Power and Influence in Healthcare

Two of the five bases of power discussed in Module 10 Lecture 5 Power are as legitimate and expert.  Legitimate power is power that results from a formal position.  Expert power is power that results from specialized information or expertise.  Physicians have a hierarchical form of power derived from legitimate and expert power.  Physicians have a formal position that, historically, has led to a certain level of respect.  Physicians also have a position based on knowledge and expertise from with they receive power.  The power and traditional view of physicians as infallible can lead to blind authority.

Cialdini (2009) stated that “the simultaneous blessing and curse of such blind obedience to authority is its mechanical character.  We don’t have to think, therefore we don’t.  Although such mindless obedience leads us to appropriate action most of the time, there will be conspicuous exceptions because we are reacting, not thinking” (p.181).  Blind obedience to authority can result in devastating outcomes for customers in the healthcare settings.  Physicians are human.  Physicians often have tremendous responsibilities to be fulfilled in a limited amount of time.  Blindly accepting the authority of physicians and their orders without checks and balances is not in the best interest of the healthcare organization or its customers.  

   

Cialdini (2009) outlined this concern in stating “the worrisome possibility arises, then, that when a physician makes a clear error, no one lower in the hierarchy will think to question it-precisely because, once a legitimate authority has given an order, subordinates stop thinking in the situation and start reacting” (p.181).  Many nurses, especially new nurses, fear questioning the order of a physician due to the inherent authority and power in place.  Blind obedience results in medication and care delivery errors.  Patients, nurses, pharmacists, etc should all be taught and encouraged to have a comfort level with respectfully questioning an order that appears to be in error.

Electronic health records and electronic order entry has allowed for another form of checks and balances within the healthcare hierarchy.  As a physician enters an order in the computer system, the program alerts the physician if the order entered is questionable or contradictory of best practice.  Medication dosages, routes, frequencies, etc are all checked by the computer system for consistency with current recommendations.  Technological advances provide another opportunity to prevent errors within the healthcare organization due to blind obedience.  Power and influence affect one another.  Many individuals in positions of power deserve the influence they have.  While authority and influence should be respected, all healthcare providers are human and subject to error.  Therefore, systems should be in place to prevent errors and discourage reacting without thinking.

References

Cialdini R B 2009 Influence: Science and practiceCialdini, R. B. (Ed.). (2009). Influence: Science and practice (5th ed.). Boston, MA: Pearson Education, Inc.  

Leadership Characteristics and Nursing Leadership Theories Recognized

The following are the core leadership competencies and characteristics with examples of how they could be displayed by nursing executives/leaders:

1.  Communication and relationship management (effective communication is witnessed between the leader and all roles and ancillary departments encountered)

2.  Leadership (this nurse leader is an effective leader of inpatient and outpatient unit staff, including nurses, physicians, and ancillary services)

3.  Business skills and principles (able to manage business skills and principles by maintaining working relationships and reporting to business and financial departments within organization)

4.  Knowledge of health care environment (the nurse director must maintain a vast and updated knowledge of issues and evidence based practice related to the specific departments)

5.  Professionalism (able to manage conflict resolution and other situations while maintaining professional and neutral behaviors) (Huber, 2010, p.1). 

Along with these core competencies, the nurse leader should also display characteristics described by Collins (2001).  An effective leader has dual characteristics of “modest and willful, humble and fearless” (p.22). 

Situational theories are a group of nursing leadership theories based on the foundation that organizational behaviors are contingent on the situation or environment.  To effectively lead, leaders must have the diagnostic ability to assess and vary leadership skills depending on the situation at hand (Huber, 2010, p.14).  In a rapidly changing and advancing healthcare system, effective nurse leaders must be able to base their actions depending on the environment and needs identified.

Specifically, Fiedler’s Contingency Theory can be found in use by today’s healthcare leaders.  As healthcare increases in complexity, leadership must advance.  Fiedler’s Leadership Contingency Model outlined a plan for nurse leaders to progress based on the environment.  The three major variables influencing leadership skills include:

1.  “Leader-member relations:  the type and quality of the leader’s personal relationships with followers

2.  Task structure: how structured the group’s assigned task is

3.   Position power:  power that is conferred on the leader by the organization as a result of the assigned job” (Huber, 2010, p.14).

