nursing strategies c. Disruptive behavior coming from physicians and other healthcare workers d. Stress triggers such as self-criticism and overanalyzing ANS: D Personal stress triggers such as self-criticism are considered intrapersonal

stressors; environmental factors such as change, work environment, and interactions with others are considered social stressors.

20. After several months of heavy patient loads in the Emergency Department and inability to secure sufficient and experienced staff, the department is especially taxed by a train accident that brings in many seriously injured individuals. You observe that Rama ignores the requests of several of the injured, even when time is available to care for them and is rude to two elderly patients. You are concerned that Rama is evidencing which state? a. Hardiness b. Depression c. Role ambiguity d. Depersonalization ANS: D A characteristic of burnout is depersonalization, a state characterized by distancing oneself from the work itself and developing negative attitudes toward work in general (Greenglass et al., 2001). Depersonalization is commonly described as a feeling of being outside one’s body, feeling as if one is a machine or robot, an “unreal” feeling that one is in a dream or that one “is on automatic pilot.” Generally, subjective symptoms of unreality make the nurse uneasy and anxious. Nurses pushed to do too much in too little time may distance themselves from patients as a means of dealing with emotional exhaustion.

21. “Stress-buffering” behaviors can be elicited to reduce stress. All of the following behavioral coping responses can be used by nurse managers to reduce and manage stress except: a. Distancing oneself from work. b. Using cognitive reframing to change irrational thoughts. c. Refusing a request to sit on a committee to evaluate scheduling software. d. Exercising regularly.

ANS: A Achieving balance between work and leisure is a useful strategy for stress reduction. Distancing, however, can be a sign of depersonalization that includes negative attitudes as well and is a characteristic of burnout.

22. The education consultant at St. Joseph’s Hospital is giving a workshop on cognitive reframing. The consultant explains that cognitive reframing reduces

stress by: a. Aiding individuals in identifying positive stressors. b. Helping people realize that negative thinking causes emotional distress. c. Eliminating negative stressors. d. Replacing positive self-statements with negative irrational beliefs.

ANS: B Cognitive reframing is a therapy that aids individuals in discovering that their irrational thoughts can be replaced with responses that are more rational. It enables individuals to gain a sense of control over the situation and can change “I’ll never …” to “I can …” or “She always …” to “Sometimes she … .” It is an approach that allows individuals to replace negative thoughts and statements with others that are more realistic and helpful.

23. Time management is very essential for the nurse manager. Which of the following is not a good time-management technique? a. Decide what not to do. b. Learn to say “No.” c. Learn to delegate. d. Break down your workload into large manageable tasks.

ANS: D To manage time successfully, it is important to break down your workload into smaller, manageable tasks. Developing PERT and Gantt charts will aid in dealing with larger, complex projects. Both charts can be used to outline how an individual will approach a large project.

24. As a unit manager, you chair the unit meetings. For each meeting, you consider and establish the purpose of the meeting. Second, you prepare an agenda. Arrange the following steps in an order that would make the meetings productive and successful.

1. Distribute an agenda.

2. Distribute minutes.

3. Select team members.

4. Start on time.

5. Keep the meeting focused and directed toward accomplishing the set objectives.

Select the correct order from the following options: a. 1, 2, 4, 5, 3 b. 4, 1, 2, 5, 3 c. 3, 1, 4, 5, 2

d. 3, 4, 2, 1, 5 ANS: C Planning, organizing, and keeping the group on task are critical in ensuring that meetings are productive and that time is managed well.

MULTIPLE RESPONSE 1. High levels of work-related stress affect all but which of the following? a. Job satisfaction b. Absenteeism and turnover c. Nurses’ health d. Client welfare ANS: A, B, C, D Many writers and researchers have found that these work-related areas are adversely affected by stress.

Chapter 29: Managing Your Career Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. A new graduate is seeking a new position in nursing and wants to “sell” herself effectively. The best strategy is to: a. Create a résumé. b. Practice interviewing. c. Call the personnel offices. d. Create a curriculum vitae.

ANS: A A résumé provides a customized overview of details of your professional background that relates specifically to a position for which you are applying.

Résumés advertise your skills to a prospective employer.

2. A nurse manager has been employed in the same facility for 20 years and has held the same position. This career style is known as: a. Linear. b. Spiral. c. Steady state. d. Entrepreneurial/transient.

ANS: C Career styles that are marked by selecting and staying in a role throughout a career are characterized as steady state.

3. The nurse executive at the local hospital began working there 20 years ago and has risen to the highest designation in nursing. This career style is known as: a. Linear. b. Spiral. c. Steady state. d. Entrepreneurial/transient.

ANS: A The linear career style, as described by Friss (1989), refers to vertical advancement in an organization and is of interest to those with a desire to gain organizational knowledge and different perspectives on nursing.

4. Before beginning her own nursing agency, a nurse worked with other temporary nursing agencies in nine states. This career style is known as: a. Linear. b. Spiral. c. Steady state. d. Entrepreneurial/transient.

ANS: D The entrepreneurial/transient career style, as described by Friss (1989), is appealing to nurses who enjoy variety in experiences.

5. A young male nurse began in nursing as a staff nurse at a hospital. After 3 years, he moved to a home healthcare agency. After 2 years, he was promoted to a managerial position and now has returned to another hospital as a new director of nursing. This career style is known as: a. Linear. b. Spiral. c. Steady state. d. Entrepreneurial/transient.

ANS: B The spiral career style, as described by Friss (1989), involves an in-and-out and up-and-down approach to opportunities.

6. A unit manager recently graduated as a clinical nurse specialist with a focus in gerontology. She applied to take a certification exam. Certification is designed to recognize: a. Basic knowledge in a specified area. b. Advanced practice in functional roles.

c. Special knowledge beyond basic licensure. d. Continued competence as a registered nurse.

ANS: C Certification is an expectation in some settings for career advancement in advanced practice or in specialized areas and goes beyond basic preparation.

7. Which of the following situations is most likely to result in a productive, whole work situation? a. Amy, RN, 5 years of experience in the emergency department. Amy accepts a position working with older clients in a home health agency because she has relocated and this is the only full-time position available. b. Adam, RN, 8 years of experience in various nursing positions, including that of a nurse manager. Adam accepts a new nurse manager position because he has a family and wants more regular hours. He is most comfortable working in direct client care. c. Louise, RN, 10 years of experience in an emergency department. She accepts a position as a case manager in home health care, working with older clients. She especially enjoys working with older adults and wants to take on leadership and management challenges. d. Courtney, RN, a new graduate. Courtney is getting comfortable with delivering nursing care as an RN. She is offered a position on surgery as a permanent team leader. The unit has had a great deal of turnover recently, and only limited mentorship is available.

ANS: C The whole of any work situation is composed of two elements: person and position. A productive, whole work situation results when a person’s talents and strengths are successfully blended with expectations of the position. Of the situations described previously, the one most likely to result in a productive, whole work situation is that of Louise, who, although her experience has not been in home health, is interested in both the roles and the responsibilities of the position, as well as the target group being served. She also considers the group being served as an area in which she demonstrates strength.

8. A nurse is applying for a new position. This position is one in which she will serve as a liaison between a hospital and a school of nursing. The nurse has to update her résumé to include her teaching experience. The goal of creating a curriculum vitae is to: a. Have a listing of facts about your professional life.

b. Provide potential employers with information about where you are in your career. c. Respond quickly whenever a position becomes available. d. Be certain you can recall facts for a prospective position.

ANS: B A curriculum vitae provides an all-inclusive but not detailed listing of your professional life. This approach allows a prospective employer to find the most recent information quickly and gain a sense of where you are in your career.

9. To develop a curriculum vitae, or résumé, a nurse must develop a personal data file. The goal of a personal data file is to: a. Create an opportunity to be interviewed. b. Have a listing of facts about your professional life. c. Have a tool in place for marketing yourself. d. Create a document that lists your skills.

ANS: B A personal data file enables storage and recall of career-specific details that can be retrieved and shaped for a specific purpose using cut-and-paste approaches rather than creating whole new documents.

10. An experienced staff nurse applies for a distinct position of patient advocate at a new clinic. Based on the various tools available to her, which of the following should she bring to her interview to best present her skills? a. Résumé b. Annual evaluations c. Portfolio d. Patient advocacy project ANS: C A portfolio enables prospective employers to view evidence of significant achievements and responsibilities that would be pertinent to the position.