According to Huber (2010), the Contingency Theory states that the leader is most influential over the group when leader-member relations are good, task structure is high, and position power is high (p.14-15).

According the Giltinane (2013), the Contingency Theory and Situation Theories are applicable to the practice of nursing leadership today.  A situational leader must be able to “identify the performance, competencies, and commitment of others, and to be flexible” (p.38).  As healthcare organizations are facing constant change, top-tier leaders must be amenable to the development of different leadership styles based on different (and ever changing) situations. 

Based on the environment, the leader would vary management the approach to maximize outcomes.  An example of leadership based on the Contingency Theory would be the management of specific situations, such as “simple or complicated situations would be best handled through a task-oriented approach such as transactional leadership” (Giltinane, 2013, p.38). 

A specific example of such a situation can be viewed by the management of implementation of Electronic Health Records (HER).  An effective leader would take the complicated situation of transitioning from paper to computerized charting and lead with a task oriented approach.  This may be a transition in leadership style.  The leader would focus on assessment of “follower” or staff skills, identify staff with strong skills, and focus specifically on the task of implementation of computerized charting.  By taking on an active role and identifying staff as resource persons, the leader is remaining flexible and available.  Such a “hands on” presence may not always be necessary, but the leader is adapting their role with staff and on the unit based on the situation experienced. 

Situational leadership gave way to transactional and transformational leadership.  These forms of leadership focused more on the interaction between leaders and followers.  While it was necessary to develop leadership styles based on relationships as is viewed in the transactional/transformational movement, the Situation Leadership Theory offered a foundation for further development of flexible leadership in healthcare.     

References

Collins, J. (Ed.). (2001). Good to great. New York, NY: HarperCollins Publishers Inc.  Giltinane, C. (2013). Leadership styles and theories. Nursing Standard, 27(41), 35-39.

Huber D L 2010 Leadership and nursing care managementHuber, D. L. (Ed.). (2010). Leadership and nursing care management (4th ed.). Maryland Heights, MO: Saunders Elsevier.  201309141311151452293873

The Decision Making Process Applied to the World of Nursing and Health Care

The steps of the decision making process are as follows:

            1.  Identify the Problem

2.  Identify Decision Criteria

3.  Allocating Weights to Criteria

4.  Developing Alternatives

5.  Analyzing Alternatives

6.  Select Alternative

7.  Implement Alternative

8.  Evaluate Decision Effectiveness

So does this transfer to the realm of nursing and, if so, how?  Well the answer is yes.  The decision making/problem solving process can be viewed in the following problem addressed by a nurse manager using the American Nurses Association (ANA) standards to analyze the problem.

1. Identify a management problem.  A management problem is the lack of consistent and accurate monitoring of daily weights for congestive heart failure patients admitted to the inpatient cardiac stepdown unit.
2. Write a problem statement.  Daily weights are a tool for monitoring hypervolemia in heart failure patients.  Daily weights are monitored every morning, obtained by night shift nursing and nurse assistant staff, as a tool for physician monitoring of fluid volume status.  Daily weights are repeatedly not being collected or inaccurately documented for heart failure patients on the unit.  Consistent and accurate daily weights while inpatient offers patient reinforcement regarding the importance of continuing this activity at home after discharge.   
3. Use the ANA standards to analyze this problem.