11. During performance appraisal interviews, Joanne’s nurse manager notices Joanne’s excitement when she talks about how she has helped patients on a rehab unit understand the complexities of their regimens. When Joanne’s nurse manager asks her about her career path plans, Joanne says that she wants to become a nurse administrator. The best response to Joanne would be: a. “Nursing administration is rewarding. What experiences would help you

along this path?” b. “You do not appear excited about nursing administration. Unless you are excited by that career path, I wouldn’t advise going in that direction.” c. “You seem to find teaching others very rewarding. Have you considered that as a possible career path?” d. “You are too inexperienced to consider administration. Work for a few years, and then consider administration.”

ANS: C Joanne evidences excitement about teaching patients, and although administration could be a rewarding path for her, education might be a better option for her to consider. Looking at job aspects that are rewarding is helpful in determining which career direction to pursue.

12. Knowing your professional strengths is important to: a. Finding your fit in positions and a career path. b. Maintain a professional status. c. Act in a manner that is legal and ethical. d. Understand the role expectations of a position.

ANS: A Being aware of your strengths is critical in determining what you will bring to a position and can be used to find your fit and possible career path.

Knowledge and experience are important in maintaining the privilege of belonging to a profession and of behaving ethically and legally.

13. You are offered an opportunity to take a temporary leave from your position as a nurse manager to lead a technology implementation project.

Which of the following reasons for accepting the opportunity is most consistent with developing a solid career path? a. You are pressured to do so by your supervisor. b. The organization has no other suitable candidate for the position. c. You have limited knowledge of information technology and no real interest, but this will increase your knowledge. d. Accepting a position outside of your established skill set may establish you organizationally as an innovative, adaptable leader.

ANS: D Although giving into organizational or supervisory pressure may bring an enhanced learning and organizational profile, what is to be gained needs to be assessed against your career goals, interest, and aspirations. Increasing and expanding your skill set within defined career interests is a valid reason to

consider a chance opportunity.

14. Steady state styles would be most likely in which of the following situations? a. Small hospital, in an isolated rural setting, with limited hierarchy b. Large urban teaching hospital c. Health network with several organizations d. Travel nurse agency ANS: A Steady state career styles (career-long commitment to a particular position) are more likely in rural settings, where commitment to the community is high and alternative career opportunities are limited.

15. On your curriculum vitae, which of the following is the recommended approach for listing employment and educational history information? a. 1979 RN Diploma 1985 BScN 2002 MN b. 2002 Mount Rush Health Center Staff Nurse 1997 Cedar Falls Clinic Staff Nurse 2007 Kilkarney Rehab Center Case Manager c. 2007 MN 2005 BScN d. 1997 Sturgeon County Hospital Head Nurse 2002 Sturgeon County Supervisor 2007 Sturgeon County Director ANS: C Information that is included in the body of the curriculum vitae should always be in reverse chronological order so that the most recent and, presumably, most relevant job information appears first.

16. Which of the following needs revision on a résumé or CV? ANS: D When including Web or e-mail addresses, it is important to use addresses that are not overly casual or that communicate personal information.

17. The primary difference between a résumé and a CV is that a résumé: a. Reflects your skills, knowledge, and background in relation to a specific position. b. Offers a detailed listing of positions held and where positions were held.

c. Includes a long and detailed explanation of academic and work experience. d. Provides contact information and focuses on your background, in general.

ANS: A A résumé is a short, customized overview of your professional life that relates to the qualifications of specific positions and how you are able to match your background to the qualifications that are desired. Provision of contact information is common to both the résumé and the CV. Résumés are more effective if details of particular positions that have been held are highlighted as compared with a detailed listing of positions held.

18. A functional résumé focuses on: a. Experience and skills gained in positions. b. Positions held and specific roles in the positions. c. Academic qualifications and achievements. d. Relating skills and experience to qualifications in a specific position.

ANS: A Functional résumés highlight skills and experience gained rather the details of specific positions. As with résumés in general, skills and experiences are customized to create an image of an individual in a particular position.

19. A cover letter and a résumé together should be no longer than ________ page(s). a. Two b. One c. Four d. Three ANS: D Two pages is recommended for a résumé and one for a cover letter.

20. During an interview for a manager’s position, you find the supervisor and staff unfriendly. Responses to questions are met with vague responses. After the interview, you decide not to pursue the position. What follow-up, if any, is most appropriate? a. There is no need for you to do anything further. You likely will not be offered the position anyway. b. You should file a complaint with Human Resources about the supervisor’s lack of interviewing skills. c. You should send a thank-you note to the interviewer, indicating appreciation for her time.

d. You should call and leave a voicemail, indicating your disinterest in the position.

ANS: C Even if you are disinterested in the position or think that the interview has gone badly, an appropriate follow-up is a thank-you note to the interviewer.

This recommended follow-up creates a positive impression and may leave open the possibility of future interactions.

21. A well-written letter of resignation is critical to: a. First announce your intent to resign. b. Formally signal discontent in your current position. c. Maintain a positive relationship with your former organization and colleagues. d. Fulfill your legal obligations as a departing employee.

ANS: C A well-written resignation letter outlines your intent to leave the organization and your appreciation of the organization but should follow an initial meeting with your manager to first discuss your intention. A well-written letter maintains a positive relationship with the organization.

22. In preparing for a fair interview process as a hiring manager, you should: a. Put water out for the candidates. b. Ensure that you know the names of all candidates. c. Dress comfortably and professionally. d. Prepare a schedule of questions to be asked of all candidates.

ANS: D Although providing water, knowing names, and dressing appropriately sets a professional and respectful tone for the interview, developing a schedule of questions to be asked of all candidates is important for gathering comparative data and ensuring equitable treatment.

23. To enhance team leadership skills for your team leaders, you arrange opportunities for: a. Certification. b. Continuing education. c. Graduate courses. d. Volunteerism.

ANS: B Continuing education provides systematic learning opportunities that

augment existing skills and knowledge for delivery of quality care and advancement of career goals. Graduate and certification courses provide advanced knowledge and skills.

24. Professional associations: a. Set regulatory requirements and establish entry requirements for nursing. b. Offer graduate programs for clinical and career advancement. c. Provide opportunities for career networking and support. d. Are open to all individuals who meet the criteria for membership.

ANS: C Professional associations are frequently, although not always, voluntary groups whose members provide leadership in issues and policies of interest to nurses. Professional associations also offer networks of nurses with similar interests.

MULTIPLE RESPONSE 1. Thomas has been a nurse in your ICU for 10 years. In facilitating Thomas’ professional development, you would focus on : a. Certification for the ICU environment. b. Discussions about how Thomas can fit with role expectations and relationships. c. Possible specializations within the ICU environment. d. Encouraging him to lead changes that leave long-term impacts after his retirement.

ANS: C, D Thomas is a mid career professional. As such, you would expect him to be interested in honing areas of expertise (such as leadership or developing a deeper expertise in a particular area of ICU nursing) as opposed to gaining skills necessary for his work environment such as certification or becoming comfortable with his role and relationships in ICU, which would be critical to an early career nurse. Legacy building is characteristic of mid career professionals.

2. An example of a career is : a. Employment in short-term contract jobs in business, nursing, and whatever is available. b. Involvement in an area of practice that is regulated. c. Continuous employment in the same position and the same arrangement for 20 years.

d. Moving into and out of nursing positions in various cities while pursuing travel and education that develop understanding of global health.

ANS: C, D Career refers to progression of skills, consistency, knowledge, and/or status.

This movement through nursing life is predicated on having a vision of a career as opposed to a series of jobs. Career styles can be defined as linear, steady state, entrepreneurial, or spiral. Deepening skills in one area is an example of a steady state career style, whereas moving into and out of positions in various cities can characterize an entrepreneurial style.

Involvement in a regulated field defines a professional interest but not necessarily a career.

Chapter 30: Thriving for the Future Leading and Managing in Nursing, 6th Edition MULTIPLE CHOICE 1. Nursing professionals in the twenty-first century will accomplish most of their work: a. Through teams of internationally prepared professionals. b. In teams and through group work. c. Through long-term, secure jobs. d. In competitive environments and work groups.

ANS: B The future is about teams and group work. Competition will be out and collaboration will be in. Job security will be out and career options will be in.

Our brightest and best may leave more often than they do at present to pursue career options internationally.

2. Based on studies of workplace environments for nurses and future projections, the workplace of the future will be: a. Less intense because of more technology. b. About the same as it is now. c. More intense because of more technology. d. Fluctuating between intense periods and less intense periods.

ANS: C Technology will continue to revolutionize health care and contribute to complexity compression. In addition to access to knowledge, electronic records, and current applications of technology, technology will include robotics, which will change how chronic disease can be managed, and

bioengineering will make possible interventions that do not yet exist.