• Standard 1
• Assessment (What data would you collect?)
• Use of evidence based practice is a core competency for nursing management and professional nursing practice (Roussel, 2013, p.26).  Focusing on evidenced based practice to support the importance of the practice of daily weights, I would collect data related to the importance of accurate fluid management strategies in heart failure patients. 
• According to Albert (2012), the “assessment of hypervolemia is important, because freedom from hypervolemia after hospitalization has been associated with improvement in long term clinical outcomes” (p.23).  Albert (2012) also listed the five signs of hypervolemia as orthopnea, peripheral edema, weight gain, need to increase diuretic dose, and jugular venous distension (p.23).  To promote the best possible outcomes for our patients, accurate daily weights must be collected and documented daily as ordered by the physician and per our unit protocol.  This not only allows for more accurate monitoring during the patient’s hospitalization, it promotes the completion of daily weights post discharge.  As Medicare reimbursement dollars decrease for HF readmissions, health care providers must provide patients with every possible tool to adequately manage their chronic health condition effectively upon discharge.    
• Standard 2
• Diagnosis the cause of the problem (Explain variables that impact the problem)
• The cause of the problem is the inconsistency of nurse versus nurse assistant weighing patients.  A knowledge gap has also been identified.  Some nurse assistants were found to be unaware of the importance of daily weights for disease management.  A knowledge gap was also identified related to the understanding of the importance of comparing the morning’s weight against that of the previous day for accuracy and evaluate if a recheck is necessary. 
• The practice had been that only patients with heart failure or as ordered by physician were weighed every day.  This lead to confusion and the increase occurence of missing patients who were ordered to be weighed daily.  Also, many nurses on the unit viewed daily weights as a “CNA responsibility” and did not follow up with the results of the daily weights.   
• Standard 3
• Identify outcomes (How does this problem impact staff and other departments?)
• This problem impacts the patient, nursing staff, physicians, and health care organization.  The patient is impacted by not receiving the best possible and recommended care.  Nursing staff are affected by not adequately completing physician orders.  Physicians are impacted, as they cannot accurately judge the fluid volume status of the heart failure patient without accurate and consistent weights obtained per orders. 
• The organization is impacted greatly by this problem.  Not only is weighing patients per orders the best practice for the patient, it is in the best interest of the organization.  By promoting healthy behaviors and educating patients, the organization promotes healthy behaviors after discharge.  Healthy behaviors and disease management behaviors improve patient health and decrease the rate of a hospital readmission.  Reimbursement for hospital readmissions for heart failure patients is decreased.  This cost becomes a responsibility of that health care organization.  For the financial wellbeing of the organization, hospital readmissions need to be prevented however possible.
• Standard 4
• Planning (Develop a plan to address the problem)
• As a manager, I want to promote staff involvement and buy in for change on the unit.  Therefore, this problem was brought to the attention of the Unit Based Committee.  As a committee made of frontline nursing staff on the unit, it is a great opportunity to give them the autonomy to initiate a change.  The UBC reviewed the problem and discussed potential plans to improve the problem under the guidance of management. 
• The UBC developed a plan for improvement of daily weights.  Daily weights accuracy and consistency will be improved if all patients are weighed.  This will decrease the “skipping” of patients needing to be weighed.  Improved communication will be promoted between nurse and CNA.  The nurse and CNAs will distinguish who will weigh each patient to ensure the weights are completed in a timely fashion.  Nurses will be re-educated regarding the importance of daily weights and monitoring the weight entered in the chart for accuracy.  CNA education will take place to educate regarding what amount of weight change must be reported to the nurse as well as what changes in weight mean.
• Standard 5
• Implementation (Develop an implementation plan)
• The implementation plan will begin at the next unit staff meeting.  At the monthly unit staff meeting, a representative from UBC will be present to “roll out” the change to the staff with the support of management.  The UBC and management will provide staff with evidence supporting the importance of accurate daily weights.  Feedback will be encouraged and appreciated to improve staff buy in to the change.
• CNA education regarding daily weights will be conducted yearly at CNA skills day as well as immediately via email, at monthly CNA meeting, and at the monthly staff meeting. 
• The unit clerical for each shift will be responsible for checking for incomplete daily weights and reporting findings to the charge nurse. 
• Standard 6
• Evaluation (Develop an evaluation plan)
• The evaluation of the plan will be done daily by the unit clerical (who reports findings to charge nurse) checking for incomplete weights.  Evaluation of the plan will also be done through promotion of frontline staff feedback regarding perceived efficacy of plan.   Lastly, chart reviews offer a concrete form of evaluation.  Daily weights are documented on the vital signs flow sheet in the electronic chart.  Daily chart reviews will be reported to the charge nurse.  A designated UBC member will also review charts weekly and report discrepancies to management. 

So as you can see, the world of nursing closely relates to the world of business.  The ANA standards of problem analyzing is very similar to the steps of the decision making process listed.  The steps of the decision making process can be found in the steps of ANA problem analysis.

References

Albert, N. M. (2012). Fluid Management Strategies in Heart Failure. Critical Care Nurse, 32(2),

20-33.

Roussel L 2013 Management and leadership for nurse administratorsRoussel, L. (Ed.). (2013). Management and leadership for nurse administrators (6th ed.). Burlington, MA: Jones & Bartlett Learning.