3. Which of the following actions is most representative of how health care of the future might be delivered? As a nurse leader, you: a. Refer families who require immediate help to a local food bank. You also work with local agencies and families to establish a mothers collective in which mothers learn about nutrition and prepare low-cost, nutritious meals that are shared with the mothers in the collective. b. Work together with a local agency to set up a free clinic in which addicts and the homeless can receive free health care and prescriptions for immediate needs. c. Ensure that individuals who are admitted to your unit are asked about their smoking history and that preoperative and postoperative planning takes into account how smoking will affect status during and after surgery. d. Address the health of those who are overweight and obese on your unit by ensuring that hospital meals offer nutritious, healthy food choices that are satisfying.

ANS: A Referral to a food bank addresses the needs of a specific population, while exemplifying an important leadership strength: thinking long-term, acting short-term. The project that involves mothers will teach mothers about nutrition and engage them in preparation of low-cost, healthy meals while promoting longer-term changes in healthy eating.

4. You notice that wait times in your Emergency Department are growing longer, because of factors such as increases in the numbers of persons with chronic disorders, discharge of patients into the community at a higher level of acuity, and limited resources for transfer of inpatients. You begin to think about an application that would use your knowledge of the Emergency Department but also software and business applications and wonder if this would reduce wait times. You have not encountered anything similar to this idea. According to the Wise Forecast Model©, you are in what phase? a. Wild thinking b. Act widely c. Think wildly d. Learn widely ANS: C The second step in the Wise Forecast Model© is to think wildly. Step two is designed to create connections among disparate thoughts. This thinking

might be seen as the start of innovations.

5. Your organization is in the middle of re-designing patient care units, with decisions based on best practices and various other sources of evidence. In the middle of the transition, there is a temporary halt called to the transition because of a re-design of the health care system and greater emphasis on primary care. What would be a healthy response to this situation? a. Salvage as much of the original planning as possible so as to reduce expenditures. b. Engage in consultation to create innovative solutions that bridge the existing plans and the new directions. c. Abandon the current planning in favor of addressing the new trends. d. Continue with the current planning because trends come and go.

ANS: B Stability and total chaos are the ends of a continuum. Moving in some way between those two ends suggests that we live in a constant state of disequilibrium in which we strive toward stability while recognizing we experience chaos. As we continue to move from “traditional” practices to evidence-based ones and from a heavy focus on tertiary care to one that values primary care, we can assume that we might experience more chaos.

Chaos can lead to new learning and new, innovative solutions. As nurses, it is important to be able to function in an evolving environment.

6. Your organization is in the middle of re-designing patient care units, with decisions based on best practices and various other sources of evidence. In the middle of the transition, there is a temporary halt called to the transition because of a re-design of the health care system and greater emphasis on primary care. As a manager in this situation, your staff experience a gap between what they expected (the original re-design of the units) and what is actually happening (a need to integrate primary care in some way). According to Selye, the nurses on your nursing team are likely experiencing what? a. Eustress b. Distress c. Stress d. Compression ANS: C Selye described stress as being on a continuum between stress that is positive (eustress) and stress that is negative (distress). Because individuals perceive the same event differently, from the information that is given, it is not

possible to determine whether the nurses experience the events as eustress or distress; what is most likely is that the nurses are experiencing stress, which is what occurs when there is a gap between expectations and what is actually occurring.

7. As a nurse manager, it is important to become a “future thinker.” Which is an example of a “future thinker”? a. Keeping traditional practices b. Moving toward evidence-based practices c. Finding less need for more knowledge d. Believing that macromarketing will be a necessity ANS: B Future forecasts include evolutions in power, structure, and knowledge; rapid change in the healthcare system; the demise of macromarketing; and increased evidence-based practice.

8. As a team, you and the staff have determined that there is a need to reduce medication errors on your unit. Together, you developed the questions that you would like addressed and searched the literature for relevant research studies. Based on the evidence, you suggested a change to your practices and now are involved in implementation of these changes. Today, there was a major study released that would significantly change what you have decided to do. What are you and your staff experiencing? a. Compression complexity b. Distress c. Information lag d. Technology advancement ANS: A This situation exemplifies complexity compression, a term that means many changes are happening almost simultaneously and before one practice can be firmly implanted in our minds, we are already addressing some other new change. This compression can be distracting or useful.

9. Nursing research has indicated that the foundation for becoming a nursing leader is the ability to: a. Write effectively. b. Speak two or three languages. c. Focus on day-to-day priorities. d. Think futuristically.

ANS: D Whether you are a leader, a follower, or a manager, being able to visualize in your mind what the ideal future is becomes a critical strategy. A vision can range from that of an individual to that of a group or to a whole organization.

10. The chief nursing officer has been developing her portfolio for years.

What is the chief nursing officer modeling? a. Her clinical expertise b. Affection for tradition c. Her employability d. Her busy professional life ANS: C Being employed is no longer sufficient; we must be employable. A portfolio outlines achievements and experiences that communicate employability.

11. Your unit has a number of patients who have undergone limb amputation.

In working with the clients, you begin to think beyond therapies such as pharmacotherapeutics and surgery and you explore biomechanics, robotics, mind-body approaches, and cognitive behavioral therapies as possibilities in working with these clients. You begin to amass information in a number of areas with which you previously had little familiarity. According to the Wise Forecast Model©, you are a. Acting wildly. b. Learning wildly. c. Engaging in interprofessional care. d. Increasing your complexity compression.

ANS: B The first step, learn widely, means that we must extend our sources of knowledge beyond our role and clinical areas of interest. In fact we must extend our learning beyond nursing and health care. Widely might encompass another discipline such as architecture or engineering.

12. The starfish analogy is exemplified in which of the following? a. A unit manager resigns after continued tension between the administration and her regarding implementation of primary nursing. The primary nursing project dies. b. Nurses try to establish a clinic that provides ambulatory care to parents and young children in an impoverished neighborhood. Community members advocate for funding from political leaders and insurers.

c. Alana, a new graduate, promotes continence care based on evidence. When she presents her ideas, senior staff refuses to consider it. d. The head of a community health service moves on to another position.

Programs are disbanded.

ANS: B The starfish analogy points to the connectivity that we have with one another and how we influence and are influenced by others all the time. This affords many opportunities for leadership that are dependent not on formal titles but on opportunities to shape the work at hand.

13. Which of the following will require greater attention in the future? a. Chronic disorders b. Obstetrical outcomes c. Prevention of hospital-based errors d. Team conflict resolution strategies ANS: A Lifestyle choices, obesity, and an aging population will lead to an increased emphasis on prevention, personal accountability, and innovations such as robotics in the management of chronic illnesses.

14. Which of the following strategies is most important in developing a strong vision? a. Seeking out evidence to support trends and out-of-the-box thinking b. Spending time with others with whom we discuss ideas c. Setting up focus groups to provide information on current realities d. Being honest and open about what we think for the future ANS: D Regardless of how we go about developing our vision (gathering evidence, testing ideas with others), honesty and openness are foundational to a strong vision.

REF: Page 569 TOP: AONE competency: Leadership 15. To move beyond stereotypical thinking and toward thinking about the future, which of the following would be most consistent with thinking wildly in the Wise Forecast Model©? a. Listing everything that we know about our current situation b. Defining which practices will remain unchanged and which will change c. Asking someone with a great deal of experience to share ideas about best practice

d. Challenging current and future practices with questions of “what if?”

ANS: D Thinking wildly includes creating wild questions. Sometimes they are what lead to a wild idea.

16. Which aspect of our tradition and history in nursing may impede our movement towards future-oriented thinking? a. Lack of confidence b. Focus on the discipline of nursing c. Focus on details in the everyday practice d. Mistrust of trends and new evidence ANS: C Because of our history of attention to details, we may need to challenge ourselves in developing our ability for leadership. Moving from micromanaging to focusing on setting expectations for those for whom we are accountable may feel uncomfortable. However, that movement reinforces our ability to deal with longer-term issues.

REF: Page 569 TOP: AONE competency: Knowledge of the Health Care Environment 17. A stroke unit experiences numerous changes related to implementation of new technology, a changed nursing care delivery model, and staff turnover within a period of 6 months. Staff members begin to show signs of reluctance to implement any more changes. This exemplifies: a. A poor relationship between leaders and staff. b. Lack of knowledge regarding the importance of changes. c. Striving to achieve stability in the midst of great disequilibrium. d. The importance of chaos in promoting adherence with established practices.

ANS: C Stability and chaos are at opposite ends of a continuum. When chaos is present, change occurs but life may seem uncontrollable. Resisting further change is a move toward establishment of equilibrium.

18. A stroke unit experiences numerous changes related to implementation of new technology, a changed nursing care delivery model, and staff turnover within a period of 6 months. Staff members begin to show signs of reluctance to implement any more changes. The phenomenon experienced by the staff is termed:

a. Eustress. b. Care process. c. Stereotypical thinking. d. Complexity compression.

ANS: D Complexity compression refers to many changes occurring simultaneously before time is sufficient to assimilate the change.

19. A business condition that may assist forecasting but add to the complexity of change is: a. Consulting with professional groups about change. b. Researching about trends on futuristic sites. c. Asking patients to examine options for change. d. Building profit projects and sustainability into planning.

ANS: C Stalk and Butman suggests that asking the customer for feedback on options may assist with forecasting. Adopting this strategy runs counter to current practice and would increase the complexity of healthcare planning and forecasting.

20. A number of changes are introduced to a unit, including changes to familiar clinical procedures and the use of PDAs to enable bedside documentation. You, as unit manager, anticipate which of the following will contribute most to complexity compression? a. Meaning of the change b. Pace of changes c. Previous experiences with change d. Confidence of the leader in the value of the change ANS: B Complexity compression is a term that means that many changes are happening almost simultaneously and before one practice can be firmly implanted in our minds, we are already addressing some other change 21. In order to plan long term, you consider what the client of the future will look like. Which of the following client profiles would best capture shifting demographics and trends in health care? a. Younger, knowledgeable about health options b. Female, uses emergency care services for parents and children c. Older, one or more chronic disorders, diverse background

d. Male, various occupationally generated disorders, diverse ethnic background ANS: C The client base is aging and more people will be living with chronic disorders. Persons will travel more and there will be increased need to speak two or more languages to address the needs of a mobile global population.

22. You have just hired a recent graduate. The graduate is thrilled with the opportunity that she has been given, as well as with the idea that “working means no more essays, tests, or assignments!” She indicates that she has no intention of touching a book, journal, or health information Website for a “long time.” Which of the following would be your best response? a. The expectations and design of educational programs means that new graduates are better prepared for the workforce. b. The new graduate will still have to learn, but it will be job-specific learning. c. An ideal learning plan for nurses emphasizes followership. d. The amount and intensity of knowledge demands lifelong learning that includes assessment of relevancy of knowledge for practice.

ANS: D Knowledge will change dramatically, requiring that we all be dedicated learners. With or without state law, continuing education will be mandatory and essential.

Knowledge will evolve from the intensity of the current information evolution so that we will access content with meaning and applicability for our work.

23. A necessary leadership strength for nurses of the future is: a. Inspiring others to work their best to create the future. b. Understanding the nuances of fundraising to make up funding shortfall. c. Guarding the tendency of other professions to encroach on nursing roles. d. Adapting work life to an aging nursing workforce.

ANS: A Senge said that all leadership is really about is people working at their best to create the future. Predictions of the future highlight the importance of interprofessional teams and of a shift towards understanding the importance of health care.

24. Nathan tells you that he has selected nursing as a career because many

jobs are available and he will have job security. Your best response to Nathan is: a. “With many young people going overseas, many jobs and options will be available. Stable jobs and job security will be part of the nursing employment market.” b. “The job market for nurses will be diminished with funding cuts to hospitals.” c. “The employment prospects for nurses are positive with many options to choose from. Flexibility and adaptability are essential to income security.” d. “It is unlikely that nursing will survive in the long term with funding cuts and a declining population of seniors.”

ANS: C Employment for nurses continues to be positive, although roles will change in a rapidly changing environment, which will increase options. With the number of options available and sporadic work opportunities, nurses will need to be flexible and able to adapt rapidly. Job security will be out; career options will be in.

MULTIPLE RESPONSE 1. In developing curricula that will address needs based on forecasts for the future, nursing educators need to contemplate : a. Prevention strategies. b. Leadership skills and knowledge. c. Violence de-escalation strategies. d. Strategies for job security.

ANS: A, B, C Future forecasts suggest that health factors such as obesity that are implicated in the development of chronic disorders will increase, as will chronic disease.

Leadership skills have been identified as a key competence for nurses of tomorrow, and competence with technology will be needed as technology continues to revolutionize health care. Rather than emphasizing job security, nurses will need to be prepared to be in an environment with many options and episodic employment.